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Surgical Instructions

AC Joint Reconstruction – Surgical Photos

Alan M. Reznik, M.D.

1-shoulder-strap-incision.jpg
2-deltoid-trapezius-muscles.jpg
3-exposing-clavicle.jpg
4-edge-unstable-bone.jpg
5-tendon-graft.jpg
6-stedinsky-clamp.jpg
7-sutures.jpg
8-suture-loops.jpg
9-coracoid.jpg
10-coracoid-process.jpg
11-collarbone.jpg
12-special-screws.jpg
13-flush-to-bone.jpg
14-coraco-clavicular-ligaments.jpg
15-drill-holes.jpg
16-ac-joint.jpg
17-graft-limbs.jpg
17a-four-ligament-repair.jpg
18-muscle-repair.jpg
19-skin-closure.jpg
20-healed-incision.jpg

Copyright © 2011, AMReznik All rights reserved.
Revised 3/7/11

AC Joint Reconstruction Surgery and Post-Op Instructions

Alan M. Reznik, M.D.

“Separation” of the shoulder is the common term used for a sprain of the AC or Acromioclavicular Joint. A fall directly on the shoulder can cause the joint to “separate.” This injury occurs most frequently in contact sports, particularly football. The main cause of a shoulder separation or AC joint dislocation is a fall on the outer upper corner of the shoulder, as may occur in a tackle or a fall onto an outstretched hand. A fall from a height, and other high energy injuries, are also major causes of AC joint separations. They also can occur skiing, snowboarding, slipping on ice, at work (a fall off a ladder or unprotected height), and in motor vehicle accidents.

Shoulder separations are different than shoulder dislocations where the ball comes out of the socket, and they are often confused with dislocations. Shoulder separations involve the small joint that connects the collar bone to the small bone above the ball and socket of the shoulder the acromion (see Figures 1 and 2). The joint can be felt as a prominent bump or ridge on the top of your shoulder. The joint is held together by strong ligaments called the coracoclavicular ligaments and the AC joint capsule. They range from minor, or grade 1 separations, that can be treated with rest, ice and an anti-inflammatory to minor displacements, or Grade 2 injuries, that can be treated the same way, to complete displacements. In the higher energy injuries, the AC joint can dislocate just like ball and socket of shoulder. In the more severe types, all of the ligaments holding the collar bone in place are torn. These higher grade injuries (grades 4, 5 and 6) are associated with a clear deformity and instability of the AC joint on examination. These high grade injuries can tent the skin and be irreducible.

shoulder-anatomy.jpg

Figure 1: Shoulder anatomy

The diagnosis is made by history, physical examination and X-rays. The injury causes pain and difficulty moving the arm. The ligament injury allows muscles attached to the clavicle to pull it away from the shoulder and, depending upon the severity may produce a very prominent bump on the top of the shoulder. Special X-rays with and without weights can help define the relative instability of the AC joint in borderline cases. An MRI is not needed or helpful in the diagnosis and treatment in this injury.

Again, in simple cases, there is only a sprain and the clavicle does not move too much out of place. Treatment may consist of rest, immobilization with a sling, ice and use of an anti-inflammatory medication. Certain exercises done under the supervision of a physical therapist may also be useful. If the ligaments holding it in position are completely ruptured, then the clavicle moves upwards and backwards (see X-ray above in figure 2). Patients may complain of popping, catching or pain with overhead activities. The deformity may be very visible and disconcerting. The deformity itself is not the true indication for surgical repair. There are several clear indications for repair. They include:

  1. Significant tenting or the skin: in these cases the muscle may be trapped below the bone and the bone edge is directly under the skin or the bone may be “button holed’ or stuck in the muscle casing pain with motion.
  2. There are nerve symptoms, shooting pains or numbness, in the hand or arm with any motion.
  3. There is significant loss of use of the dominant arm or in many cases, the nondominant arm.
  4. Continued pain and instability of the end of the collar bone after failing nonsurgical treatment.

If there is a significant deformity and or symptoms with activities of daily living, surgery may be required to bring the clavicle back into its normal position. The goal is to restore stability and function to the shoulder. Surgery is not indicated for small separations, minimal deformity or for only cosmetic reasons.

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full-elevation-shoulder.jpg

Healed incision for the repair

Full elevation at eight weeks post op.

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X-ray showing reduced AC Joint and bone tunnels

The vast majority of the time the reconstructive surgery is very successful. Remember, as with any surgery, there is always a risk of complications including, but not limited to, infection or failure of the repair. Having AC joint ligament reconstruction surgery in cases with minor or weak indications is not worth even the limited risks of surgery and is discouraged. In some of those minor cases, a less invasive approach, like an arthroscopic Mumford procedure or resection of the prominent tip of the distal collar bone, or even no surgery at all, may be a better choice.

Procedure and Instructions

If surgical repair is needed, the ligament reconstruction involves a special incision being made over the front and the top of the AC joint. The collar bone is then reduced into position and the torn tendons replaced with a tendon graft and small biocompatible screws supplemented with heavy duty sutures (Fiberwire ™ and Ethibond™).

Dr. Reznik performs this surgery under a light general anesthesia with Marcaine and Lidocaine for post op pain relief on an out-patient basis. You should expect to have some post op soreness and you will be given oral pain medications for home to provide extra comfort. (To learn more see the photos from a real surgical repair performed by Dr. Reznik on this web site).

Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended.

To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

A-C Joint Reconstruction Recovery Plan and Post-Op instructions:

Day 1 Post Op: arriving home from the surgery center: Maintain dressing, adding 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. (Do not place ice directly on skin to avoid frostbite.) Keep pillow sling on at all times. Move fingers and wrist often. Expect some swelling, if you have any change in skin color or sensation in arm, notify our office. When sleeping, most patients find sleeping in a semi-upright position is more comfortable for the first few weeks after shoulder surgery. Begin Hand Squeezing and Wrist range of motion exercises at home after surgery. (See exercise list) The arm sling with its pillow must remain on at all other times, including bedtime.

Day 2: The Day after Surgery: Same as Day 1

Day 3: (usually about 48 hours after surgery): Continue same activities, including using ice for 20 minute periods as needed. You should remove your dressing. You may remove the sling to shower today, supporting the affected arm with the opposite hand. You may wash the skin around the incisions as long as you keep the white Steri strips dry. When washing the under arm, do not use a large amount of soap. It may dry out the skin and cause a rash. After a short shower, dry the shoulder well and place Band-aids over incisions.

Day 3- 4: Start Therapy with a physical therapist. This is to help avoid a frozen shoulder. The range of motion will be limited at first. The goal is to start motion while protecting the repair.

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at least (3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication. Use Ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed.

Dressing: The dressing is to remain clean and dry. After 48 hours you may remove the dressings. Keep any white “steri-strips”in place. They will be removed along with any sutures at your 1st postop visit with Dr Reznik. You may shower today and after gently patting the incision dry, replace the dressing with Band-Aids.

Sling: Patients are to wear the pillow sling at all times (including while sleeping) for the first 3 weeks. Move fingers and wrist often. Expect some swelling. Patients should then wear the sling with the pillow removed when going out and in public places for the next 3 weeks. The sling will help to alert others to avoid the affected arm during this healing period.

Driving: Patient cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Airline Flights: Only if necessary, patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should in general wait 6-8 weeks for longer flights. If you must fly, you should get up and walk frequently to avoid blood clots and take an aspirin a day (unless allergic) for the week before and six weeks after the flight.

Returning to Work: A patient with low demand work can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Heavy labor work with overhead lifting can take at least 4-6 months.

Blood Clots: Patients at high risk for blood clots include: Those with long car or train commutes, may be overweight* BMI>30, have a history of having cancer, females on birth control pills and males over the age of 40. These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin. Patients with more than two risk factors or prior history of clots should ask their primary physician if a blot thinner is required.

*BMI or Body Mass index is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body composition. A muscle/fat ratio if you will. The index is used to screen for weight categories that may lead to health problems.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting;
  • You develop a fever above 101.
  • You develop any type of rash;
  • You experience calf pain.

Dental Work:

***YOU CANNOT HAVE ANY ROUTINE DENTAL WORK (INCLUDING CLEANING) FOR AT LEAST 3 MONTHS AFTER YOUR SURGERY OR YOU RISK INFECTING THE SUTURES, SCREWS AND MOST IMPORTANTLY THE TENDON GRAFT. AN INFECTED GRAFT MAY NEED TO BE REMOVED IF THE INFECTION DOES NOT RESPOND TO QUICK TREATEMENT.

AFTER 3 MONTHS YOU MAY SEE THE DENTIST BUT YOU WILL NEED TO TAKE ANTIBIOTICS BEFORE AND AFTER DENTAL WORK FOR ONE YEAR FROM DATE OF SURGERY, DR. REZNIK WILL GIVE YOU A PRESCRIPTION***

Physical Therapy:

It is vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. You will begin simple exercises AT HOME the day of surgery. Wrist range of motion, gripping the squeeze ball supplied with the sling and simple elbow motion to reduce pain and swelling. They should be done every day for at least the first 3 weeks post-op, to maintain blood flow and help prevent blood clots.

Post Operative Exercises:

Do three times each day as directed

Starting Day 1: Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener. Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

Day 3 add: Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This rubbing you belly motion will decrease pain and prevent elbow stiffness. Physical therapy usually begins today. It is a key part of your post op care. The physical therapist will guide you in your rehabilitation program.

Day 7 add: Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable try it holding a very small can to start, in a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful, you should decrease or eliminate the weight.

Not before Day 10 add: Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the sot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.

Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

ACL Tears and Reconstruction with Postop Instructions

Alan M. Reznik, M.D.

The Anterior Cruciate Ligament or ACL is a ligament that connects the femur (thighbone) to the tibia (shinbone). It is located in the center of the knee. The ACL provides stability and keeps the tibia from moving too far forward relative to the femur. Most ACL tears are the result of a twisting injury or a rapid forward translation of the tibia as shown below. After an ACL injury, the tibia shift forward with activity causes the knee to buckle more easily. This instability prevents most athletes from returning to sports, puts other structures in the knee at risk and, with higher levels of laxity, and even causes instability of activities of daily living. It is the instability and the risk of increased damage to the cartilage that prompts patients to seek repair of the knee.

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Treatment: ACL Reconstruction

acl-repair.jpgSurgery to reconstruct the ACL ligament can be done arthroscopically through small incisions and is done on an out-patient basis (avoiding a hospital stay and allowing the patient to recover in the comfort of their own home.) It requires placing a tendon graft obtained from your own patella tendon, hamstrings or donor graft. There are advantages of each graft type and pending your particular situation your surgeon will pick the best graft for your knee. In the operating room, Dr. Reznik first examines the knee with the KT1000 knee arthrometer. This device measures the exact level of stability of both the normal and injured knees. The measurements help confirm the diagnosis and a sterile version used at the end of the procedure confirms the stability after the repair. Once the diagnosis is confirmed by the exam under anesthesia, the knee is then evaluated with the arthroscope. Dr. Reznik checks each compartment of the knee for other related problems like cartilage tears. These are repaired and then attention is turned back the ACL injury. The torn fragments are cleared from the knee. The ligament’s natural position in the knee is identified and tunnels are then drilled into the tibia, and the femur. The graft is guided through the tunnels and anchored in place with dissolving pins and/or titanium screws. Once the graft is in place the small incisions are closed.

acl-process.jpg

Copyright © 2011, AMReznik All rights reserved. Revised 3/30/11

Post-Surgery Instructions

When you wake up in the recovery room, you knee will be protected in a long leg knee immobilizer. Inside the immobilizer, the knee is wrapped with a cotton dressing and a special cooling pad. This is all wrapped in an Ace bandage. The cooling pad helps with swelling and relieves pain. The cooling pad connects to a cooler with ice water and a pump. It is yours to take home and simple to set up for use. The knee will have also been injected with a long and short acting local anesthetic for pain control so with the cooling pad, pain medications and the local anesthetic most patients are a little sore but not uncomfortable. Using the ice machine will help you remain comfortable and will also aid in reducing the swelling. You should follow this schedule:

Ice Machine Schedule:

Day 1 and 2: Use continuously (including throughout the night). Disconnect from the machine only to go to the bathroom.

Day 3 and 4: At least 2 hours on and 1/2 hour off. You may find that the combination of 3 hours on and 3 hours off also works well. Start physical therapy.

Day 5 and after: Use as needed for comfort and swelling.

Change the ice and water when you are unable to maintain a temperature of 50- 52 degrees

Dressings: The first dressing change will be at your first therapy appointment, after that change you may shower. It is recommended to use an antibacterial soap. The small white “steri-strips” should not be removed. Keep them dry; they will be removed, as well as any stitches, at your first post-op visit with Dr. Reznik. Gently bend your knee a few times while in the shower. After your shower place a small bandage over the front kneecap incision and Band-Aids over the other two incisions. When replacing the ice machine pad do not place directly on skin as this can cause frostbite. Wrap in a cloth or place between Ace bandages.

ACL Recovery Plan

Diet: You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a sandwich. If you become nauseated, return to clear liquids.
Lungs: After surgery you are encouraged to deep breath and cough frequently (at least 3- 4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing pneumonia.

Pain Control: Take pain medication as prescribed by Dr. Reznik. Please call our office with any questions regarding your medication. Ice as directed above. Elevate leg above heart level using 2-3 pillows. This will also decrease swelling.

Stop smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body's white blood cells.

Deep Breathing: Be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after anesthesia. Immobilizer: You will wear this for 2 - 3 weeks (Remove only for showering and physical therapy) and then change into the custom knee ACL brace. This is to be worn even while sleeping.

Crutches: Use 2 crutches for 7-10 days putting light weight on the foot with each step. Increase the weight as tolerated. When you are able to bear weight comfortably, you may then advance to one crutch for the next few days and then to no crutch. Most patients can be full weight bearing after 2-3 weeks while wearing the ACL brace.

Driving: Right knee patients and left knee patients with a standard transmission car cannot drive until off all pain meds and can fully weight bear without pain.

Return to Work: People with light work (desk work with no squatting, kneeling or lifting can return to work within 2 weeks. The exception is for people who may have long commutes. By staying still with the leg down for long periods, THEY ARE AT RISK FOR BLOOD CLOTS. Patients with active office work or very light labor with variable tasks can sometimes go back by 6 weeks. Heavy work, lifting or unprotected heights usually need at least 6 weeks and clearance from their physical therapist and will return with the ACL brace on.

Blood Clots: Those at higher risk of blood clots include those patients who have sedentary life styles, long car or train commutes, have a history of prior cancer, women on birth control pills, may be overweight or males over the age of 40. These patients should be taking an at least a baby aspirin per day (unless allergic or sensitive). Doing the exercises (ankle pumps below), using aspirin and at times compressive stockings will also reduce the risk of blood clots. Patients who have a history of clots in the past or three or more of the above risk factors should ask if they should be on a blood thinner post op for at least six weeks.

Call the physician if:

  • You develop excessive, prolonged nausea or vomiting;
  • You develop a fever above 101;
  • You develop any type of rash;
  • You experience calf pain.

 

Post-Op Exercises

Vital to your recovery of good knee function is a graduated activity and exercise program to increase muscle strength and knee motion. Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your knee rehabilitation program. It is VERY important for you to start therapy when recommended. To avoid complications, post-operative follow up appointments with your physician are also required to monitor your progress.

You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow in the surgical leg and help prevent blood clots. Formal physical therapy will begin between three to five days after surgery. The goal is for you to get to 90 degrees of flexion by the end of two week and 120 degrees by 6 weeks post op. Your therapist should not push you (and let me know if they do) to gain more than this since it may stretch the graft or prevent it from healing properly. More is not better at this time and may compromise your results.

ankle-pump.jpg

 

Ankle Pumps: pump your ankle up and down (like pressing the gas pedal). Do this 10 times per hour while awake.

 

 

straight-leg-raises.jpg


Straight Leg Raises: Tighten your quads muscle (the front of your thigh), and raise your leg 8 to 12 inches off the bed. Do this 10 to 15 times, 4 or 5 times per day.

 

 

Your therapist will do your first dressing change.

Follow schedule for use as directed in “post surgery instructions” above.

Always keep a thin gauze or cloth between the skin and the cooling pad. Do not allow the pad to contract the skin directly as this may cause frostbite.

After the first dressing change, inspect the skin regularly and notify our office staff if there are any sign of changes in skin appearance or increasing redness.

Change the ice and water when you are unable to maintain a temperature of 50-52 degrees

Additional Precautions for all Patients

Dental Work: ACL patients CANNOT have any routine DENTAL WORK for at least 3 months after their surgery (including cleaning), or they will risk infection of the graft. After 3 months, they may see the dentist but will need to take antibiotics before and after dental work. They should continue this for one year from the date of surgery. If an emergency dental procedure is needed, the dentist should be notified of the need to give protective “prophylactic” antibiotics before and after the procedure.

Airline Flights: All flying should wait at least 6 weeks after this procedure. Some short flights may be okay but then aspirin or other clotting protection is needed. If you do need to fly, you should get up and walk frequently to avoid blood clots. All patients planning to fly the first 6 months after surgery should be on aspirin (81mg per day) at least one week before and 6 weeks after a flight (unless allergic). Please check with Dr. Reznik or his nurse if you have any questions about flying or long trips.

