Yes, you will be asleep during the procedure. Most shoulder surgeries are performed using a combination of “light” general anesthetic and regional anesthesia (nerve block). With “light” general anesthesia, medication is administered to allow you to sleep during the procedure, an oral airway with oxygen supplementation is used instead of a breathing tube in your main airway, but you are breathing on your own, and your body is not paralyzed. This is quite similar to the anesthesia you might receive for a colonoscopy. Only more complicated or lengthy procedures might require deeper anesthetic, true intubation with a breathing tube, and muscle relaxation.
Regional anesthesia is a key component of effective anesthesia for shoulder and elbow surgery. This procedure involves the injection of medication around the nerves of the upper arm as they exit the cervical spine, so that the entire arm is numb throughout the procedure and afterwards. This procedure provides excellent comfort and pain relief during the perioperative period. Other medications can be added to prolong the effect of the nerve block. Current techniques and medications can provide up to 72 hours of effective pain relief. As the nerve block wears off, the patients will begin to feel tingling of the hand and fingers, and improvement in sensation and motor strength, with gradually return to normal. If you notice that the block has not worn off after 72 hours, or that the neurological symptoms are worsening rather than improving, you shoulder notify Dr. Kowalsky and his care team.
Our understanding of post-operative pain, and our strategies for managing this pain have improved significantly over time. In fact, our team at the ONS Foundation for Clinical Research & Education has published research in this area of study that has changed standards of care and best practices for pain control after orthopedic surgery. We use multimodal pain control, which refers to the use of multiple different, safe medications that treat different steps of the pain cascade to more effectively manage pain without reliance on opioid medication. A significant portion of our patients either use none or minimal opioid medication after orthopedic surgery at ONS. You will be given prescriptions for tylenol, prescription strength anti-inflammatory medication, and a medication for nerve pain. Using these medications together on a schedule will effectively control pain, and minimize the need for opioid medication. We do not recommend taking prescribed opioid medication ahead of time, to anticipate or stay ahead of pain, as this may lead to the use of opioid medication you likely would not have required.
For arthroscopic procedures, the wound should stay dry for 48 hours. For open procedures with a longer incision, the wound should stay dry for 5 days. If you have a waterproof dressing, you can shower before this time, as long as the dressing remains dry and intact. Otherwise, you should wait this amount of time before showering. Avoid a direct stream of water on the dressing if showering earlier, and if the dressing becomes saturated, remove and replace it with dry sterile gauze and an occlusive dressing (i.e. Tegaderm).
Once the dressing is removed and you begin showering normally, avoid spraying/submerging/soaking/scrubbing the wound. Simply leave alone, and allow water to drip over the wound. Pat it dry after showering, and either leave it open to the air or cover it if desired.
For most shoulder procedures, you will wear the sling for 4-6 weeks. You will wear the sling for 4 weeks all of the time, including during sleep. You will then wear the sling for the next two weeks most of the time, including primarily out of the house and when in crowded spaces. Specific instructions will depend on the nature of your procedure. Some patients will require a pillow affixed to the sling to maintain arm position in abduction. If you need to use your hand and fingers for gentle, waist-level activities including computer, mouse and phone use, the arm can be gently removed from the sling for this. When you shower, the sling can be removed, and the arm can be held against the body, or allowed to hang at your side while showering.
Some patients will choose to rent or purchase a cryotherapy device to assist with icing the operative shoulder. You can speak to Dr. Kowalsky’s coordinator about this during the scheduling process. Otherwise, patients can acquire ice packs and sleeves online if desired, as an alternative to a typical bag of ice. It is often helpful to sleep upright with a wedge pillow or in an arm chair. Some patients may explore renting an arm chair during the early post-operative period of time for this purpose. There is other equipment that might be helpful that can be found on the website on the “home equipment” page (insert hyperlink).
For most procedures, it is encouraged to sleep with the sling to protect the operative arm. For most patients who have had shoulder surgery, it is most comfortable to sleep upright. This can be accomplished propped up with pillows, using a wedge pillow, or sleeping in an arm-chair or on a couch. Some patients will rent an arm chair to help with sleep during the early post-operative period of time. The transition to normal sleep positions is typically determined by the patient’s comfort level. It is, however, discouraged to sleep on the affected side until cleared by your surgeon.
