What you need to know before your surgery
When should I arrive in hospital?
Typically, you should arrive on the morning of the surgery at a time and ward designated by the hospital. I will meet you on the ward prior to the surgery to mark the arm which is to be operated, to confirm consent for the operation with you, and to answer any further questions you might have regarding the surgery.
Should I take my normal medications?
In general, you should take all of your usual medications, with a small sip of water, on the morning of surgery unless specifically instructed otherwise.
Should I remove my wedding ring?
Yes, if it is attached to the arm that the surgery is taking place on. This is because your arm can swell during and after the surgery which may cause the ring to dig in around the base of your finger, causing pain and restriction of blood supply to the fingertip.
“Nil by mouth”:
Leading up to an anaesthetic it is important not to eat or drink anything for at least 6 hours before. This helps prevent potentially life-threatening problems caused by regurgitation and inhalation of stomach contents during the anaesthetic. Therefore, most patients are asked to be “nil by mouth” from midnight of the day of surgery. Clear fluids such as water and black tea may be allowed up until 2 hours before the anaesthetic, but this needs to be clarified with the treating anaesthetist when you meet them on the morning of surgery. Those patients who are scheduled toward the end of a list are told a time up to which they can consume clear fluids and may occasionally be allowed to eat up until a certain time.
Occasionally, the order of an operating list may need to be changed on the day of surgery for a number of reasons that are usually not foreseeable – it is best to clarify this with me when you meet me on the morning of surgery.
Nearly all patients that undergo shoulder surgery under my care are offered a general anaesthetic combined with an interscalene nerve block. Some patients may have certain medical conditions which make a nerve block inadvisable, such as those with longstanding breathing problems. In such cases a general anaesthetic combined with conventional painkillers will typically be provided.
Nerve blocks provide excellent pain relief for the first 24-48 hours after surgery, which is usually the most painful time. They are given by the anaesthetist, who usually does this just after you go under the anaesthetic. The nerve block involves an injection of local anaesthetic into your neck on the side of the surgery, usually guided by ultrasound, aiming to “block” the nerves that supply pain fibres to the shoulder area. A good “block” will result in total or near total numbness of the shoulder and upper arm. Temporary paralysis of the arm, but usually not the hand, will also occur. It is thus very important to wear a sling to support the arm whilst the block is working, since a paralysed and numb arm can easily be damaged inadvertently by knocking into things without realising. A sling will be in place by the time you come round from the anaesthetic, which is necessary to control your arm whilst it is under the block.
Side effects of the nerve block:
Occasionally the block can also temporarily affect nerves supplying other areas, such as the diaphragm (causing shortness of breath), face (causing a droopy eyelid) or vocal cords (causing a hoarse voice). Further discussion regarding the benefits, risks and complications of nerve blocks can be had with the anaesthetist who will see you prior to the surgery.
What happens after the surgery?
You will wake up in the theatre recovery room and once you have come round from the anaesthetic, which usually takes about 15 mins, will be transferred back to the ward. You may eat and drink as you feel able once back on the ward. I will visit you on the ward shortly after the surgery to explain my findings and any changes to the aftercare plan based on the procedure that was actually carried out (sometimes decisions on the type of surgery carried out have to be made during the operation itself, although the various options possible will be discussed beforehand during the consent process). Usually the physiotherapist will also see you on the ward before you go home to go through this as well.
Dressings (keyhole/arthroscopic surgery):
There will be a large outer absorbent dressing in place on top of the shoulder. This can be removed the day following the surgery. Care must be taken when removing this outer pad that the smaller dressings underneath are undisturbed as much as possible. The smaller dressings underneath are splashproof and allow you to use a shower, however you should direct the flow of water away from the operated area as much as possible. Ideally it is best to avoid changing these dressings unnecessarily, or getting the wounds wet until the stitches are removed. If one of the dressings has become soaked or poorly adherent it is best to change it however, and spare dressings are usually provided by the ward before your discharge. Stitches are removed at 10-14 days either by your GP practice nurse or at the hospital.
Dressings (open surgery):
After open surgeries such as total shoulder replacement there will be a splash proof dressing covering the wound. This should ideally be left intact until the wound is checked at 14 days. Unnecessary changes of the dressing risks introducing infection and is to be avoided. Care must be taken to avoid getting the wound wet as much as possible by keeping the wound out of the water in the bath or by directing the shower stream away from the wound.
After reverse total shoulder replacement surgery I usually use a suction drain, which is a length of plastic tubing which comes out of the skin just below the main wound and leads to a bottle. This helps prevent pools of blood forming within the shoulder after the surgery which could potentially lead to painful haematomas (tense blood collections) or infection.
Length of hospital stay:
Keyhole shoulder operations and most other surgeries are typically done as day case surgeries, meaning you can go home on the day of surgery. You must, however, be accompanied by a responsible adult who is prepared to escort you home and provide support for the first 24 hours after surgery. You will not be able to drive home yourself on the day of surgery. Most patients undergoing total shoulder replacement generally only require a 1 night hospital stay after the surgery.
Follow up after surgery:
This is dependent on the type of surgery you have had but I will usually see you at 2 and/or 6 weeks following the surgery, at which point you will have the opportunity to go through what was done again, and to ask further questions regarding your recovery. Further follow up after this may be necessary and will be determined according to your progress.
Length of time in sling:
Typical times in a sling for the following procedures may be expected, although may be altered according to individual circumstance.
Subacromial decompression/distal clavicle excision: 1 day all the time (whilst nerve block is working) then as required for the next 2 weeks
Arthroscopic capsular release: 1 day (for the duration of the nerve block only)
Rotator cuff repair: 4 or 6 weeks, dependent on the size of the tear and security of the repair – ie whether it is 4 or 6 weeks in the sling will only be known after the surgery
Arthroscopic stabilisation: 3 weeks (with waistband)
Acromioclavicular joint stabilisation: 2 weeks
Total/reverse shoulder replacement: 3 weeks
Typical times before safe driving for the following procedures may be expected, although may be altered according to individual circumstance. Return to driving is only advised if you feel able to control the steering wheel safely, which typically requires comfortable movement of the arm above shoulder height.
Subacromial decompression +/- distal clavicle excision: 1-2 weeks
Arthroscopic capsular release: 1-2 weeks
Rotator cuff repair: 6-8 weeks
Arthroscopic stabilisation: 6-8 weeks
Acromioclavicular joint stabilisation: 2-3 weeks
Total/reverse total shoulder replacement: 6-8 weeks
Time off work:
Typical times before return to work for the following procedures are advised, although may be altered according to individual circumstance. Return to work also depends on whether you have a manual or desk based job, and also whether you would be allowed back on light duties/phased return (if manual).
Subacromial decompression +/- distal clavicle excision: 2 weeks (desk job), 4 weeks (manual job, mainly below shoulder height), 6 weeks (manual, mainly above shoulder height)
Arthroscopic capsular release: 2-3 weeks (desk job), 4-6 weeks (manual job)
Rotator cuff repair: 2-4 weeks (desk job), 12+ weeks (manual job)
Arthroscopic stabilisation: 2-3 weeks (desk job), 12+ weeks (manual job)
Acromioclavicular joint stabilisation: 2-3 weeks (desk job), 12+ weeks (manual job)
Total/reverse total shoulder replacement: 6-8 weeks (desk job)