Risk of Infection: Infection after surgery has been in the news recently. There is always a risk of infection. The risk of infection in regular open surgery is less than 1%. However, the risk in arthroscopic surgery is less than 1 in 2000 (less than one twentieth of a percent). For this combined surgery the real risk is in between. In addition, Dr. Reznik routinely uses antibiotics during surgery and post-operatively to reduce this risk as well.

Copyright © 2011, AMReznik All rights reserved.
Revised 3/30/11

Acromioclavicular Joint (AC Joint)

Alan M. Reznik, M.D.

The photos are presented here with the explicit permission of Dr. Reznik’s patient, for education purposes only. The images cannot be reproduced or modified for any use without specific written permission in advance. All rights reserved.

(Warning: These are real photos from an actual surgical procedure preformed by Dr. Reznik. Do not view if you are averse to seeing surgery photos of a live patient!)

Figure 1: Shoulder Strap Incision - this is used because of the ability to extend the exposure if needed. It lies in the natural lines of the skin, making it a more cosmetic incision than would a transverse incision in this same location.

1-shoulder-strap-incision.jpg

Figure 2: Developing the next layer the muscle/fascia plane of the deltoid and trapezius muscles.

2-deltoid-trapezius-muscles.jpg

Figure 3: Exposing the clavicle (collar bone).

3-exposing-clavicle.jpgFigure 4: Seeing the edge of the unstable bone.

4-edge-unstable-bone.jpgFigure 5: The holes have been drilled in the distal collar bone for the placement of the tendon graft after replacing the tone ligaments in their natural position around the coracoid process (not seen here) of the scapula (shoulder blade).

5-tendon-graft.jpg

Figure 6: A special clamp, the Stedinsky Clamp (often used in open heart surgery) is used to pass the sutures around the coracoid process. These sutures aid in passing the actual tendon graft that has been prepared separately on the OR table for graft placement later in the procedure.

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Figure 7: The guide sutures are passed prior to passing the graft.

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Figure 8: The suture loops that are attached to the leading ends of the graft are passed through the guide sutures.

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Figure 9: These loops are then passed under the coracoid process.

9-coracoid.jpgFigure 10: The graft follows the loops under the tip of the coracoid process.

10-coracoid-process.jpg

Figure 11: The graft is passed through the pre-drilled holes in the collar bone.

11-collarbone.jpgFigure 12: The graft is fixed in place with special screws with mechanical properties similar to natural bone.

12-special-screws.jpgFigure 13: The screw is seated flush to bone.

13-flush-to-bone.jpgFigure 14: Once the coraco-clavicular ligament grafts are set and secure, the graft ends are tensioned and pulled laterally to repair the ligaments between the acromion and the clavicle.

14-coraco-clavicular-ligaments.jpgFigure 15: Close up of the grafts passing out of the drill holes.

15-drill-holes.jpgFigure 16: Positioned toward the AC joint.

16-ac-joint.jpgFigure 17: Graft limbs secured to the acromion.

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Figure 17A: Close up of complete four ligament repair.

17a-four-ligament-repair.jpgFigure 18: Closure: Deltoid- Trapezius Muscle repair.

18-muscle-repair.jpg

Figure 19: Skin closure, repair completed.

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Figure 20: Healed incision for the repair.

20-healed-incision.jpg

Copyright © 2011, AMReznik All rights reserved.
Revised 3/7/11

Acromioplasty/ Mumford Procedure Recovery Plan (Post-Op Tips for a Better Recovery)

Alan M. Reznik, M.D., MBA

shoulder-joint-muscle-tendon.jpg

The tip of the scapula (shoulder blade) forms the roof of the shoulder joint is also known as the Acromion. Normally, the tendons of the shoulder (the Rotator Cuff) and a fluidfilled bursa sac have plenty of room underneath the Acromion. They glide freely in this space and it allows for a full range of motion. Overuse of the shoulder may lead to damage of the tissues underneath the Acromion process. The tendons and bursa may thicken and then pinch against the bone and/or the coraco-acromial ligament, causing irritation and pain. This is referred to as “impingement syndrome.”

Athletes and laborers who participate in sports or work that have overhead movements as at risk for this shoulder problem. People whose work involves performing repetitive shoulder movements or frequent overhead movements are also susceptible to shoulder impingement.

Some patients have anatomic variation of the acromion (an over hanging tip) and are more prone to this problem. Impingement can also occur where this bone meets the collarbone (clavicle) at the acromioclavicular or AC joint. Occasionally there are significant spurs at the AC Joint, and like a hooked acromion, the cuff is “impinged” upon by the spurs. The AC joint can also become arthritic, injured (as in a shoulder separation), or worn by repetitive motion like weight lifting or become cystic (a condition know as osteolysis of the clavicle). It too can be a source of pain.

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abnormal-ac-joint.jpg

Loss of use of the arm, pain with activity, loss of sleep or waking from sleep are common concerns with this condition and often the pain with activities of daily living (taking milk out of the refrigerator, washing your hair or putting a coat on) cause patients to seek care. The complete inability to sleep a full night can worsen and prompt treatment.

Treatment: If the problem has failed to improve with non-surgical methods and when the problem relates to an overhanging acromion, calcified acromial-clavicular ligaments, or a thickened bursa, arthroscopic surgery can help. Through the arthroscope Dr Reznik can remove any damaged tissue, increase the sub-acromial space and clear the inflamed bursa. This procedure is called an “Acromioplasty” and is done on an outpatient basis. When the AC joint is the source of pain, the spurs, arthritic surface, cysts and softened bone can also be removed arthroscopically. This is known as a “Mumford procedure” (resection of the distal clavicle). The choice of procedure depends on the problem you have and in some cases, both are needed to relieve the persistent symptoms of shoulder pain.

spur-removal.jpg

Acromioplasty/Mumford Recovery Plan (Post Op Tips for a better recovery)

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If you become nauseated, check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication.
Sling: It is recommended that patients wear the sling when going out for the next 3 weeks. .This will help to alert others to avoid the affected arm during this healing period.

Driving: Patient cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Returning to Work: Most patients performing sedentary or low demand work can return to work within 7 to 10 days. They will still have restrictions on lifting (usually 5 lbs), repetitive and overhead use. Patients performing medium work that may require some light lifting may return in about 3-4 weeks. Patients with higher demand occupations with infrequent repetitive arm use will need at least 6-8 weeks. Heavy laborers or those with frequent repetitive or overhead work (as in manufacturing or construction) will need a minimum of 3-4 months and then a work conditioning program prior to returning to work.
Note: Most patients see 80% of their improvement by 4 months with the remainder occurring over the first year after surgery.
Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but in general, should wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic)

Blood Clots:
Patients at high risk for blood clots include:

  • Those with long car or train commutes
  • May be overweight
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40
  • Prior history of a clot


These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin. Patients with more than two risk factors or prior history of clots should ask their primary physician if a blood thinner is required.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting
  • You develop a fever above 101
  • You develop any type of rash
  • You experience calf pain

 

Physical Therapy:

Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. You will begin simple exercises the day of surgery. Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended.

To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress. Blood clots are rare after shoulder surgery. Patients should be up and walking as soon as comfortable. Leg and foot motion is encouraged several times during each day and they should be done every day for the first 3-6 weeks post-op to maintain blood flow and help prevent blood clots.

Post operative Instructions for ShoulderArthroscopy
Acromioplasty/Mumford

Day 1: The Day of Surgery: You will start moving your arm and simple exercises in the recovery room. When home, maintain dressing. You may add 4x4 bandages if needed for drainage through dressing. Apply ice pack for 20 minute periods throughout the day. Take care to avoid ice for too long or directly to the skin. Prolonged ice to the skin can cause frost bite.
Move your fingers and wrist often. Expect some swelling. If the color of your arm or hand changes, or sensation changes, please notify the physician. Start pendulum and wall walk (see list) exercises tonight.
**All patients find sleeping semi-upright is more comfortable the first few weeks after shoulder surgery. A reclining chair is often most comfortable, sleeping with pillows propped on a couch will help if reclining chair not available.

Day 2: The Day after Surgery (The same as day 1.)

Day 3-4: (48 hours post-operatively) Resume same activities as the surgical day: use ice for 20 min. periods as needed. Continue gripping exercises, and be sure to move your wrist and fingers frequently. Take your dressing off and shower today. In the shower; support the affected arm with the opposite hand. In the shower; begin to flex and extend your elbow. You should move the arm freely in the shower. You may wash under the arm, but do not use a large amount of soap. Too much soap may dry out the skin and cause a rash. After your shower, dry the shoulder well and place Band-aids over incisions. Physical therapy usually begins day 3-4. It is a key part of your post op care. Continue the therapy program, each week they will be adding to your home program based on your individual progress.
**Now, use your arm sling is for comfort only, use it only as needed and when in a crowded place (this will warn people to avoid your injured area). Do your elbow, wrist, and hand exercises at least three times each day – 15 Reps.

Day 4 – 10: Change Band-aids daily or as needed. Maintain sling use for comfort. Continue with exercises as directed. Add Biceps curls and increase the circle size when doing the Pendulum exercises. Depending on what type of surgery you had and you own recovery rate, physical therapy will start 3-4 days after surgery.

Day 7 – 10: Keep your Visit with the doctor. Dr Reznik will check your motion, incisions, review your surgical findings and give you further instructions on how to continue your rehabilitation and recovery.

Exercises: do three times each

Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.

Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This rubbing you belly motion will decrease pain and prevent elbow stiffness.

Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable try it holding a very small can to start, in a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.

Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.

Copyright © 2011, AMReznik All rights reserved.
Revised 3/7/11

Bankhart Lesion Repair & Post-Op Instructions

Alan M. Reznik, M.D., MBA

Repairing Damage from Shoulder Joint Dislocation

The shoulder is the junction of three bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The shoulder joint is the result of the head of the humerus bone fitting in the cavity (glenoid cavity) of the shoulder blade. Like a golf ball sitting on a tee, it doesn’t take a lot to dislodge or dislocate the humeral head (Ball) from the glenoid (Tee).

dislocated-shoulder.jpgThe fragility of the shoulder is reinforced by a series of ligaments, and a rim of tissue that surrounds the cavity called the glenoid labrum. If excessive force is applied to the arm, the shoulder may become “dislocated,” that is, the head of the humerus may be forced out of the cavity and the supporting ligaments of the shoulder may be torn, displaced or stretched out of shape.

scapular.jpgWhen the shoulder dislocates, the smooth cartilage surface of the humerus (“ball”) slides over the rim of the glenoid portion of the scapula (the lip of the cup or golf tee). At the time of shoulder dislocation, or more often at the time of relocation, this can cause a complication and damage to the head of the humerus (the “ball” portion of the joint.) This occurs when the humeral head passes into, or out of, the socket as the ball is impinged against the sharp glenoid rim. The back of the ball can be fractured or dented just like a dent in your car after a fender bender. The dent from this injury is referred to as a “Hill Sachs Lesion.” An x-ray of a dislocated shoulder is shown below in figure 1a.

dislocated-shoulder-xray.jpg

An arthroscopic photo of the damage to the ball is shown below. The larger this dent is, the easier the shoulder will dislocate again. At the same time the ligaments in the front of the shoulder are avulsed or torn off the rim of the Glenoid (as shown in the drawing above). It is the combination of the dent size and ligament damage that is the true measure of future instability of the shoulder.

hill-sachs-lesion.jpg

A Bankhart procedure, Labral repair or Gleno-humeral ligament repair, are surgical techniques for the repair of the damage from a single or recurrent shoulder joint dislocations. In this procedure, the torn labrum (or lip of the socket) with the attached ligaments are reattached to the proper place in the shoulder joint. By re-attaching these ligaments and cartilage we can prevent future dislocations. With the proper tightening of the lining, the Hill Sachs Lesion (the dent) will not hit the rim with routine motion. The shoulder is made stable and the re-injury risk is greatly reduced by avoiding “dent/ rim” contact. Dr. Reznik does this repair through the arthroscope with sutures and tiny absorbable anchors. The goal is to restore normal function in a minimally invasive way as an out patient procedure. If the ligaments alone are torn or stretched and the labrum is still attached they can be repaired in a similar manor.

labral-tear.jpgFrequently the ligaments and the capsule lining are stretched out of shape. This may also cause instability, subluxation or recurrent dislocations. Many of these patients cannot work overhead or throw any object. They also have difficulty with overhead sports. When this occurs the loose capsule can be tightened at the same time the ligaments are repaired. This is referred to a “Capsular Shift” procedure.

Dr. Reznik also performs this surgery with a minimally invasive technique through an arthroscope (fiber optic scope) with little disruption to the other shoulder structures. The surgery is done on an out patient basis which allows patients to be home in a few hours instead of days. On rare occasions the dent is so large that is needs to be grafted. Arthroscopic assisted methods are available for this procedure as well.

arthroscope-1.jpgarthroscope-2.jpgarthroscope-3.jpg

Patient's Recovery Plan

The Day of Surgery

Maintain dressing. You may add 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. KEEP SLING ON AT ALL TIMES.

Move fingers and wrist often. Expect some swelling. If you have skin color changes or changes in sensation in your arm, notify the doctor. When sleeping, place 1 or 2 pillows under the operative side elbow to keep arm in place. Begin grip strengthening and wrist range of motion exercises tonight. (See exercise list below.)

Most patients find sleeping in a semi-upright position is more comfortable for the first few days after shoulder surgery. A reclining chair is often most comfortable.

Post-op Day 1: The Day after Surgery

Follow the same instructions as for the day of surgery noted above

Day 2: (48 hours post-operatively):

Remove the dressing. The Xeroform gauze strips (small yellow ‘tapes’) can be removed at the time of your first dressing change. You can shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below.) Support the affected arm with the opposite hand. You may wash under the arm, but do not use a large amount of soap. Too much soap may dry out the skin and cause a rash. After a short shower, dry the shoulder well. Pat the incisions dry, don’t rub the scabs off. Cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.

Resume same activities as surgical day; use ice for 20 min. periods as needed.

Exercise: Once a day, in the shower, you may begin to flex and extend your elbow, keep your arm close to your body, rub palm over stomach, keep palm facing inward. Do your elbow, wrist, and hand exercises at least 2 other times each day.

The arm sling must remain on at all other times, including bedtime.

Day 3 - 4: Start formal physical therapy program. Continue home exercise as listed below (adjust exercises as per therapist’s instructions.

Day 4 – 10: Change Band-aids daily or as needed. Maintain sling use. Continue exercises as directed under Day 3.

Day 7 – 10: The first post-op visit: see Dr Reznik in the office. He will review your surgery with you and further instructions will be given for your rehabilitation and recovery.

Exercises

Do three times each day as directed

Starting Day 1:
Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

On Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.

On Day 4 add:
Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day.

Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Walk your finders down the wall as well as up. If you will have weakness on the way down, so use the other arm to help.

Important: Do not let the hand drop down from the wall—this will be painful and strain the repair.

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable, try it holding a very small can. In a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.

General Instructions for Labral Repair Patients

You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a non-spicy sandwich. If you become nauseated, return to clear liquids. You can also try Tums, Zantac or Pepcid AC to help settle your stomach. After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs and will reduce the risk of developing pneumonia.

Pain Control: Take medication as prescribed by Dr. Reznik. Do not take all your meds at the same time. Take anti-inflammatory medication with food to avoid stomach upset. Please call our office with any questions regarding your medication. After surgery, some patients will see some swelling. Use an ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed for comfort and to reduce swelling.

Blood Clots: Patients at high risk: These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

 

  • Those with long car or train commutes
  • May be overweight: BMI>30*
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40 

 

  • (*BMI or Body Mass Index is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body composition. A muscle/ fat ratio if you will. The index is used to screen for weight categories that may lead to health problems.)

Sling: Patients are to wear the pillow sling at all times (including while at sleep) for the first 3 weeks. Then, it is recommended that patients wear the sling with the pillow removed when going out for the next 3 weeks. This will help to alert others to avoid the affected arm during this important healing period. Move fingers and wrist often. Expect some swelling.
Dressing: The Xeroform gauze strips (small yellow ‘tapes’) can be removed after 48 hours. At this time you may shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below). Pat the incisions dry, using care not to rub the scabs off and cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.

Exercise: You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.
Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended.

Physical Therapy: Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting
  • You develop a fever above 101
  • You develop any type of rash
  • You experience calf pain

Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic.)

Returning to Work: Patients with a small tear, and/or low demand work, can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Any heavy labor with overhead lifting can take at least 4-6 months.

**Dental Work: You cannot have any routine dental work (including cleaning) for at least 3 months after your surgery, or you risk infecting the suture anchors. After 3 months, you may see the dentist, but for one year from date of surgery, you will need to take antibiotics before and after dental work. Call our office, and Dr. Reznik will give you a prescription.

Copyright © 2011, AMReznik. All rights reserved.
Revised 3/11/11

Biceps Repair Surgery (Ruptures, Tears, Subluxation,Tenodesis, Tenotomy)

Alan M. Reznik, M.D.