Cryotherapy is most helpful during the early post-operative period of time, but can be helpful throughout your recovery. If using ice or ice-packs, you should only apply ice for maximum 20 minutes, and there should be a towel or fabric between the ice and your skin to avoid skin burns. Dr. Kowalsky’s care team may discuss cryotherapy devices with you. These devices have a cooler of iced water that is pumped into a pad secured to the operative arm for continuous cooling therapy. While they can be used for an extended period of time, you are encouraged to follow the doctor’s and manufacturer’s instructions, avoid excessive compression, always keep a barrier between the device and skin, and check the skin frequently (every 1-2 hours) for redness or other signs of an adverse reaction.
Heat can also be helpful, primarily for the muscles that surround the operative joint. Consult with Dr. Kowalsky regarding the use of heat during the early post-operative period of time, and if using heat, only apply the heating pad to the muscles adjacent to the joint, for maximum 20 minutes.
If regional anesthesia was administered for your procedure, you will not be able to use your hand and fingers until the nerve block wears off. For most procedures, you can use your hand and fingers right away, once the nerve block wears off, for gentle waist-level activities including computer, mouse and phone use. Activities that require lifting the arm away from the body or moving the shoulder in rotation should be done primarily with the other arm.
While most patients will require a sling during that time, they still can perform gentle, waist-level activities including computer, mouse and phone use, for example. Furthermore, while protecting the repair in a sling is important for most procedures, small movements to perform activities of daily living, including bathing and dressing, are allowed. Most activities, however, should be performed primarily with the non-operative arm.
For most surgical procedures, you will regain full use of the arm by at most, 6 months after surgery. In fact, most people will regain full use of the arm for most activities of daily living by 3 months after surgery. The first 6 weeks can be quite limited, particularly if a sling is required for the entirety of that first phase of recovery, but between 6 weeks and 3 months, patients will achieve gradually-increasing ability to perform activities with the operative arm.
The timeline to return to work will depend on the nature of your work and of the procedure that was performed. For most shoulder procedures, desk workers will be able to return to work within 1-2 weeks. Strenuous manual laborers may require up to 3-6 months to return to full duty. There are occupations that involve a hybrid of deskwork and strenuous activities, and return to work for these professionals is handled based on the unique demands of these patients and the details of their conditions and procedures. Typically these patients may require at least 6 weeks to return to work.
There are no universal or specific guidelines for driving after surgery, and there is no specific test or criteria to determine when it is safe to drive. It is best to consult with your local DMV, state and local laws for guidance. If you require opioid medication to control post-operative pain, you should not drive. If you still require sling immobilization, you should be extremely careful before deciding to drive. Most patients will wait at least 1-2 weeks to drive, and some will wait 4-6 weeks after more significant procedures. When you do begin driving, exercise caution, drive short distances in perfect conditions, and observe defensive driving strategies. Some patients will also obtain a steering wheel knob to assist in controlling the wheel primarily with the other arm, until they regain full use of the operative arm.
This will be determined based on the details of your condition and of the procedure. Most patients who have undergone shoulder surgery will start physical therapy at 4 weeks after surgery. The PT protocol will be specified by Dr. Kowalsky, and will outline the weekly plan of exercises you and your therapist can perform, as well as precautions and limitations to protect the repair or reconstruction. You will typically attend therapy twice weekly for several months. The physical therapist will provide home exercises that you can perform on your own between sessions.
Dr. Kowalsky and his care team will usually call you the day after surgery to check in with you. Your first post-operative appointment will usually occur at 10 - 14 days. You will then see Dr. Kowalsky 6 weeks after surgery, 3 months after surgery, and 6 months after surgery. This schedule will be modified if needed based on your progress.
At your first post-operative appointment, Dr. Kowalsky will discuss with you any events over the first two weeks, and evaluate your comfort and pain control. The wound will be examined and sutures will be removed if needed. A thorough examination will be performed, and x-rays will be obtained and reviewed if needed. The details of the procedure will be reviewed, and the post-operative plan, including physical therapy, will be discussed.
Dr. Kowalsky encourages you to contact him and his care team with any concerns during the early post-operative period. Specific concerns that would require immediate contact include fever > 101.5°F, chills/malaise/night sweats, severe pain not controlled with prescribed medications, persistent drainage from the surgical site, persistent or worsening numbness/tingling, shortness of breath or chest pain, persistent nausea or vomiting, or hives/itching/rash.