Biceps Tendonitis, Partial Biceps Tears, Biceps Subluxation, Biceps Rupture, and Biceps Tenodesis

One of the more common complaints about the shoulder is biceps tendonitis. The biceps muscle starts at the elbow, passes up the arm and splits into two tendons or "heads". The shorter tendon ends at the coracoid process of the "shoulder blade" (the scapula) and the longer one enters the shoulder joint. There, the longer end (the “long head”) attaches to the top of the socket (the glenoid) at a cartilaginous lip that covers the edge of the socket (the labrum). It is in the bicepital grove just as the tendon enters the shoulder that the long head tends to get most worn and inflamed. This is the primary location for biceps tendonitis, partial tears and ruptures.

Crossing the shoulder joint and the elbow joint is the long head of the biceps, (whose true function in the shoulder joint is debated in the orthopedic and sports medicine community.) At the elbow it acts, partnered with the short head of the biceps, in flexion of the elbow and with supination of the hand (clockwise rotation of the right hand and counter-clockwise on the left).


When it does occur, biceps tendonitis can range from a mild self limited case to a chronic problem or even an acute rupture. A problem with the biceps tendon typically involves a partial or complete tear of the long tendon, inflammation around the tendon or involvement of the tendon, the nearby bursa (bursitis) and the rotator cuff.

Complete ruptures of the long head of the biceps are more common after the age of forty. Many times it is associated with an acute injury or a painful pop. Then, the muscle attached to the long head tends to ball up further down the arm. It often looks like a “Popeye” arm. The short head almost always remains intact. Many patients often have a long history of inflammation of the tendon (chronic biceps tendonitis) before the injury. When that occurs, the tendon failure is usually due to years of wear and tear on the shoulder. It is often associated with repetitive overhead lifting, chronic inflammatory tendonitis and a heavy lifting injury, or repetitive work trauma.

In other cases, a more severe sudden traumatic injury is the cause. This is more common in younger patients but can occur at any age. A traumatic torn biceps sometimes occurs during heavy weightlifting or from actions that cause a sudden load on the upper arm, such as a hard fall with the arm outstretched during competitive sports. Forced extension of the elbow against resistance or a fall in a position that forces the tendon to trap between the humeral head (ball of the shoulder) and the sharper bone edges of the scapula or acromion can also cause a tear or rupture. The long head of the biceps can be also injured by repetitive motion, local trauma, rapid extension of the arm, force applied while trying to actively flex the elbow or during a fracture or dislocation of the shoulder. About 50% of long head of the biceps tendon ruptures are associated with rotator cuff tears (mostly supraspinatus tears). Subluxation of the long head is associated with a subscapularis tear. If there are signs and symptoms associated with a rotator cuff tear found on examination, further testing may be needed. When a patient has significant symptoms, an MRI is frequently required to make the diagnosis of additional shoulder problems associated with a rupture of the long head of the biceps.

right-shoulder.jpg

Please note: Tears of the biceps tendon at the elbow are a completely different problem. Both heads of the biceps muscle join and attach in one common location on the proximal radius. Together, they are a major flexor of the elbow and these tears should, in general, always be repaired. The discussion here is focused on injuries to the long head of the biceps only.

Treatment: Biceps tendonitis is the most common problem seen in the long head of the biceps. It can often be treated with anti-inflammatories, ice and rest. In chronic cases, injection, NSAIDs and/or therapy may be needed. Many partial and even complete tears can be treated without surgery. A well performed physical exam by an orthopedic surgeon and an X-ray of the shoulder are often the best ways to see what treatment is most appropriate and rule out other problems with the shoulder. Occasionally there is a structural issue, and tenolysis (release of the tendon sheath), an arthroscopic decompression of the shoulder or a tendonotomy (release of the tendon itself) or tenodesis (removing the diseased segment of tendon and moving the tendon to a new location that preserves function while relieving the pain) may be required.

Surgery is often reserved for patients with evidence of other concomitant shoulder problems. When the long head of the biceps is completely torn, the acute soreness will resolve in weeks. Some patients actually feel better than before the injury. If the muscle itself is painful with activity, the shoulder needs to be examined. If patients have weakness and pain with supination of the hand (clockwise rotation of the right hand and counter clockwise on the left), after failing conservative measures, a biceps tenodesis may be required. Laborers that use screw drivers frequently at work with the injured arm may notice the deficit after a rupture and may require a tenodesis. Biceps ruptures are also frequently associated with bone spurs near the tendon’s path into the shoulder joint. When these are painful they should be removed. If am MRI confirms the rotator cuff is torn, it should be repaired at the same time.

Special considerations: When the biceps is subluxated (out of its normal groove) and the subscapularis is torn, releasing the tendon and tenodesis may be necessary to protect the subscapularis repair. When there is a tear of the superior labrum (a cartilage lip on the socket of the shoulder joint) and it involves the attachment of the biceps, repair of the labrum (lip) is needed, and a release of the tendon or tenodesis may also help resolve the symptoms (this is a newer concept and there is no clear agreement on the best treatment at this time). Chronic partial tears with pain that have failed other treatment may also benefit from a tendotomy or a tenodesis. Your surgeon will have to take all these factors into account and make a judgment on what would be best for you based on the findings at the time of surgery.

When needed, a Biceps tenodesis is a surgical procedure that anchors the ruptured end of the biceps tendon to the upper end of the humerus. Dr. Reznik performs arthroscopic evaluation of the shoulder to check for other related injuries to the shoulder first. Once any rotator cuff issues are treated, if a tenodesis is needed, it is done through small incisions over the front of the humerus. Depending on the length and condition of the tendon, the location of the tenodesis will vary. Newer arthroscopic tendon transfers are also possible in some cases. The type of procedure will depend on your anatomy and the problem found at the time of surgery. When tenodesis is performed, the tendon itself can be fixed in place with a special absorbable screw, sutures, special suture anchors or a combination of these methods. The surgery is done on an outpatient basis with the goal of decreasing pain with activity and improving overall function in the affected arm.

bicep-tendon.jpg

bicep-tendon-2.jpg

 

Biceps Tenotomy: In some cases, the biceps is partially torn and painful. The tendon is swollen, worn, frayed or inflamed in its groove. Forward flexion of the arm, supination of the hand and pressing on (palpating) the bicepital groove is painful. If the non-dominant arm is involved, the patient has a low demand occupation and the shape of the muscle (cosmetic appearance) is not a concern, a tenotomy (a release of the tendon) as opposed to tenodesis (moving the tendon to a new location) can be an excellent option with good pain relief and a shorter recovery time.

Post Operative Instructions after a Biceps Tenodesis

Day 1: The Day of Surgery: Maintain dressing, adding 4x4 bandages if needed for drainage through the dressing. Use ice pack for 20 minute periods throughout today. (Do not place ice directly on skin to avoid frostbite.) Keep pillow sling on at all times. Move fingers and wrist often. Expect some swelling, if you have any change in skin color or sensation in arm, notify our office. You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.

Hand Squeezing and Wrist range of motion exercises tonight. (See exercise list) The arm sling must remain on at all other times, including bedtime.

When sleeping, most patients find that sleeping in a semi-upright position in a recliner or propped up on pillows on a couch is much more comfortable than trying to lie in bed for the first few weeks after shoulder surgery. I do not recommend trying to sleep in bed for at least the first 2 weeks.

Day 2: The Day after Surgery: Same as Day 1

Day 3: Starting about 48 hours after surgery: Continue same activities, including using ice for 20 minute periods as needed. You should remove your dressing. You may remove the sling to shower today, supporting the affected arm with the opposite hand. You may wash the skin around the incisions. When washing the under arm, do not use a large amount of soap. It may dry out the skin and cause a rash. After a short shower, dry the shoulder well and place Band-aids over incisions. Some of the prep solutions are yellow in color do not be surprised if it will not come off with soap and water. Sometimes only nail polish remover works.

Day 3- 4: Start Therapy with a physical therapist: This is to help avoid a frozen shoulder. The range of motion will be limited at first and the exact rehab protocol will depend on the status of your rotator cuff. The size and type of any associated rotator cuff tear will alter the rehab program. You should not do any resisted elbow flexion exercises for at least six weeks post op. You can do additional exercise only as the therapist instructs. Do not try to speed the process by doing more than asked because you can risk disrupting the repair. This may sound funny but you cannot fool Mother Nature or when you are not moving the way you should, Dr. Reznik. Overdoing it, not following the directions and “creative” mistakes become obvious very quickly. To avoid complications, follow the therapy guidelines and keep all your postoperative follow-up appointments with your physician. These appointments are required to monitor your progress.

Physical Therapy: Physical Therapy is vital to your recovery of good shoulder function. It will include a graduated activity and exercise program to increase muscle strength and motion while protecting the repair. Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

General Instructions for all Rotator Cuff Repair and Biceps Tenodesis Patients

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth, adding crackers or toast, then a non-spicy sandwich. If you become nauseated, check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle your stomach and drink plenty of clear liquids.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication. Take with food to avoid stomach upset. After surgery, some patients will see some swelling. Use an ice pack over the dressing throughout the first 24 hours after surgery and then for 20 minute periods as needed for comfort and to reduce swelling.
Dressing: The dressing is to remain clean and dry. After 48 hours you may remove the dressing and the yellow Xeroform gauze strips (the small yellow tapes). You may then shower with the dressings off. Pat the incisions dry, using care not to rub the scabs off and then cover each incision with a plain Band-Aid. Do not use creams or ointments on the incisions. This delays early scab formation and healing.

Sling: Patients are to wear the pillow sling at all times (including while at sleep) for 3 weeks. Move fingers and wrist often. Expect some swelling. Use Ice pack for 20 minute periods throughout the first 24 hours after surgery and then as needed. After the first three weeks, patients should wear the sling (with the pillow removed) when going outside of their home for the following 3 weeks completing a total of 6 weeks of sling use. This will help to alert others of your surgery. The sling will remind them it is not healed yet and help them avoid the affected arm during this healing period.

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at least 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.

Blood Clots: Patients at high risk for blood clots include:

  • Those with long car or train commutes or planning any air travel (these trips should be avoided in the first 6 weeks post op)
  • May be overweight: BMI>30*
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40


These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

*BMI (or Body Mass index) is a number calculated from a person’s weight and height.BMI provides a reliable indicator of body composition. A muscle/fat ratio if you will. The index is used to screen for weight categories that may lead to health problems.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting
  • You develop a fever above 101.5
  • You develop any type of rash
  • You experience calf pain


Dental Work: You cannot have any routine dental work (including cleaning) for at least 3 months after your surgery, or you risk infecting the suture anchors. After 3 months, you may see the dentist, but for one year from date of surgery, you will need to take antibiotics before and after dental work. If emergency dental work is needed call our office for a prescription.
Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12 o’clock position of the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Airline Flights: Patients may fly 3 weeks after surgery on short flights (up to 2 hours) only and should wait 6-8 weeks for longer flights. You should get up and walk frequently Call the Physician or go to the ER if: *You develop excessive, prolonged nausea or vomiting *You develop a fever above 101.5 *You develop any type of rash. *You experience calf pain. to avoid blood clots and take an aspirin (unless allergic). You cannot carry any luggage for 3-4 months with the operated arm.

Returning to Work: Those patients with low demand work (no lifting) may be able to return to work within 3 weeks. They will still have restrictions on lifting, repetitive and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks off. Any heavy labor with overhead lifting can require at least 4-6 months before returning to work, they still may have restrictions up to one year.

Exercises - Do three times each day as directed

Starting Day 1:
Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.

Day 4 add:
Pendulum Exercise:Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day

Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.
Biceps Curls: Those patients with a tenodesis cannot do any biceps curls while the tendon heals. They can start moving the elbow without resistance in a limited range in the first 3 weeks; increase the range between 3-6 weeks, leading to full range after 6 weeks, but no resistive exercises for at least 3 months. To monitor your progress and avoid complications after surgery, it is important to keep your postoperative follow up appointments with Dr. Reznik and your physical therapist.

Copyright © 2011, AMReznik, All rights reserved.
Revised 3/7/11

Biceps Tenodesis Surgical Procedure

Alan M. Reznik, M.D.

Biceps Tendonitis, Partial Biceps Tears, Biceps Subluxation, Biceps Rupture, and Biceps Tenodesis

One of the more common complaints about the shoulder is biceps tendonitis. The biceps muscle starts at the elbow, passes up the arm and splits into two tendons or "heads". The shorter tendon ends at the coracoid process of the "shoulder blade" (the scapula) and the longer one enters the shoulder joint. There, the longer end (the “long head”) attaches to the top of the socket (the glenoid) at a cartilaginous lip that covers the edge of the socket (the labrum). It is in the bicepital grove just as the tendon enters the shoulder that the long head tends to get most worn and inflamed. This is the primary location for biceps tendonitis, partial tears and ruptures.

Crossing the shoulder joint and the elbow joint is the long head of the biceps, (whose true function in the shoulder joint is debated in the orthopedic and sports medicine community.) At the elbow it acts, partnered with the short head of the biceps, in flexion of the elbow and with supination of the hand (clockwise rotation of the right hand and counter-clockwise on the left).


When it does occur, biceps tendonitis can range from a mild self limited case to a chronic problem or even an acute rupture. A problem with the biceps tendon typically involves a partial or complete tear of the long tendon, inflammation around the tendon or involvement of the tendon, the nearby bursa (bursitis) and the rotator cuff.

Complete ruptures of the long head of the biceps are more common after the age of forty. Many times it is associated with an acute injury or a painful pop. Then, the muscle attached to the long head tends to ball up further down the arm. It often looks like a “Popeye” arm. The short head almost always remains intact. Many patients often have a long history of inflammation of the tendon (chronic biceps tendonitis) before the injury. When that occurs, the tendon failure is usually due to years of wear and tear on the shoulder. It is often associated with repetitive overhead lifting, chronic inflammatory tendonitis and a heavy lifting injury, or repetitive work trauma.

In other cases, a more severe sudden traumatic injury is the cause. This is more common in younger patients but can occur at any age. A traumatic torn biceps sometimes occurs during heavy weightlifting or from actions that cause a sudden load on the upper arm, such as a hard fall with the arm outstretched during competitive sports. Forced extension of the elbow against resistance or a fall in a position that forces the tendon to trap between the humeral head (ball of the shoulder) and the sharper bone edges of the scapula or acromion can also cause a tear or rupture. The long head of the biceps can be also injured by repetitive motion, local trauma, rapid extension of the arm, force applied while trying to actively flex the elbow or during a fracture or dislocation of the shoulder. About 50% of long head of the biceps tendon ruptures are associated with rotator cuff tears (mostly supraspinatus tears). Subluxation of the long head is associated with a subscapularis tear. If there are signs and symptoms associated with a rotator cuff tear found on examination, further testing may be needed. When a patient has significant symptoms, an MRI is frequently required to make the diagnosis of additional shoulder problems associated with a rupture of the long head of the biceps.

right-shoulder.jpg

Please note: Tears of the biceps tendon at the elbow are a completely different problem. Both heads of the biceps muscle join and attach in one common location on the proximal radius. Together, they are a major flexor of the elbow and these tears should, in general, always be repaired. The discussion here is focused on injuries to the long head of the biceps only.

Treatment: Biceps tendonitis is the most common problem seen in the long head of the biceps. It can often be treated with anti-inflammatories, ice and rest. In chronic cases, injection, NSAIDs and/or therapy may be needed. Many partial and even complete tears can be treated without surgery. A well performed physical exam by an orthopedic surgeon and an X-ray of the shoulder are often the best ways to see what treatment is most appropriate and rule out other problems with the shoulder. Occasionally there is a structural issue, and tenolysis (release of the tendon sheath), an arthroscopic decompression of the shoulder or a tendonotomy (release of the tendon itself) or tenodesis (removing the diseased segment of tendon and moving the tendon to a new location that preserves function while relieving the pain) may be required.

Surgery is often reserved for patients with evidence of other concomitant shoulder problems. When the long head of the biceps is completely torn, the acute soreness will resolve in weeks. Some patients actually feel better than before the injury. If the muscle itself is painful with activity, the shoulder needs to be examined. If patients have weakness and pain with supination of the hand (clockwise rotation of the right hand and counter clockwise on the left), after failing conservative measures, a biceps tenodesis may be required. Laborers that use screw drivers frequently at work with the injured arm may notice the deficit after a rupture and may require a tenodesis. Biceps ruptures are also frequently associated with bone spurs near the tendon’s path into the shoulder joint. When these are painful they should be removed. If am MRI confirms the rotator cuff is torn, it should be repaired at the same time.

Special considerations: When the biceps is subluxated (out of its normal groove) and the subscapularis is torn, releasing the tendon and tenodesis may be necessary to protect the subscapularis repair. When there is a tear of the superior labrum (a cartilage lip on the socket of the shoulder joint) and it involves the attachment of the biceps, repair of the labrum (lip) is needed, and a release of the tendon or tenodesis may also help resolve the symptoms (this is a newer concept and there is no clear agreement on the best treatment at this time). Chronic partial tears with pain that have failed other treatment may also benefit from a tendotomy or a tenodesis. Your surgeon will have to take all these factors into account and make a judgment on what would be best for you based on the findings at the time of surgery.

When needed, a Biceps tenodesis is a surgical procedure that anchors the ruptured end of the biceps tendon to the upper end of the humerus. Dr. Reznik performs arthroscopic evaluation of the shoulder to check for other related injuries to the shoulder first. Once any rotator cuff issues are treated, if a tenodesis is needed, it is done through small incisions over the front of the humerus. Depending on the length and condition of the tendon, the location of the tenodesis will vary. Newer arthroscopic tendon transfers are also possible in some cases. The type of procedure will depend on your anatomy and the problem found at the time of surgery. When tenodesis is performed, the tendon itself can be fixed in place with a special absorbable screw, sutures, special suture anchors or a combination of these methods. The surgery is done on an outpatient basis with the goal of decreasing pain with activity and improving overall function in the affected arm.

bicep-tendon.jpg

bicep-tendon-2.jpg

 

Biceps Tenotomy: In some cases, the biceps is partially torn and painful. The tendon is swollen, worn, frayed or inflamed in its groove. Forward flexion of the arm, supination of the hand and pressing on (palpating) the bicepital groove is painful. If the non-dominant arm is involved, the patient has a low demand occupation and the shape of the muscle (cosmetic appearance) is not a concern, a tenotomy (a release of the tendon) as opposed to tenodesis (moving the tendon to a new location) can be an excellent option with good pain relief and a shorter recovery time.

Post Operative Instructions after a Biceps Tenodesis

Day 1: The Day of Surgery: Maintain dressing, adding 4x4 bandages if needed for drainage through the dressing. Use ice pack for 20 minute periods throughout today. (Do not place ice directly on skin to avoid frostbite.) Keep pillow sling on at all times. Move fingers and wrist often. Expect some swelling, if you have any change in skin color or sensation in arm, notify our office. You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.

Hand Squeezing and Wrist range of motion exercises tonight. (See exercise list) The arm sling must remain on at all other times, including bedtime.

When sleeping, most patients find that sleeping in a semi-upright position in a recliner or propped up on pillows on a couch is much more comfortable than trying to lie in bed for the first few weeks after shoulder surgery. I do not recommend trying to sleep in bed for at least the first 2 weeks.

Day 2: The Day after Surgery: Same as Day 1

Day 3: Starting about 48 hours after surgery: Continue same activities, including using ice for 20 minute periods as needed. You should remove your dressing. You may remove the sling to shower today, supporting the affected arm with the opposite hand. You may wash the skin around the incisions. When washing the under arm, do not use a large amount of soap. It may dry out the skin and cause a rash. After a short shower, dry the shoulder well and place Band-aids over incisions. Some of the prep solutions are yellow in color do not be surprised if it will not come off with soap and water. Sometimes only nail polish remover works.

Day 3- 4: Start Therapy with a physical therapist: This is to help avoid a frozen shoulder. The range of motion will be limited at first and the exact rehab protocol will depend on the status of your rotator cuff. The size and type of any associated rotator cuff tear will alter the rehab program. You should not do any resisted elbow flexion exercises for at least six weeks post op. You can do additional exercise only as the therapist instructs. Do not try to speed the process by doing more than asked because you can risk disrupting the repair. This may sound funny but you cannot fool Mother Nature or when you are not moving the way you should, Dr. Reznik. Overdoing it, not following the directions and “creative” mistakes become obvious very quickly. To avoid complications, follow the therapy guidelines and keep all your postoperative follow-up appointments with your physician. These appointments are required to monitor your progress.

Physical Therapy: Physical Therapy is vital to your recovery of good shoulder function. It will include a graduated activity and exercise program to increase muscle strength and motion while protecting the repair. Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

General Instructions for all Rotator Cuff Repair and Biceps Tenodesis Patients

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth, adding crackers or toast, then a non-spicy sandwich. If you become nauseated, check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle your stomach and drink plenty of clear liquids.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication. Take with food to avoid stomach upset. After surgery, some patients will see some swelling. Use an ice pack over the dressing throughout the first 24 hours after surgery and then for 20 minute periods as needed for comfort and to reduce swelling.
Dressing: The dressing is to remain clean and dry. After 48 hours you may remove the dressing and the yellow Xeroform gauze strips (the small yellow tapes). You may then shower with the dressings off. Pat the incisions dry, using care not to rub the scabs off and then cover each incision with a plain Band-Aid. Do not use creams or ointments on the incisions. This delays early scab formation and healing.

Sling: Patients are to wear the pillow sling at all times (including while at sleep) for 3 weeks. Move fingers and wrist often. Expect some swelling. Use Ice pack for 20 minute periods throughout the first 24 hours after surgery and then as needed. After the first three weeks, patients should wear the sling (with the pillow removed) when going outside of their home for the following 3 weeks completing a total of 6 weeks of sling use. This will help to alert others of your surgery. The sling will remind them it is not healed yet and help them avoid the affected arm during this healing period.

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at least 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.

Blood Clots: Patients at high risk for blood clots include:

  • Those with long car or train commutes or planning any air travel (these trips should be avoided in the first 6 weeks post op)
  • May be overweight: BMI>30*
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40


These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

*BMI (or Body Mass index) is a number calculated from a person’s weight and height.BMI provides a reliable indicator of body composition. A muscle/fat ratio if you will. The index is used to screen for weight categories that may lead to health problems.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting
  • You develop a fever above 101.5
  • You develop any type of rash
  • You experience calf pain


Dental Work: You cannot have any routine dental work (including cleaning) for at least 3 months after your surgery, or you risk infecting the suture anchors. After 3 months, you may see the dentist, but for one year from date of surgery, you will need to take antibiotics before and after dental work. If emergency dental work is needed call our office for a prescription.
Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12 o’clock position of the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Airline Flights: Patients may fly 3 weeks after surgery on short flights (up to 2 hours) only and should wait 6-8 weeks for longer flights. You should get up and walk frequently Call the Physician or go to the ER if: *You develop excessive, prolonged nausea or vomiting *You develop a fever above 101.5 *You develop any type of rash. *You experience calf pain. to avoid blood clots and take an aspirin (unless allergic). You cannot carry any luggage for 3-4 months with the operated arm.

Returning to Work: Those patients with low demand work (no lifting) may be able to return to work within 3 weeks. They will still have restrictions on lifting, repetitive and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks off. Any heavy labor with overhead lifting can require at least 4-6 months before returning to work, they still may have restrictions up to one year.

Exercises - Do three times each day as directed

Starting Day 1:
Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.

Day 4 add:
Pendulum Exercise:Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day

Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.
Biceps Curls: Those patients with a tenodesis cannot do any biceps curls while the tendon heals. They can start moving the elbow without resistance in a limited range in the first 3 weeks; increase the range between 3-6 weeks, leading to full range after 6 weeks, but no resistive exercises for at least 3 months. To monitor your progress and avoid complications after surgery, it is important to keep your postoperative follow up appointments with Dr. Reznik and your physical therapist.

Copyright © 2011, AMReznik, All rights reserved.
Revised 3/7/11

Capsular Shift Repair & Post-Op Instructions

Alan M. Reznik, M.D., MBA

Repairing Damage from Shoulder Joint Dislocation

The shoulder is the junction of three bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The shoulder joint is the result of the head of the humerus bone fitting in the cavity (glenoid cavity) of the shoulder blade. Like a golf ball sitting on a tee, it doesn’t take a lot to dislodge or dislocate the humeral head (Ball) from the glenoid (Tee).

dislocated-shoulder.jpgThe fragility of the shoulder is reinforced by a series of ligaments, and a rim of tissue that surrounds the cavity called the glenoid labrum. If excessive force is applied to the arm, the shoulder may become “dislocated,” that is, the head of the humerus may be forced out of the cavity and the supporting ligaments of the shoulder may be torn, displaced or stretched out of shape.

scapular.jpgWhen the shoulder dislocates, the smooth cartilage surface of the humerus (“ball”) slides over the rim of the glenoid portion of the scapula (the lip of the cup or golf tee). At the time of shoulder dislocation, or more often at the time of relocation, this can cause a complication and damage to the head of the humerus (the “ball” portion of the joint.) This occurs when the humeral head passes into, or out of, the socket as the ball is impinged against the sharp glenoid rim. The back of the ball can be fractured or dented just like a dent in your car after a fender bender. The dent from this injury is referred to as a “Hill Sachs Lesion.” An x-ray of a dislocated shoulder is shown below in figure 1a.

dislocated-shoulder-xray.jpg

An arthroscopic photo of the damage to the ball is shown below. The larger this dent is, the easier the shoulder will dislocate again. At the same time the ligaments in the front of the shoulder are avulsed or torn off the rim of the Glenoid (as shown in the drawing above). It is the combination of the dent size and ligament damage that is the true measure of future instability of the shoulder.

hill-sachs-lesion.jpg

A Bankhart procedure, Labral repair or Gleno-humeral ligament repair, are surgical techniques for the repair of the damage from a single or recurrent shoulder joint dislocations. In this procedure, the torn labrum (or lip of the socket) with the attached ligaments are reattached to the proper place in the shoulder joint. By re-attaching these ligaments and cartilage we can prevent future dislocations. With the proper tightening of the lining, the Hill Sachs Lesion (the dent) will not hit the rim with routine motion. The shoulder is made stable and the re-injury risk is greatly reduced by avoiding “dent/ rim” contact. Dr. Reznik does this repair through the arthroscope with sutures and tiny absorbable anchors. The goal is to restore normal function in a minimally invasive way as an out patient procedure. If the ligaments alone are torn or stretched and the labrum is still attached they can be repaired in a similar manor.

labral-tear.jpgFrequently the ligaments and the capsule lining are stretched out of shape. This may also cause instability, subluxation or recurrent dislocations. Many of these patients cannot work overhead or throw any object. They also have difficulty with overhead sports. When this occurs the loose capsule can be tightened at the same time the ligaments are repaired. This is referred to a “Capsular Shift” procedure.

Dr. Reznik also performs this surgery with a minimally invasive technique through an arthroscope (fiber optic scope) with little disruption to the other shoulder structures. The surgery is done on an out patient basis which allows patients to be home in a few hours instead of days. On rare occasions the dent is so large that is needs to be grafted. Arthroscopic assisted methods are available for this procedure as well.

arthroscope-1.jpgarthroscope-2.jpgarthroscope-3.jpg

Patient's Recovery Plan

The Day of Surgery

Maintain dressing. You may add 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. KEEP SLING ON AT ALL TIMES.

Move fingers and wrist often. Expect some swelling. If you have skin color changes or changes in sensation in your arm, notify the doctor. When sleeping, place 1 or 2 pillows under the operative side elbow to keep arm in place. Begin grip strengthening and wrist range of motion exercises tonight. (See exercise list below.)

Most patients find sleeping in a semi-upright position is more comfortable for the first few days after shoulder surgery. A reclining chair is often most comfortable.

Post-op Day 1: The Day after Surgery

Follow the same instructions as for the day of surgery noted above

Day 2: (48 hours post-operatively):

Remove the dressing. The Xeroform gauze strips (small yellow ‘tapes’) can be removed at the time of your first dressing change. You can shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below.) Support the affected arm with the opposite hand. You may wash under the arm, but do not use a large amount of soap. Too much soap may dry out the skin and cause a rash. After a short shower, dry the shoulder well. Pat the incisions dry, don’t rub the scabs off. Cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.

Resume same activities as surgical day; use ice for 20 min. periods as needed.

Exercise: Once a day, in the shower, you may begin to flex and extend your elbow, keep your arm close to your body, rub palm over stomach, keep palm facing inward. Do your elbow, wrist, and hand exercises at least 2 other times each day.

The arm sling must remain on at all other times, including bedtime.

Day 3 - 4: Start formal physical therapy program. Continue home exercise as listed below (adjust exercises as per therapist’s instructions.

Day 4 – 10: Change Band-aids daily or as needed. Maintain sling use. Continue exercises as directed under Day 3.

Day 7 – 10: The first post-op visit: see Dr Reznik in the office. He will review your surgery with you and further instructions will be given for your rehabilitation and recovery.

Exercises

Do three times each day as directed

Starting Day 1:
Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

On Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.

On Day 4 add:
Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day.

Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Walk your finders down the wall as well as up. If you will have weakness on the way down, so use the other arm to help.

Important: Do not let the hand drop down from the wall—this will be painful and strain the repair.

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable, try it holding a very small can. In a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.

General Instructions for Labral Repair Patients

You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a non-spicy sandwich. If you become nauseated, return to clear liquids. You can also try Tums, Zantac or Pepcid AC to help settle your stomach. After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs and will reduce the risk of developing pneumonia.

Pain Control: Take medication as prescribed by Dr. Reznik. Do not take all your meds at the same time. Take anti-inflammatory medication with food to avoid stomach upset. Please call our office with any questions regarding your medication. After surgery, some patients will see some swelling. Use an ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed for comfort and to reduce swelling.

Blood Clots: Patients at high risk: These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

 

  • Those with long car or train commutes
  • May be overweight: BMI>30*
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40 

 

  • (*BMI or Body Mass Index is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body composition. A muscle/ fat ratio if you will. The index is used to screen for weight categories that may lead to health problems.)

Sling: Patients are to wear the pillow sling at all times (including while at sleep) for the first 3 weeks. Then, it is recommended that patients wear the sling with the pillow removed when going out for the next 3 weeks. This will help to alert others to avoid the affected arm during this important healing period. Move fingers and wrist often. Expect some swelling.
Dressing: The Xeroform gauze strips (small yellow ‘tapes’) can be removed after 48 hours. At this time you may shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below). Pat the incisions dry, using care not to rub the scabs off and cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.

Exercise: You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.
Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended.

Physical Therapy: Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting
  • You develop a fever above 101
  • You develop any type of rash
  • You experience calf pain

Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic.)

Returning to Work: Patients with a small tear, and/or low demand work, can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Any heavy labor with overhead lifting can take at least 4-6 months.

**Dental Work: You cannot have any routine dental work (including cleaning) for at least 3 months after your surgery, or you risk infecting the suture anchors. After 3 months, you may see the dentist, but for one year from date of surgery, you will need to take antibiotics before and after dental work. Call our office, and Dr. Reznik will give you a prescription.

Copyright © 2011, AMReznik. All rights reserved.
Revised 3/11/11

Cartilage Defects & Osteochondritis Dissecans Surgical Repair and Post-Op Instructions

Alan M. Reznik, M.D.

Osteochondritis Dissecans or OCD is a condition that can cause pain and swelling in a joint. It occurs when fragments of bone below the joint surface lose blood supply and separate from the rest of the bone. The most common site for OCD is the knee and the most common location in the knee is the lateral side of the medial femoral condyle. Although no one knows why a segment of bone should lose its blood supply, most doctors believe that it is due to repetitive trauma with microscopic fractures below the surface of the joint or clogging of the tiny blood vessels inside the bone associated with a number of differing medical conditions. The age of presentation varies. OCD occurs commonly in older children and adolescents who actively participate in sports. The theory is that the repetitive motion of sports, like running, throwing or jumping, causes a small area of the bone to fatigue and then fracture under its surface. The continued microtrauma from the repetitive loading, for example continued running on the already injured knee prevents the defect from healing. If it does not heal, soon the trauma may loosen the bone fragment. The loose fragment then can cause locking, swelling and pain.

Cartilage defects in the bone and loose bodies can also occur in any age group after an acute injury. In those cases, the bone may be fractured and the fracture fails to heal. In time, OCD fragments and traumatic loose bodies in any joint space grow in size. They grow because the joint fluid nourishes the fragment from all sides and before the injury it only was nourished from one side. The fragment enlarges enough to cause recurrent locking and the most common symptoms of a locking loose fragment of cartilage are pain joint and swelling.

OCD, a traumatic bone defect or a loose body can be diagnosed using special X-Ray images. An MRI may better define the lesion and help in surgical planning when the fragment is partially detached.

Not every OCD lesion requires surgery, in a growing child, an early lesion, that is still in its bed and not detached, may heal with crutches, non-weight bearing, and complete rest in a cast or brace. If the defect is displaced or loose and/or an MRI shows fluid under it, surgery is required to put back the piece or graft the defect in the bone. Still, if the symptoms from a cartilage defect are ignored and spontaneous healing doesn’t occur, cartilage and its base eventually separate from the bone and a fragment breaks loose into the knee joint. Fragments that cannot be mended are removed. This leaves a defect or a hole that needs repair.

If surgical intervention is necessary and the cartilage fragments have not broken loose, the surgeon may fix them in place using special pins or screws that are sunk into the cartilage. In general, these dissolving (bioabsorbable) pins do not need to be taken out once the bone heals. If fragments are loose, the surgeon may clean the cavity to reach fresh healthy bone. At the same time the base can be drilled to stimulate growth of a new blood supply to the damaged bone. Damaged fragments that cannot be repaired can be removed to stop the locking and the base can be cleaned and drilled to stimulate new growth of cartilage. This method of repair is often called “micro-fracture.” In the microfracture technique, the surface is drilled or “cracked” with a microscopic drill or awl to help blood and marrow get to the surface. Just like aerating the soil before seeding the lawn, the idea is to promote the formation of new fibro-cartilage. The new cartilage would then cover the surface with fresh tissue. This works nicely for many small defects but not well for larger ones. Occasionally, newer graft materials, or cartilage transplantation can be used to fill larger defects.

Shallow Cartilage Defects without bone loss is different from OCD lesions and can be caused by wear and tear or arthritis. These also can be treated by the micro- fracture technique.

knee-cartilage-diagram.jpg

In summary: Small defects can be treated with the micro-fracture technique, but larger ones require grafting. Loose bodies that cannot be replaced need to be removed. The defects need to be cleaned, drilled, repaired or grafted. Grafts can be obtained through autograft (transplanting cartilage from one part of the knee to another), allograft (frozen grafts from a donor), cultured cartilage or sterile preserved cartilage grafts and/or synthetic bone substitute that fills in over time with the patient's own cells.

For all of the repairs, the full healing process takes time. You may be asked to use crutches and a brace to protect the knee from impact load (often the original cause of the problem) which lets the body do the hard work of healing these defects. At first you may be in a knee immobilizer, a straight brace with Velcro straps. This allows you to protect that repair and still place a little weight on the leg for balance while using crutches. After the initial healing phase, 3-4 weeks, a knee hinge brace is often used to continue the protection of the healing cartilage for the first 3-4 months after surgery. A brace would be needed for heavier activities for up to one year after surgery in almost all cases. Sometimes in patients with heavier demands (bowed legs or a large defect), a specially made unloader brace will be used to allow for a return to activity while the graft incorporates and the new cartilage grows.

OCD Recovery Plan and Post-Operative Instructions

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.

Lungs: After surgery, you are encouraged to deep breathe and cough frequently (at least 3-4 times per day.) This will reduce mucous from building up in your lungs and will reduce the risk of developing a post anesthetic pneumonia.

Stop smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body's white blood cells.

Pain Control: Take pain medications as prescribed by Dr. Reznik. Please call our office with any questions regarding your medications. Ice as needed (never place ice directly on skin) and elevate leg above heart level using 2-3 pillows. This will also decrease swelling.

Dressing: The dressing is to remain clean and dry. After 48 hours, you may remove all dressings. You may shower today.

Pat the incisions dry, don't rub the scabs off. Cover each incision with a plan Band-Aid. Do not use creams or ointments on the incisions.

Driving: Right knee patients and left knee patients with a standard transmission car cannot drive until off all pain meds and can fully weight bear without pain.

Crutches: You must use crutches for at least the first three weeks. After that, you will be fitted with a hinged knee brace in our office. Once in the knee hinged brace or custom unloader brace; you can advance to one crutch as comfort allows. Most patients are off crutches completely and in a protective brace by 6 weeks.

call-physician.jpgReturn to Work: People with light work (desk work with no squatting, lifting or kneeling) can return to work within a week. Patients with active office work or very light labor with variable tasks can sometimes go back to work at two or three weeks, depending on lifting requirements. Heavy work, (lifting or unprotected heights) cannot usually return before 6 weeks. Most will need to be cleared by their physical therapist. The exception is for people who may have long commutes. By staying still for too long after surgery or with the leg down for long periods, the blood flow slows and that increases your risk of a blood clot (DVT or Deep Vein Thrombosis).

Blood Clots: Those at high risk of blood clots (DVT) include patients who have long car or train commutes, may be overweight (BMI >30)*, have a history of cancer, women on birth control pills or males over the age of 40. These patients should be taking an aspirin per day (unless allergic) for about 6 weeks depending on risk factors. Doing the exercises Dr. Reznik prescribed will also reduce the risk of blood clots.

*BMI or body mass index is a number calculated from a person's weight and height. BMI provides a reliable indicator of body composition. This index is used to screen for weight categories that may lead to health problems.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take aspirin unless allergic.

Dental Work: If you have any graft or implant in place, you cannot have any dental work (except for an emergency or to clear an infection) for at least three months following surgery. This includes all types of dental cleanings. The dental work can cause bacteria to get into the blood and infect the graft.

Any time that you have dental work, including any dental emergency, you will need an antibiotic for the first full year following your surgery.

Post-Operative Exercises

You will start doing exercises while still in the recovery room.

While resting in bed after surgery, do the following every hour:

Ankle Pumps: Pump your ankle up and down for 1 minute (like pressing on the gas pedal). This will increase circulation and reduce the risk of developing a blood clot. Do this with both legs. These help to decrease swelling and the risk of blood clots. You cannot overdo ankle pumps.

Straight Leg Raise: Tighten your quads (muscle in the front of your thigh) with the knee immobilizer on, and raise you leg 8 to 12 inches off the bed. Do three sets of 8-10 reps, alternating sides.

Deep breathing: be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after an anesthetic.

Stop smoking: smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body’s white cells.

If you find yourself in bed or resting frequently, move you arms when in bed. You can use very light weights for upper arm exercises when in bed to keep your muscles ready for the demands of using crutches.

Add other exercises as your therapist prescribes.

Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

Chondrofix Osteochondral Allograft Clinical Study - Zimmer
Clavicle Fractures – Indications for Operative Treatment

Alan M. Reznik, M.D.

Believe it or not, the clavicle is the only true bone connection between the entire arm and the rest of your skeleton. You may wonder how this is possible since your shoulder and arm seem to be directly connected to your body. To understand this better, think of how far your arm and shoulder can move. Think of how you can touch the middle of your back, your toes and the back of your head. Try this yourself and feel your shoulder blade move on your back. Feeling its movement, you can tell it is not attached directly to the chest. It rides both up and down and in and out over the ribs, controlled by an amazing group of muscles.

Now, feel your collarbone (clavicle) as you move. It is attached to the shoulder blade through a small joint near the top outer tip of the blade, just next to where the deltoid muscle (the largest muscle in your shoulder) attaches. If you follow the collarbone with your finger back towards the center of your body, you will find it attaches to the upper part of your sternum. That joint, the sternal-clavicular joint, is the only point where your whole arm attaches to the rest of the skeleton. It's hard to believe! But, because of this single attachment, the arm and shoulder are allowed a good deal of freedom in their movement. Because the shoulder is attached at one point near the middle of the upper chest, to a bone that's shaped like a thin stick, you can touch almost any part of the rest of your body with little difficulty.

Understanding that the shoulder is attached to the body only through the collarbone helps to explain why the clavicle is frequently fractured (broken) when we fall. Its thin, long shape also explains why it fractures with a direct blow, as in a football tackle. Since it is connecting the body and the arm, it can break if the arm is used as protection during a fall. It is also frequently injured during falls off of a bike or motorcycle accidents.

The clavicle typically breaks in the middle. These breaks can be simple (just two pieces with little displacement) or complex (many pieces and/or displaced). They can be closed (not breaking the skin) or open (breaking through the skin). It can also break near either end. When it breaks, the acromioclavicular (AC) joint or supporting ligaments could also be involved. The injury can occur in young children, teenagers and active adults. The location of the fracture, the angulation, the displacement, the skin status and the age of the patient are all important in considering treatment.

Treatment for Clavicle Fractures

In young children, the fracture ends are often close, and there may be a lot of deformity of the bone. In growing children, the bones will heal even with a lot of displacement or angulation. In general, many simple fractures can be treated with a sling until the fracture starts to mend (or as we often say, gets sticky). A lump may appear as it heals. Then some arm movement will be permitted. When X-rays show good healing, the patient can gradually resume activities. In time, and with proper treatment, the lump of new bone that first appears will remodel itself back to the shape of the smooth bone. When the fracture is more complex or other structures are involved, surgery can be necessary.

Indications for Operative Treatment of Clavicle Fractures

In general, clavicle fractures in children are treated in a sling. However, there are exceptions: fractures that break through the skin (open fractures), fractures that threaten to break the skin by the nature of their sharp bone ends and how much they tent the skin, fractures with muscles trapped between the bone ends and fractures that cause nerve compression. If any of the above is true, the fracture should be surgically repaired. The same is true in adults except adults heal more slowly and less reliably. Also, in children, the fracture “remodels” as the child grows so the deformity we can expect to heal and remodel back to the normal clavicle shape increases with decreasing age. In other words, the younger the child the more deformity we can accept for an excellent outcome.

There are a few additional considerations for adult patients. One significant factor is the shortening of the fracture. “Shortening” means that the bone is overlapped more that 2 cm or is 2 cm shorter than normal. In those cases, it should be fixed. Other doctors would add that if it is angulated more than 45 degrees, and, if the shortening is in the dominant arm or in a throwing athlete, no more than 1 cm of shortening can be accepted. In any case, patients with deformity, muscle trapped between the fragments or the other factors noted already also require an open reduction and internal fixation.

Fractures near the acromioclavicular (AC) joint or the outer end of the clavicle may require special care. The fractures that are lateral (away from the neck) to the coracoclavicular ligaments seem to heal well if the ligaments are intact. If the ligaments are torn or the fracture is medial (closer to the neck) to at least one of the two coraco-clavicular alignments, there is a high rate of non-healing (or non-union). These need to be fixed, and if the lateral fragment is small, the challenge is to hold them in place until they heal. Some of these fragments are small and involve the AC joint. When that occurs and the ligaments are torn, removing the fragments and reconstructing the ligaments may be the only viable choice. Newer plates were invented in an effort to solve this complex problem with better results. Once the fracture heals, this special plate may be removed. The distal (most lateral) fractures in children may be growth plate injuries and also need to be fixed.

Fractures of the mid-third of the clavicle do well with non-operative treatment, except for those in which the fracture is displaced posteriorly. That type of fracture can place pressure on major blood vessels and nerves that are just behind the clavicle in this location. In those cases, an open reduction and fixation are needed.

Surgical Fixation of a Displaced Fracture of the Clavicle

The photos are presented here are of a surgery performed by Dr. Reznik with the explicit permission of Dr. Reznik’s patient. They are for education purposes only.
(Warning: these are real photos from an actual surgical procedure performed by Dr. Reznik. Do not view if you are averse to seeing surgery photos of a live patient!)

The images cannot be reproduced or modified for any use without specific written permission in advance. All rights are reserved.

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Figure 1: Comminuted fracture of the left clavicle

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Figure 2: X-ray of a right clavicle fracture reduced with plate 

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Figure 3: Simple right clavicle fracture with shortening 

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Figure 4: Surgical Approach

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Figure 5: Medial fracture fragment 

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Figure 6: Lateral fracture fragment 

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Figure 7: Fracture reduced

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Figure 8: Plate in position

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Figure 9: Holes being drilled

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Figure 10: Screws being placed

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Figure 11: Screws being placed 

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Figure 12: Tightening screws 

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Figure 13: Plate in place with screws

After the repair most patients are much more comfortable than before the broken bones are stabilized by the plate. A sling is used for to protect the arm after the surgery and although the bone is held in place by the plate the bone does not heal for some time. You can start to use the hand for simple activities but not for lifting, pushing (sorry no pushups) or pulling for 3-4 months.

Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

Frozen Shoulder- Treatment Options (Conservative /Surgical) with Post Op Surg Instructions

Alan M. Reznik, M.D., MBA

An Inflamed Shoulder Capsule

inflamed-shoulder-capsule.jpgA “Frozen shoulder,” is the common term used for the medical condition called adhesive capsulitis. It is an inflammatory condition characterized by stiffness, pain and progressive loss of shoulder motion. It can be very “sneaky.” Many patients don’t notice the slow steady loss of motion. Sometimes the injury that starts the process is not even noticed or recalled. Then, with time, the motion is so restricted it prevents some activities of daily living. The pain, loss of motion and inability to reach behind the back or over head and get dressed often prompts an office consultation.

Your shoulder is a ball-and-socket joint. The round end of your upper arm bone (humerus) fits into a shallow groove on your shoulder blade (scapula) much like a golf ball rest on a tee. The muscles, ligaments and joint lining help increase the stability of this inherently unstable joint. The joint lining is made of connective tissue and is called the shoulder capsule. It surrounds the joint and plays an important role in stability while allowing movement. When the capsule becomes inflamed and the joint stiffens it can slowly “freeze.”

capsule-of-normal-shoulder.jpgWhen frozen shoulder occurs, the inflammation progressed and scar tissue may cause bands of tissue (adhesions) to develop between your tendons, bones and ligaments. The shoulder bones are unable to move freely within the joint. This loss can resolve with simple stretching or be progressive and slowly over time, decrease useful motion can. As a result, pain and significant loss of movement worsens. It can be a vicious cycle of pain - loss of motion- pain- more loss of motion and so on. In some cases, mobility may decrease so much that performing everyday activities such as combing your hair, brushing your teeth or reaching is difficult or even impossible.

Patients at risk of frozen shoulder include women over the age of 40 (frozen shoulders are twice as common in women as men), people with jobs that require repetitive motion, patients that have experienced prolonged immobility of their shoulder-perhaps due to trauma or hospitalization, and people with overuse injuries. It also can occur after the inflammation as a result of shoulder surgery, which is why early motion after shoulder surgery is so important. Diabetics are much more likely to have problems with their shoulders than others. In very rare cases a frozen shoulder can be the first “symptom” of new diabetes. Elevated blood sugars seem to affect the lining of the joint and make it more likely to freeze even after only minor trauma. Still, often, there is no known exact cause.

Treatment Options for Frozen Shoulder

The first treatment for frozen shoulder includes medications to reduce the inflammation and physical therapy. Physical therapy is key in stretching the joint lining and helping to restore motion and function. Sometimes muscle relaxers or medications that reduce nerve sensitivity are also used. Frequently a steroid injection is required to stop the inflammatory cycle that keeps the shoulder from improving.

If these treatments are not successful or if the condition is ignored too long, surgery may be required to restore motion. Surgery for a frozen shoulder involves manipulating the joint to release the scar tissue, removing the scar tissue and removing the adhesions from inside your shoulder. If there is an underlying condition at the root of the frozen shoulder like a rotator cuff tear, ligament injury or bone spurs, these can be treated at the same time to prevent recurrence of the shoulder problem. Dr Reznik performs this surgery through a fiber-optic scope using small incisions on an out-patient basis followed by starting ROM as soon as possible after the surgery and progressive physical therapy. This procedure has been shown to be very effective in restoring motion with a low risk of complications.

Recovery Plan: Post surgical instructions

Day 1: The Day of Surgery
Maintain dressing, add 4x4 bandages if needed for drainage through dressing. Apply ice pack for 20 minute periods throughout the day. You will start exercises in the recovery room. Remember: The key to keeping your motion is early movement! Use the good arm to help keep the injured arm moving.

Move your fingers and wrist often. Expect some swelling. If the color of your arm or hand changes, or sensation changes notify the physician. Start pendulum and wall walk (see list) exercises tonight.

Most patients find sleeping semi-upright the first few weeks after shoulder surgery is much more comfortable than sleeping flat.

Post Op Day 1: The same as day of surgery. Exercise: You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help to prevent blood clots. Once a day, in the shower, begin to flex and extend your elbow. (See list) Continue gripping exercises, and be sure to move your wrist and fingers frequently.
Your arm sling is for comfort only, use it only as needed and when in a crowded place (this will warn people to avoid your injured area). Do your elbow, wrist, and hand exercises at least three other times each day – 15 Reps. Some patients like to do them during commercial breaks when watching TV.

DAY 2 (48 hours post-operatively): Continue same activities including using ice for 20 min. periods as needed. Take your dressing off. Shower today; supporting the affected arm with the opposite hand. You may wash under the arm, but do not use a large amount of soap. Too much soap may dry out the skin and cause a rash. Move the arm freely in the shower. It is good to move it under the water. Don’t be afraid to do this, it will aid in your recovery. After your shower, dry the shoulder well and place Band-aids over incisions. Physical therapy usually begins today.

Physical Therapy

It is vital to your recovery of good shoulder function. A graduated activity and exercise program to increase muscle strength and motion is part of the post operative care.

Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program.

It is very important for you to start therapy when recommended.

To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

DAY 4 – 10: Change Band-aids daily or as needed. Do not use creams or antibiotic gels on the wounds the wounds. They heal faster when they can dry out and the scab can contract to close them. Maintain sling use for comfort. Continue with exercises as directed. Add biceps curls and increase the circle size when doing the Pendulum exercises. Ask your therapist for a home shoulder pulley set and start pulley exercises daily.

DAY 7 – 10: Visit with the doctor. Further instructions will be given to continue your rehabilitation and recovery. Depending on what type of surgery you had and you own recovery rate, physical therapy will start 3 days after surgery.

General Instructions for Adhesive Capsulitis (Frozen Shoulder)

Patients You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a non-spicy sandwich. If you become nauseated, return to clear liquids. You can also try Tum's, Zantac or Pepcid AC to help settle your stomach.

After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing pneumonia.

It is important to move arm and shoulder immediately after surgery to prevent refreezing.

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If you become nauseated, check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication. Moving the affected shoulder immediately after surgery is important to prevent “refreezing” of the joint. If pain is preventing movement, please call our office.

Driving: Patient cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Blood Clots: Patients at high risk for blood clots include:

  • Those with long car or train commutes
  • May be overweight: BMI>30 *BMI or Body Mass index is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body health for most people and is used to screen for weight categories that may lead to health problems.
  • Have a history of having cancer;
  • Females on birth control pills;
  • Males over the age of 40.

These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

Sling: Patients are to wear the sling as needed for comfort. It is recommended that patients wear the sling when going out. This will help to alert others to avoid the affected arm during this healing period. Move fingers and wrist often. Expect some swelling.

Dressing: The dressing is to remain clean and dry. After 48 hours you may remove the dressing but keep the small steri strips on. You may shower today and replace the dressing with Band-Aids.

Returning to Work: Patients with sedentary or low demand work can usually return to work within 7-10 days. They will still have restrictions on lifting (less than 5 pounds) repetitive and overhead use on the surgical side. Medium work that requires some light lifting will need at least 3-4 weeks. Patients with slightly higher demand jobs or infrequent repetitive arm use will need at least 6-8 weeks. Heavy laborers (patients with repetitive work, overhead work of any kind, such as manufacturing or construction work) may need a minimum of 3-4 months and possibly a work conditioning program prior to returning to work.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic) if you must fly.


Physical Therapy Reminder: Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help to prevent blood clots.

EXERCISES

Do as many times you can each day after surgery (at least three times a day.)

Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.

Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This rubbing you belly motion will decrease pain and prevent elbow stiffness.

Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable try it holding a very small can to start, in a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful, decrease or eliminate the weight.

Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.

 Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

Knee Arthroscopy - General

Alan M. Reznik, M.D.

Arthroscopy is a procedure that allows the doctor to inspect the inside of your knee with an arthroscope, which is a thin fiber optic scope. Surgery is performed with special instruments requiring only very small incisions while viewing through the scope. Remember, even though the incisions are small, surgery has been performed inside the knee joint. And though you may have the same incisions as another patient, you may have had a completely different injury and therefore a different operation and will have a different recovery plan. Therefore your recovery instruction will be tailored to your needs not someone else’s needs.

As with any arthroscopic surgery you should expect some mild post-operative discomfort that is typically a lot less than a more classic open surgery. There will be a local anesthetic in your knee after surgery and medication will be ordered to provide additional pain relief as needed. Don’t forget to take your pain medications the first day. They will help your recovery even if your knee feels “fine” right after the surgery. The local anesthesia will wear off and it is nice to have taken pain meds before it does. Taking the pain medications after the local wears off is always less effective.

knee-arthroscopy.jpg

You will be able to leave the hospital after you recover from anesthesia. You will need someone to drive you home from the hospital. Ice and elevation is important post op to keep the swelling down. Remember a less swollen knee is more comfortable and recovers more quickly. You may find crutch walking more comfortable for the first few weeks after surgery. Physical therapy will start three days after surgery, in most cases. You will be given a prescription at the time of your pre-op exam with Dr. Reznik.

The following are tips to help you be ready for your surgery:

Workman’s Compensation patients only: If your injury is covered by Worker’s Compensation, we must have written approval for your surgery. Please confirm this with Dr. Reznik's secretary before you do the following:

All patients are required to have current blood-work and a urinalysis done within 30 days prior to surgery. Our secretary will mail you the necessary requisition form to bring to the lab with you.

You may need to schedule a pre-op exam. In general, patients over age 50 or any patient with medical concerns need a physical exam with your primary care physician within 30 days of your surgery date. This may include a chest x-ray and EKG prior to surgery.Please check with Dr. Reznik or his nurse to see if this is required.

If a pre-op exam is needed and scheduled with your Primary Care Physician, please call Dr. Reznik's secretary, Theresa, at (203) 865-6784 ext. 327 to let her know the date and time of this appointment. She will then fax over the necessary paperwork to your Primary Care Physician, who will need to complete and return the paperwork to our office.

Our secretary will also give you your appointments for both your pre-op and post-op visits with Dr. Reznik. Your pre-op appointment with Dr. Reznik is usually scheduled for approximately one week prior to surgery. It is during this visit that Dr. Reznik will answer any questions you may have regarding your procedure and give you all the prescriptions you need following your surgery.
It is okay to fill your prescriptions prior to your surgery, BUT DO NOT START TAKING THEM UNTIL AFTER YOUR SURGERY.Your post-op visit will be scheduled for seven to ten days following your surgery.

Physical Therapy usually starts three or four days post-op unless otherwise indicated. You will also receive a prescription for this at your pre-op visit. Please be sure to schedule the first three to four therapy appointments while you are in the office for your pre-op appointment.

Pre-Operative Planning

Inform your family and friends about your upcoming surgery, should you need help during your recovery.

Plan and freeze meals in advance for your recovery time. Move scatter rugs out of walking areas to avoid tripping.

Have ice bags available. Gel ice packs work well also. A large bag of frozen peas or corn wrapped in a towel works well.

Have pillows available to elevate your leg as needed. Have appropriate footwear (Sneakers or comfortably fitting shoes).

Stop taking Herbal supplements, Aspirin and aspirin-like drugs such as: Advil, Motrin, Aleve, Daypro or Naprosyn, 7-10 days prior to surgery. *See our list of “medications to avoid 10 days prior to surgery”

The Day of Surgery

Do not eat or drink anything after midnight the night before surgery!! You may brush your teeth, provided you do not swallow ANY water. Remove all jewelry. Remove nail polish.

Have someone to drive you to and from the hospital. You will not be allowed to drive yourself home from your surgery.

Get your prescriptions filled before your surgery day but do not start to take until after your surgery.

Put crutches in the car.

Wear loose fitting, comfortable clothes to the hospital.

If you wear contact lenses, remove them and wear glasses to the hospital.

Post-Operative Instructions

Medications: Take your medications as prescribed after surgery. If you have questions regarding your medication, please call Dr. Reznik's office at (203)-865-6784.

Fluids: Drink plenty of fluids while you are taking pain medication as it can cause constipation; Increasing your fluid intake will help prevent this problem.

Dressing/Showering: The dressing is to remain clean and dry. After many arthroscopic procedures, you may remove the dressings and any small yellow Xeroform strips and shower after 48 hours. If little white tapes or "steri-strips" are on the incisions, leave them on and keep them dry, these will be removed along with any stitches you may have, at your first post-op visit. After a shower, pat the incisions dry, don't rub the scabs off. Cover each incision with a plan Band-Aid. Do not use creams or ointments on the incisions.

With some arthroscopic procedures, your 1 st dressing change will be at your first physical therapy appointment by the therapist and you may shower after that. Please check with Dr Reznik or his nurse to be sure when you should change your dressing and shower.

Ice: Use ice bags for 24-48 hours post-op to reduce pain and swelling. Alternate ice bag 20 minutes on and 10 minutes off. Always wrap ice in a towel or cloth, never place ice bag directly on skin as this can cause frostbite.

Elevation: When resting in bed after surgery place 2-3 pillows under effected leg and elevate slightly above heart level, this will help reduce swelling.

Blood Clots: Patients at high risk for blood clots include:

  • Those with long car or train commutes 
  • May be overweight (*BMI>30)
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40

These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

*BMI or body mass index is a number calculated from a person's weight and height. BMI provides a reliable indicator of body composition. The index is used to screen for weight categories that may lead to health problems: http://www.cdc.gov/nccdphp/dnpa/bmi/

Stop smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body's white blood cells.

Deep Breathing: Be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after anesthesia. Call Dr. Reznik immediately if you develop a fever, experience stomach upset, or notice excessive redness, warmth, or swelling at surgical site or if you have excessive bleeding or odorous drainage from surgical site.

Driving: You may not resume driving until you are off all pain meds, can place full weight on the leg without pain and are seen by the physician.

Copyright © 2011, AMReznik All rights reserved.
Revised 3/7/11

Labral Repair & Post-Op Instructions

Alan M. Reznik, M.D., MBA

Repairing Damage from Shoulder Joint Dislocation

The shoulder is the junction of three bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The shoulder joint is the result of the head of the humerus bone fitting in the cavity (glenoid cavity) of the shoulder blade. Like a golf ball sitting on a tee, it doesn’t take a lot to dislodge or dislocate the humeral head (Ball) from the glenoid (Tee).

dislocated-shoulder.jpgThe fragility of the shoulder is reinforced by a series of ligaments, and a rim of tissue that surrounds the cavity called the glenoid labrum. If excessive force is applied to the arm, the shoulder may become “dislocated,” that is, the head of the humerus may be forced out of the cavity and the supporting ligaments of the shoulder may be torn, displaced or stretched out of shape.

scapular.jpgWhen the shoulder dislocates, the smooth cartilage surface of the humerus (“ball”) slides over the rim of the glenoid portion of the scapula (the lip of the cup or golf tee). At the time of shoulder dislocation, or more often at the time of relocation, this can cause a complication and damage to the head of the humerus (the “ball” portion of the joint.) This occurs when the humeral head passes into, or out of, the socket as the ball is impinged against the sharp glenoid rim. The back of the ball can be fractured or dented just like a dent in your car after a fender bender. The dent from this injury is referred to as a “Hill Sachs Lesion.” An x-ray of a dislocated shoulder is shown below in figure 1a.

dislocated-shoulder-xray.jpg

An arthroscopic photo of the damage to the ball is shown below. The larger this dent is, the easier the shoulder will dislocate again. At the same time the ligaments in the front of the shoulder are avulsed or torn off the rim of the Glenoid (as shown in the drawing above). It is the combination of the dent size and ligament damage that is the true measure of future instability of the shoulder.

hill-sachs-lesion.jpg

A Bankhart procedure, Labral repair or Gleno-humeral ligament repair, are surgical techniques for the repair of the damage from a single or recurrent shoulder joint dislocations. In this procedure, the torn labrum (or lip of the socket) with the attached ligaments are reattached to the proper place in the shoulder joint. By re-attaching these ligaments and cartilage we can prevent future dislocations. With the proper tightening of the lining, the Hill Sachs Lesion (the dent) will not hit the rim with routine motion. The shoulder is made stable and the re-injury risk is greatly reduced by avoiding “dent/ rim” contact. Dr. Reznik does this repair through the arthroscope with sutures and tiny absorbable anchors. The goal is to restore normal function in a minimally invasive way as an out patient procedure. If the ligaments alone are torn or stretched and the labrum is still attached they can be repaired in a similar manor.

labral-tear.jpgFrequently the ligaments and the capsule lining are stretched out of shape. This may also cause instability, subluxation or recurrent dislocations. Many of these patients cannot work overhead or throw any object. They also have difficulty with overhead sports. When this occurs the loose capsule can be tightened at the same time the ligaments are repaired. This is referred to a “Capsular Shift” procedure.

Dr. Reznik also performs this surgery with a minimally invasive technique through an arthroscope (fiber optic scope) with little disruption to the other shoulder structures. The surgery is done on an out patient basis which allows patients to be home in a few hours instead of days. On rare occasions the dent is so large that is needs to be grafted. Arthroscopic assisted methods are available for this procedure as well.

arthroscope-1.jpgarthroscope-2.jpgarthroscope-3.jpg

Patient's Recovery Plan

The Day of Surgery

Maintain dressing. You may add 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. KEEP SLING ON AT ALL TIMES.

Move fingers and wrist often. Expect some swelling. If you have skin color changes or changes in sensation in your arm, notify the doctor. When sleeping, place 1 or 2 pillows under the operative side elbow to keep arm in place. Begin grip strengthening and wrist range of motion exercises tonight. (See exercise list below.)

Most patients find sleeping in a semi-upright position is more comfortable for the first few days after shoulder surgery. A reclining chair is often most comfortable.

Post-op Day 1: The Day after Surgery

Follow the same instructions as for the day of surgery noted above

Day 2: (48 hours post-operatively):

Remove the dressing. The Xeroform gauze strips (small yellow ‘tapes’) can be removed at the time of your first dressing change. You can shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below.) Support the affected arm with the opposite hand. You may wash under the arm, but do not use a large amount of soap. Too much soap may dry out the skin and cause a rash. After a short shower, dry the shoulder well. Pat the incisions dry, don’t rub the scabs off. Cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.

Resume same activities as surgical day; use ice for 20 min. periods as needed.

Exercise: Once a day, in the shower, you may begin to flex and extend your elbow, keep your arm close to your body, rub palm over stomach, keep palm facing inward. Do your elbow, wrist, and hand exercises at least 2 other times each day.

The arm sling must remain on at all other times, including bedtime.

Day 3 - 4: Start formal physical therapy program. Continue home exercise as listed below (adjust exercises as per therapist’s instructions.

Day 4 – 10: Change Band-aids daily or as needed. Maintain sling use. Continue exercises as directed under Day 3.

Day 7 – 10: The first post-op visit: see Dr Reznik in the office. He will review your surgery with you and further instructions will be given for your rehabilitation and recovery.

Exercises

Do three times each day as directed

Starting Day 1:
Hand Squeezes or Grip Strengthening: Using a small soft rubber ball or soft sponge, squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.
Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

On Day 3 add:
Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.

On Day 4 add:
Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day.

Not before Day 7-10 add:
Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk” the fingers of the affected hand up the wall as high as comfort allows. Mark the spot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Walk your finders down the wall as well as up. If you will have weakness on the way down, so use the other arm to help.

Important: Do not let the hand drop down from the wall—this will be painful and strain the repair.

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable, try it holding a very small can. In a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.

General Instructions for Labral Repair Patients

You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a non-spicy sandwich. If you become nauseated, return to clear liquids. You can also try Tums, Zantac or Pepcid AC to help settle your stomach. After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs and will reduce the risk of developing pneumonia.

Pain Control: Take medication as prescribed by Dr. Reznik. Do not take all your meds at the same time. Take anti-inflammatory medication with food to avoid stomach upset. Please call our office with any questions regarding your medication. After surgery, some patients will see some swelling. Use an ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed for comfort and to reduce swelling.

Blood Clots: Patients at high risk: These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

 

  • Those with long car or train commutes
  • May be overweight: BMI>30*
  • Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40 

 

  • (*BMI or Body Mass Index is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body composition. A muscle/ fat ratio if you will. The index is used to screen for weight categories that may lead to health problems.)

Sling: Patients are to wear the pillow sling at all times (including while at sleep) for the first 3 weeks. Then, it is recommended that patients wear the sling with the pillow removed when going out for the next 3 weeks. This will help to alert others to avoid the affected arm during this important healing period. Move fingers and wrist often. Expect some swelling.
Dressing: The Xeroform gauze strips (small yellow ‘tapes’) can be removed after 48 hours. At this time you may shower with the dressing off. Do the elbow exercises and shoulder pendulum motion in the shower (see the exercises below). Pat the incisions dry, using care not to rub the scabs off and cover each incision with a plain Band-Aid. Do not use and creams or ointments on the incisions.

Exercise: You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.
Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. It is very important for you to start therapy when recommended.

Physical Therapy: Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion. To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

Call the physician or go to the ER if:

  • You develop excessive, prolonged nausea or vomiting
  • You develop a fever above 101
  • You develop any type of rash
  • You experience calf pain

Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 – 3:00 position.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic.)

Returning to Work: Patients with a small tear, and/or low demand work, can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Any heavy labor with overhead lifting can take at least 4-6 months.

**Dental Work: You cannot have any routine dental work (including cleaning) for at least 3 months after your surgery, or you risk infecting the suture anchors. After 3 months, you may see the dentist, but for one year from date of surgery, you will need to take antibiotics before and after dental work. Call our office, and Dr. Reznik will give you a prescription.

Copyright © 2011, AMReznik. All rights reserved.
Revised 3/11/11

Lateral Release Surgery for Patellofemoral Problems

Alan M. Reznik, M.D.

cartilage-degenerates.jpgThe patella or kneecap is the moveable bone on the front of the knee. The patella is wrapped inside a large tendon that connects the large muscles on the front of the thigh, the quadriceps, to the lower leg bone. The underside of the patella is covered with articular cartilage, the smooth covering of joint surfaces. This slippery surface helps the patella glide in a special groove of the thigh bone or femur. Together the patella and the groove in the femur are called the patello-femoral mechanism.

Problems commonly develop when the patella suffers wear and tear and underlying cartilage begins to degenerate.

Degeneration may occur as part of the aging process or because of the way the patella moves through the groove in the femur. Remember, the quadriceps muscle controls the movement of the patella and if this muscle becomes weak for any reason an imbalance can occur which causes the patella to pull to one side more than the other. This places more pressure on one side of the underlying cartilage and can cause damage over time.

Patella Malalignment/Dislocation

patella-malalignment.jpg

The normal patella should track in the groove of the femur in a relatively straight manner, but sometimes the patella can slip out of place due to injury or congenital abnormalities in the shape of the knee. This slippage may be very minor, or you may actually see that the patella is in the wrong position. If it slips all the way out of position this is called dislocation. If it only partially slips this is called subluxation.

Sometimes the bands of tissue that hold your kneecap in place can become too tight on one side and pull the patella out of the groove in the femur. This causes pain on stairs, squatting, kneeling and getting out of a car. The pressure may cause softening of the knee cap surface (chondromalacia of the patella). If this occurs your physician may prescribe physical therapy exercises, orthotics and patella bracing or taping to correct the problem. If all of the conservative measures fail to help you, you may require surgery. The surgery is called Lateral Release and for the proper indications it can help reduce the pain dramatically. This procedure is done to allow the patella to shift back to a more normal position and relieve the pressure on the articular cartilage. In this operation, the tight ligaments on the outside of the patella are released to allow the patella to slide more towards the femoral groove. The arthroscopic procedure as routinely performed by Dr. Reznik can be seen on Dr Reznik’s YouTube channel at Youtube.com/DrAReznik.lateral-release.jpg

Lateral Release Recovery Plan

Pain Control: There will be Novocain in your knee. It will wear off and it is important to take you pain meds the first day even if you have no pain. Take pain medication as prescribed by Dr. Reznik. Please call our office with any questions regarding your medication Use ice as needed and elevate leg above heart level. This will decrease swelling and help with a common complaint of “throbbing” pain associated with a lateral release procedure.

Dressing and Bleeding: After a lateral release procedure, a moderate – large amount of blood tinged drainage post-op is not unusual. You may need to reinforce the dressing during the first 24 – 48 hours. Applying pressure to area will help reduce this drainage.

Crutches: Patients are to use two crutches for the first week, putting light weight on the operative leg with each step. Remember to put your foot flat on the ground even when lightly weight bearing. Increase the weight as tolerated. Advance to one crutch a few days and then a cane if needed. Most patients can be full weight bearing by the end of the first week.

Return to Work: People with light work (desk work with no squatting, lifting or kneeling) can return to work within a week. The exception is for people who may have long commutes. By staying still with the leg down for long periods, THEY ARE AT RISK FOR BLOOD CLOTS. Patients with active office work or very light labor with variable tasks can sometimes go back to work at two or three weeks, depending on lifting requirements. Heavy work, (lifting or unprotected heights) cannot usually return before 6 weeks. Most will need to be cleared by their physical therapist.

Driving: Right knee patients and left knee patients with a standard transmission car cannot drive until out of the knee immobilizer, off all pain meds and can fully weight bear without pain. Airplane Flights: You may fly 2-3 weeks after surgery on short flights (under 2 hours), 6-8 weeks for longer flights. You should also take an aspirin per day unless allergic. Call our office with any questions.

Blood Clots: Those at higher risk of blood clots include those patients who have sedentary life styles, long car or train commutes, have a history of prior cancer, women on birth control pills, may be overweight or males over the age of 40. These patients should be taking an at least a baby aspirin per day (unless allergic or sensitive). Doing the exercises (ankle pumps below), using aspirin and at times compressive stockings will also reduce the risk of blood clots. Patients who have a history of clots nin the past or three or more of the above risk factors should ask if they should be on a blood thinner post op for at least six weeks.

Call the Physician if:

  • You develop excessive, prolonged nausea or vomiting
  • Fever above 101.
  • You develop any type of rash
  • You experience calf pain

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the small risk of developing a post anesthetic pneumonia even further.

Dressing and Bleeding: After a lateral release, a moderate to amount of blood tinged drainage (mostly Novocaine used in the knee before during the procedure for post op pain control) is common. Sometimes this is brought on by the first few times the knee is bent or after the first few steps at home. You may need to reinforce the dressing during the first 24 – 48 hours. Applying pressure to area will help reduce this drainage.

dressing-drainage-lateral-release.jpg

Post-Operative Exercises: You will start these exercises while still in the recovery room. Then, while resting after the surgery, do the following:

ankle-pump.jpg

Ankle Pumps: Pump your ankle up and down for 1 minute (like pressing on the gas pedal). This will increase circulation and reduce the risk of developing a blood clot. If watching TV, do this during every commercial.

straight-leg-raises.jpg

Straight Leg Raise: Tighten your quads (muscle in the front of your thigh) with the knee immobilizer on and raise your leg 8 to 12 inches off the bed. Do at least three times a day.

Weight Bearing: You may start weight bearing that day of surgery with two crutches as pain allows. You should use two crutches for the first 3 days, then one crutch for 3-4 days and then a cane if needed. Most patients are free of crutches by their first post op visit with Dr. Reznik.

Copyright © 2011, AMReznik All rights reserved.
Revised 3/7/11

Medications to Avoid 10 days before your Surgery
  • Advil
  • Aleve
  • Alka-Seltzer Tablets
  • Alka-Seltzer Plus Cold Medicine
  • Anacin Capsules and Tablets
  • Anacin Maximum Strength Capsules and Tablets
  • APC Tablets
  • APC with codeine, Tablet Brand
  • Arthritis Formula by the makers of Anacin Tablets
  • Ascodeen – 30
  • Ascriptin
  • Aspirin
  • Aspergum
  • Aspirin Suppositories
  • Anaprox
  • Bayer Aspirin
  • Bayer Children's Chewable Aspirin
  • Bayer Children's Cold Tablets
  • Bayer Timed-Released Aspirin
  • BC Powders
  • Buff-a Comp Tablets
  • Buffadyne
  • Bufferin
  • Bufferin Feldene
  • Butalbital
  • Cama Inlay Tablets
  • Celebrex
  • Centrum Vitamins
  • Cetased, Improved
  • Cheracol Capsules
  • Clinoril
  • Congespirin
  • Cope
  • Coricidin D Decongestant Tablets
  • Coricidin for Children
  • Coricidin Medilets Tablets for Children
  • Coricidin Tablets
  • Darvon
  • Darvon with Aspirin
  • Darvon –N with Aspirin
  • Daypro
  • Dristan Decongestant/Tablets and Capsules
  • Duragesic
  • Ecotrin
  • Empirin
  • Empirin with Codeine
  • Emprazil Tablets
  • Emprazil – C Tablets
  • Equagisic
  • Excederin
  • Fiorinal with Codeine
  • Four (4) – Way Cold Tabletsv
  • Garlic
  • Gemnisyn
  • Goody's Headache Powders
  • Ginger
  • Ginko Biloba
  • Ibuprofen
  • Indocin
  • Measurin
  • Midol
  • Mobic
  • Momentum Muscular Backache Formula
  • Monacet with Codeine
  • Motrin
  • Naprosyn
  • Norgesic/Norgesic Forte
  • Norwich Aspirin
  • Pabirin Buffered Tablets
  • Panalgesic Percodan/Percodan Demi Tablets
  • Persistin
  • Plavix
  • Quiet World Analgesic/Sleeping Aid
  • Relafen
  • Robaxisal Tablets
  • Salsalate
  • SK-65 Compund
  • St. John's Wort
  • St. Joseph 's Aspirin for Children
  • Sine-Aid
  • Sine-Off Sinus Medicine/Aspirin Formula
  • Stendin
  • Stero-Darvon with Aspirin
  • Sulindac
  • Supac
  • Synalgos Capsules
  • Tolectin
  • Triamcinilin
  • Verin
  • Viromed Tablets
  • Vitamin E
  • Zorpin

****Please notify Dr. Reznik or his nurse of any and all medications that you are taking, including vitamins and herbal remedies.

Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

Patella Realignment

By Alan M. Reznik, M.D.

Tibial Tuberosity Transfer with Lateral Release

The knee is made of three bones, the kneecap (patella), the shin bone (tibia) and thigh bone (femur). To make the movement smooth and pain free, these bones are covered with a layer of cartilage on their contact surfaces. The patella is also held in place by a broad tendon and one of the largest muscles in the body. This tendon mechanism connects the thigh muscle (quadriceps) to the shin bone (tibia) just below the knee joint. The patella and patella tendon together with the quadriceps muscle are responsible for the ability to stand, walk, jump, kneel and navigate stairs. To do all of this, a normal functioning kneecap slides up and down a groove on the end of the femur as the knee bends. For stability, this groove (the patellofemoral articulation) is designed to guide the kneecap down the center of the knee joint and slide evenly within the groove.

knee-ligaments-patella.jpg
knee-cap.jpg

The groove varies in people, sometimes it is steep and in other people it is very shallow. The tendon can also be aligned to the inner or outer side of the knee. The ligaments on either side of the knee cap can be loose of tight. When the grove is shallow or the tendon is mal-aligned, the kneecap can jump over the edge of its groove. Occasionally this is worsened by a direct result of trauma or a sports injury. An injury of this type can weaken the soft tissue support for the knee cap in its grove and subluxation or dislocation can occur more easily. When this happens frequently, it causes pain and disability. In recurrent patella subluxation the patient complains of a sensation of knee cap dislocation or “giving way.” Sometimes the feeling is difficult to describe and it can be confusing since other knee problems (like ligament or cartilage tears) also cause the sense of giving way. Physical examination of the knee with the findings of pain along the outside or under the knee cap or mal-tracking of the patella with squatting bending or stairs can help make the correct diagnosis.

Treatment: In those patients where tightness of one part of the tendon over powers the other the patella tends to subluxate toward the tight side (it is almost always lateral tightness). When the diagnosis is clear, one type of surgery to improve alignment and stability involves using the arthroscopy to release the tight tissue on the outer side of the patella (a “lateral release.”) Releasing the tighter side often decreases the subluxation, reduces the pressure on the cartilage, decreases pain and improves function. Other patients have both tightness on the outer side of the knee and a mal-position of the tibial insertion of the patella tendon. The tendon mal-alignment also pulls the knee cap to one side. The distance between the center of the grove and the location of the tendon insertion on the tibia helps us to decide if this is an important factor in this problem. In those cases, moving the bony attachment point is the best way to control the kneecap’s position in its grove.

In the tibia tubercle realignment procedure (also known as a tibia tubercle transfer), the location at which the tendon attaches to the tibial tubercle (the bony prominence below the patella) is moved forward and toward the inner side. It is then held in place with two screws. The screws hold the bone in place while it heals and help the patient become active sooner. The procedure is done in a special way to avoid some of the pitfalls of older methods used to correct this problem. The end effect of this procedure is to hold the patella within its normal grove, correcting the tendency for it to slide out of position to the outer or lateral side with a quicker recovery than traditional corrections.

realignment-procedure.jpg

Dr. Reznik does this as a minimally invasive procedure using the arthroscope to prepare the knee and a smaller incision for the movement of the bone attachment. He does this as an out-patient procedure avoiding a hospital stay and allowing the patient to recover in the comfort of their own home.

Recovery Plan: Below are helpful tips when planning surgery and the recovery at home.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication. Use ice machine as directed and elevate leg above heart level. This will decrease swelling and help with a common complaint of “throbbing” pain associated with a tibial tuberosity, lateral release procedure.

Immobilizer: You will need a knee immobilizer for 2-3 weeks to protect the knee. When the knee is more stable you will change into a knee hinge brace. Most patients can start full weight bearing as symptoms allow after 3 weeks while wearing the hinge brace.

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If you become nauseated, check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids. Avoid grapefruit, tomato and orange juice since they have a high acid content.

knee-bandage-dressing-bleeding.jpgLungs: After surgery you are encouraged to deep breathe and cough frequently (at lease 3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the small risk of developing a post anesthetic pneumonia even further.

Dressing and Bleeding: After a tibial tuberosity transfer and a lateral release, a moderate to amount of blood tinged drainage (mostly Novocain used in the knee before during the procedure for post op pain control) is common. Sometimes this is brought on by the first few times the knee is bent or after the first few steps at home. You may need to reinforce the dressing during the first 24 – 48 hours. Applying pressure to area will help reduce this drainage.

Important Precautions with Ice Machine Use

  • Always keep a thin gauze or cloth between the skin and the cooling pad. Do not allow the pad to contact the skin directly as this may cause frostbite.
  • After the first dressing change, inspect the skin regularly and notify our office staff if there are any sign of changes in skin appearance or increasing redness.
  • Change the ice and water when you are unable to maintain a temperature of 48-52 degrees. Lower temperatures may damage the skin.

When you wake up in the recovery room, a long leg immobilizer and a cold pad wrapped in with an Ace bandage will be on the surgical leg connected to an ice machine. Using the ice machine will help you remain comfortable and will also aid in reducing the swelling. You should follow this schedule:

Day 1 and 2: Use the cooling machine most of the time (including throughout the night). Disconnect from the machine to the bathroom.

Day 3 and 4: At least 2 hours on and ½ hour off. You may find that the combination of 3 hours on and 3 hours off also works well. Start physical therapy.

Day 5 and after: Use as needed for comfort and swelling.

**Change the ice and water when you are unable to maintain a temperature of 50-52 degrees

Dressings: The first dressing change will be at your first therapy appointment, after that change you may shower. It is recommended to use an antibacterial soap. Do not remove the small white “steri-strips” and keep them dry; they will be removed, as well as any stitches, at your first post-op visit with Dr. Reznik. Gently bend your knee a few times while in the shower. After your shower place a small bandage over the front kneecap incision and Band-Aids over the other two incisions. When replacing the ice machine pad do not place directly on skin as this can cause frostbite. Wrap in a cloth or place between Ace bandages.

Crutches: Patients are to use two crutches for 7-10 days putting light weight on the foot with each step. Increase the weight as tolerated. After 10 days, most patients can advance to one crutch for short distances. After 3-4 weeks, once in the hinge brace, when you are able to fully bear weight comfortably, you may then advance to one crutch for the next few days and then to no crutches.

Return to Work: People with light work (desk work with no squatting, lifting or kneeling) can return to work in a week. The exception is for people who may have long commutes. By staying still with the leg down for long periods, THEY ARE AT RISK FOR BLOOD CLOTS. Patients with active office work or very light labor with variable tasks can sometimes go back to work at two or three weeks, depending on lifting requirements. Heavy work, (lifting or unprotected heights) cannot usually return before 6 weeks, most will need to be cleared by their physical therapist.

Blood Clots: Those at higher risk of blood clots include those patients who have sedentary life styles, long car or train commutes, have a history of prior cancer, women on birth control pills, may be overweight or males over the age of 40. These patients should be taking an at least a baby aspirin per day (unless allergic or sensitive). Doing the exercises (ankle pumps below), using aspirin and at times compressive stockings will also reduce the risk of blood clots. Patients who have a history of clots in the past or three or more of the above risk factors should ask if they should be on a blood thinner post op for at least six weeks.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours) but should wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic) Check with Dr Reznik if you have any questions before flying.

Dental Work: You CANNOT have any routine DENTAL WORK for at least 3 months after your surgery (including cleaning) or you risk infection. After 3 months you may see the dentist but you will need to take antibiotics before and after dental work for one year from date of surgery. If you need an emergency dental procedure make sure you tell you dentist you need protective “prophylactic” antibiotics before and after the procedure.

Remember Therapy is vital to your recovery of good knee function is a graduated activity and exercise program to increase muscle strength and knee motion. Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your knee rehabilitation program. It is VERY important for you to start therapy when recommended. To avoid complications, post-operative follow up appointments with your physician are also required to monitor your progress.

You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow in the surgical leg and help prevent blood clots. Formal physical therapy will begin between three to five days after surgery.

Post-Operative Exercises

You will start these exercises while still in the recovery room. Then, while resting after the surgery, do the following:

ankle-pumps-exercise.jpgAnkle Pumps:

Pump your ankle up and down for 1 minute (like pressing on the gas pedal). This will increase circulation and reduce the risk of developing a blood clot.straight-leg-raises.jpg

Straight Leg Raises:

Tighten your quads (muscle in the front of your thigh) with the knee immobilizer on and raise your leg 8 to 12 inches off the bed. At least three times a day as prescribed by Dr. Reznik. Please call out office with any questions regarding your medication. ice as directed. Elevate leg above heart level using 2-3 pillows. This will also decrease swelling.

Deep breathing: be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after an anesthetic.

Stop smoking: smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body’s white blood cells.

If you find yourself in bed or resting frequently: Move you arms when in bed. You can use very light weights for upper arm exercises when in bed to keep your muscles ready for the demands of using crutches.

 

Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

Partial Meniscectomy and Post Op Instructions

Alan M. Reznik, M.D.

What is a Meniscus?

The Medial and Lateral meniscal cartilages are gasket like cushions in the knee. Positioned between the femur and tibia, they distribute the weight transferred from the larger femur above to the smaller tibia below. The Menisci also help with the stability of the knee joint. Healthy Menisci convert the relatively flat tibial surface into a more stable shallow socket.

Why do They Tear?

meniscus-tear.jpgMeniscal tears can occur in any age group. In younger people, the meniscus is a fairly tough and rubbery structure. Tears in the meniscus usually occur as a result of a forceful twisting injury or with hyperflexion of the knee. In younger age groups, meniscal tears are more likely to be caused by a sports injury. In more mature individuals, it can occur with squatting down, twisting or a fall. In older individuals, the meniscus can be weaker and easier to tear. Sometimes meniscal tears can occur as a result of a minor injury, even from the up and down motion of simple squatting. Degenerative tears of the meniscus can also be seen as a part of osteoarthritis of the knee, gout and other arthritic conditions.

In many cases, there is no one associated injury that leads to a meniscal tear and knee pain is the most common complaint. The pain may be felt along the joint line where the meniscus is located. Sometimes the symptoms are vague and occasionally involve the whole knee. If the torn portion of the meniscus is large enough, locking may occur. Locking simply refers to the inability to fully straighten the knee or loss of the ability to move the knee. Locking occurs when a piece of torn cartilage, or meniscus, is stuck between the bones. In other words, the meniscus is caught in the hinge mechanism of the knee. Once stuck, it will not let the knee straighten out or move completely. (See Dr. Reznik's video, "The Locking Knee" on You Tube.) Left alone, over time the constant rubbing of the torn meniscus on the articular cartilage will cause damage or degeneration of the knee joint. As a result, the knee may also become swollen, stiff and tight.

 

Treatment: Partial Meniscectomy

Once a meniscus is torn, it won’t heal on its own. Surgery is required to either remove the
torn portion of the meniscus or repair the tear. Most often, with Arthroscopic surgery the
offending torn portions of the meniscus can be removed with special instruments. Repair
of the meniscus is not possible in all cases. In these cases, removal of the offending,
impinging fragments is necessary to return the knee to good function. Degenerative type
tears in older patients are frequently unrepairable. In these cases, arthroscopic removal of
the loose unrepairable fragments frequently resolves the problems caused by the tear.
Examples of tears that cannot be repaired are seen in images three, five, six, seven and
eight below.

types-tears.jpg

Partial Meniscectomy Recovery Plan

Diet: You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a sandwich. If you become nauseated, return to clear liquids.
Pain Control: Take pain medication as prescribed by Dr. Reznik. Please call our office with any questions regarding your medication. Ice as needed (never place ice directly on skin) and elevate leg above heart level using 2-3 pillows. This will also decrease swelling.

Dressing/Showering: The dressing is to remain clean and dry. After 48 hours, you may remove the dressings, leaving the small yellow zeroform "steri-strips" on if present. These will be removed along with any stitches you may have, at your first post-op visit. You may shower today. Pat the incisions dry, don't rub the scabs off. Cover each incision with a plain Band-Aid. Do not use creams or ointments on the incisions.

Stop smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body's white blood cells.

Deep Breathing: Be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after anesthesia.

Crutches: Partial meniscectomy patients usually need to use two crutches for only a few days. You should remember to put the involved foot flat on the ground, even when lightly weight bearing. Increase the weight on the foot as tolerated. You can advance to one crutch for the next few days and then a cane if needed. Most patients can be full weight bearing by the end of the first week.

Driving: Right knee patients and left knee patients with a standard transmission car cannot drive until off all pain meds and can fully weight bear without pain.

Return to Work: People with light work (desk work with no squatting, lifting or kneeling) can return to work within a week. The exception is for people who may have long commutes. By staying still with the leg down for long periods, THEY ARE AT RISK FOR BLOOD CLOTS. Patients with active office work or very light labor with variable tasks can sometimes go back to work at two or three weeks, depending on lifting requirements. Heavy work, (lifting or unprotected heights) cannot usually return before 6 weeks. Most will need to be cleared by their physical therapist.

Blood Clots: Those at higher risk of blood clots include patients who have long car or train commutes, may be overweight, and have a history of prior cancer, women on birth control pills or males over the age of 40.

These patients should be taking an at least a baby aspirin per day (unless allergic or sensitive).

Doing the exercises (ankle pumps below), using aspirin and at times compressive stockings will also reduce the risk of blood clots. Patients who have a history of clots in the past should ask if they should be on a blood thinner post op for at least six weeks.

Call the physician if:

  • You develop excessive, prolonged nausea or vomiting
  • Fever above 101.
  • You develop any type of rash
  • You experience calf pain

Post-Operative Exercises

Start doing exercises while still in the recovery room. Dr. Reznik or your nurse will instruct you on what to do. At home, while resting in bed after surgery do the following every hour or with each set of TV commercials.

ankle-pump.jpg

Ankle Pumps: Pump your ankle up and down for 1 minute (like pressing on the gas pedal). This will increase circulation and reduce the risk of developing a blood clot. If watching TV, do this during every commercial.

straight-leg-raises.jpg

Straight Leg Raise: Tighten your quads (muscle in the front of your thigh) with the knee immobilizer on and raise your leg 8 to 12 inches off the bed. Do at least three times a day.

3. Side raises: Laying on your side lift the leg 12- 24 inches off the bed. Start slowly working toward three sets of 8-12 by the end of the first two weeks.

4. Knee bends/heel slides: With your heel on the bed, bend your knee while sliding your heel toward you. Start with bending 30-45 degrees and work toward 90 degrees during the first week.

5. If you find yourself in bed or resting frequently, move your arms regularly. You can use weights for upper arm exercises to keep your muscles ready for the demands of using crutches.

6. Add other exercises as your therapist gives them to you.

Copyright © 2011, AMReznik All rights reserved.
Revised 4/18/11

Preoperative Instructions

Preoperative Instructions
Alan M. Reznik, M.D.

Schedule your pre-op clearance exam with your primary care physician if required. (If this is a Workman's compensation case, please wait for our office to obtain authorization.)

Call Dr Reznik's secretary with the date of your pre-op appointment so she may fax all appropriate paperwork. She will schedule your pre-op appointment with Dr Reznik one week prior to surgery and your post-op exam 7-10 after surgery.

Please let Dr. Reznik's nurse know if you are taking one of the following: Accutane, Coumadin, Plavix or other blood thinners, Insulin, hypertensive medications and/or seizure medications. Accutane patients will need blood tests pre operatively to check liver functions. Patie nts taking blood thinners will need to adjust or stop them to decrease intra operative bleeding. Heart valve replacement patients on Coumadin must switch to Lovenox 5 to 7 days preop. Hypertensive and seizure meds should be taken as directed.

Stop taking Herbal supplements, Aspirin, Advil, Motrin, Aleve, Daypro, Naprosyn and aspirin-like drugs 7-10 days prior to surgery. Please refer to list of "Medications not to take" prior to surgery.

Pre-Op Planning Tips

Inform your family and friends about your surgery, should you need help during your recovery.

Plan and freeze meals in advance for your recovery time.

Have ice bags available. A large bag of frozen peas or corn wrapped in a towel works well. Have pillows available to positioning and elevating the limb.

Get your post - op prescriptions filled before your surgery day

DO NOT START TAKING YOUR POST - OPERATIVE MEDICATIONS UNTIL AFTER THE SURGERY

Schedule your physical therapy appointments. Dr. Reznik will inform you when physical therapy should begin, usually the third day after surgery.

DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT THE NIGHT BEFORE SURGERY !!

The Morning of the Day of Surgery

You may brush your teeth, provided you do not swallow ANY water.

Remove all jewelry. Remove nail polish

Wear loose fitting, comfortable clothes to the hospital. If you wear contact lenses, remove them and wear glasses to the surgery center.

Copyright © 2011, AMReznik All rights reserved. Revised 3/7/11

Rotator Cuff Repair & Post-Op Instructions

Dr. Alan M. Reznik, M.D.

The rotator cuff is made up of four muscles and their tendons. The four muscles originate from the “wing bone” of the shoulder (the scapula) and together form a single tendon unit. This unit inserts on the upper humerus. It primarily helps to stabilize the ball of the shoulder within the joint, rotates the humerus and helps lift the arm. Rotator cuff tears are most common in people over the age of 40 who do repetitive overhead work, sports or weight training. It may also occur in younger patients following acute trauma or sports activity. Tears can be partial or full thickness. Partial tears can be within the tendon itself, on the upper or lower surface. Sometimes these partial tears are associated with calcium deposits; this is called calcific tendonitis.

Patients with rotator cuff tears usually experience loss of motion, weakness and pain. Night pain and pain with certain arm motions are typically the most difficult for a patient with a rotator cuff tear. Loss of sleep often affects daily life and inability to lift common items (like a container of milk) frequently brings the patient to the doctor.

normal-anatomy.jpgFigure 1: Normal anatomy of the shoulder

Treatment:When a rotator cuff tear is involving more that ½ the thickness of the tendon and/or the patient has failed conservative treatments, surgical repair is often the best option. Dr. Reznik performs this surgery through a fiber-optic scope using small incisions on an out patient basis. The type of repair and recovery depends on the size, shape and location of the tear. A partial tear may require only a trimming or smoothing procedure called a“debridement.”Removing thickened bursal tissues (bursitis) or calcium deposits may also help. When bone spurs are impinging on the tendon they can also be a source of pain and would be removed at the same time. A complete tear within the substance of the tendon is repaired by suturing the two sides of the tendon. If the tendon is torn from its insertion on the tuberosity of the humerus, it can be repaired directly to the bone using tiny suture anchors. The complication rate for arthroscopic repair is extremely low. For example the risk of infection for open surgery is near 1 in 100 were as in arthroscopic surgery it is less than 1 in 2000. Remember, the sutures hold the tendon in place while your body heals, so your post op activities and restrictions will depend on the type of tear you have.

Arthroscopic Repair The cuff is seen through arthroscopic cannula (Figure 1) and then the cuff can be cleared of scar tissue and debris (Figure 2). Once the repair site is ready an anchor is introduced and placed in the bone (Figures 3 and 4). With the suture firmly in the bone (Figure 5) the suture can be passed through the tendon (Figure 6) and tied in place. Pending the size of the tear, repeating these steps multiple times completes the repair (Figure 7).

cannula-placement.jpg
rotator-cuff-tear.jpg

Figure 1: Cannula placement Lateral shoulder.

Figure 2: Rotator cuff tear with exposed bone edge.

bone-anchor.jpg
placing-anchor.jpg

Figure 3: Introducing the Bone anchor.

Figure 4: Placing anchor in bone.

suture-passing.jpg
sutures-anchored.jpg

Figure 5: Sutures anchored to the bone.

Figure 6: Suture passing.

cuff-tear-sutured.jpgFigure 7: The cuff tear is sutured to the bone

General Instructions All Rotator Cuff Repair Patients:

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth adding crackers or toast, then a non-spicy sandwich. If you become nauseated,check to see if one of your medications is upsetting your stomach, most narcotics can. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.

Lungs: After surgery you are encouraged to deep breathe and cough frequently (at lease3-4 times per day). This will reduce mucous from building up in your lungs, and will reduce the risk of developing a post anesthetic pneumonia.

Pain Control: Take medication as prescribed by Dr Reznik. Please call our office with any questions regarding your medication.

Sling: Patients are to wear the pillow sling at all times for 3 weeks. Move fingers and wrist often. Expect some swelling. Use Ice pack for 20 minutes periods throughout the first 24 hours after surgery and then as needed. It is recommended that patients wear the sling with the pillow removed when going out for the next 3 weeks. .This will help to alert others to avoid the affected arm during this healing period.

Driving: Patients cannot drive until they are off all pain medications, completely out of the sling, and can easily place hands at 12:00 position on the steering wheel and can move hands freely from the 9:00 –3:00 position.

Airline Flights: Patients may fly 2-3 weeks after surgery on short flights (up to 2 hours)but should in general wait 6-8 weeks for longer flights. You should get up and walk frequently to avoid blood clots and take an aspirin (unless allergic).

Returning to Work: A patient with a small tear, and/or low demand work, can usually return to work within 3 weeks. They will still have restrictions on lifting and overhead use. Patients with higher demand jobs or repetitive arm use need at least 6 weeks. Any heavy labor with overhead lifting can take at least 4-6 months.

call-physician.jpgBlood Clots:

Patients at high risk for blood clots include:

  • Those with long car or train commutes
  • May be overweight Have a history of having cancer
  • Females on birth control pills
  • Males over the age of 40

These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin.

Physical Therapy:

Vital to your recovery of good shoulder function is a graduated activity and exercise program to increase muscle strength and motion.You will begin simple exercises the day of surgery. They should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots.

Your physical therapy will begin 3-4 days after surgery. The physical therapist will guide you in your shoulder rehabilitation program. And, it is very important for you to start therapy when recommended.

To avoid complications, postoperative follow up appointments with your physician are also required to monitor your progress.

Rotator Cuff Repair Recovery Plan:

Day 1: The Day of Surgery

Maintain dressing and 4x4 bandages if needed for drainage through dressing. Use ice pack for 20 minute periods throughout today. (Do not place ice directly on skin to avoid frostbite.) Keep pillow sling on at all times. Move fingers and wrist often. Expect some swelling, if you have any change in skin color or sensation in arm, notify our office.When sleeping, most patients find sleeping in a semi-upright position is more comfortable for the first few weeks after shoulder surgery. Begin hand squeezing and wrist range of motion exercises tonight. (See exercise list) The arm sling must remain on at all other times, including bedtime.

Day 2: The Day after Surgery Same as Day 1

Day 3: (usually about 48 hours after surgery)Continue same activities, including using ice for 20 minute periods as needed. You should remove your dressing. You may remove the sling to shower today, supporting the affected arm with the opposite hand. You may wash the skin around the incisions. When washing the under arm, do not use a large amount of soap. It may dry out the skin and cause a rash. After a short shower, dry the shoulder well and place Band-aids over incisions. You may begin elbow range of motion exercise today. Physical therapy will start today unless otherwise directed by Dr. Reznik. Add Biceps Curls to your home exercise program.

Days 7-10:

Change band-aids as daily as needed. Maintain sling use. Continue exercises, adding Wall Walking and Pendulum exercises.

The first Post-op visit: Usually after 7-10 days: Your sutures will be removed at this visit. Further instructions will be given to your rehabilitation and recovery. You may increase your biceps curls by add light weight only if comfortable.

Exercises: Do three times each day as directed

Starting Day 1:

Hand squeezes or grip strengthening: Using a small soft rubber ball or soft sponge,squeeze your hand. When in the shower, you can use a sponge filled with water. Do this for 3-5 sets of 10-20 repetitions each day. If this is too easy, later in the rehab course you can use a grip strengthener.

Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.

On Day 3 add:

Elbow Range of Motion: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows. This will decrease pain and prevent elbow stiffness.

On Day 4 add:

Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down. Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, then repeat for a total of 5 minutes, 3 times per day.

Not before Day 7-10 add:

Wall Walking: Stand facing a blank wall with your feet about 12 inches away. “Walk”the fingers of the affected hand up the wall as high as comfort allows. Mark the sot and try to go higher next time. Do at least 10 repetitions, 3 times per day. When more comfortable and stronger (not before three weeks) do these exercise sideways, with the affected side facing the wall. Do not let the hand drop down from the wall- walk your fingers down as well as up. Dropping the arm will strain the repair and be painful. If having weakness on the way down, feel free to use the other arm to help.

Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. When comfortable try it holding a very small can to start, in a few days you can increase can size only as comfort allows. This exercise should not be painful. If painful decrease or eliminate the weight.

Copyright © 2010, TOG All rights reserved. Revised 4/18/11

Shoulder Arthroscopy - General

General Shoulder Arthroscopy
Alan M. Reznik, M.D.
The Orthopaedic Group, LLC

shoulder-athroscopy.jpgArthroscopy is a procedure that allows the doctor to inspect the inside of your shoulder with an arthroscope, which is a thin fiber optic scope. Most shoulder problems that require surgery can be managed with special instruments requiring only very small incisions while viewing through the arthroscope. Keep in mind that though you may have the same incisions as another patient, you may have had a completely different injury and therefore a different operation and thus a different recovery plan. Therefore, your recovery plan will be tailored to your particular needs.

Remember, even though the incisions are small, surgery has been performed inside the shoulder. You should expect some post-operative discomfort which is typically a lot less than a more classic open surgery. There will be a local anesthetic in your shoulder after surgery and medication will be ordered to provide additional pain relief at home. Don’t forget to take your pain medications the first day even if your shoulder feels “fine”. The local anesthesia will wear off and it is nice to have taken pain meds before it does and will help in your recovery. Taking the pain medications after the local anesthesia wears off is always less effective.

You will be able to leave the hospital after you recover from anesthesia. You will need someone to drive you home from the hospital. Physical therapy will be ordered if necessary.

The following are tips to help you be ready for your surgery:

For workers compensation patients only: If your injury is covered by Worker’s Compensation, we must have written approval for your surgery. We must have written approval for your surgery. Please confirm this with Dr. Reznik's secretary before you do the following:

All Patients are required to have current blood-work and a urinalysis done with 30 days prior to your surgery date. Our secretary will mail you the necessary requisition form to bring to the lab with you.

You may need to schedule a pre-op exam. In general, patients over age 50 or any patient with medical concerns need a physical exam within 30 days prior to surgery. This may include a chest x-ray and EKG prior to surgery. Please check with Dr. Reznik or his nurse to see if this is required for you.

If a pre-op exam is needed and scheduled with your Primary Care Physician, please call Dr. Reznik's secretary, Theresa, at (203) 865-6784 to let her know the date and time of this appointment. She will then fax over the necessary paperwork your Primary Care Physician, who will need to complete and return the paperwork to our office.

Our secretary will also give you your appointments for both your pre-op and post-op visits with Dr. Reznik. Your pre-op appointment with Dr. Reznik is usually scheduled for approximately one week prior to surgery. It is during this visit that Dr. Reznik will answer any questions you may have regarding your procedure and give you all the prescriptions you need following your surgery. It is okay to fill your prescriptions prior to your surgery, BUT DO NOT START TAKING THEM UNTIL AFTER YOUR SURGERY. Your post-op visit will be scheduled for seven to ten days following your surgery.

Physical Therapy usually starts three or four days post-op unless otherwise indicated. You will also receive a prescription for this at your pre-op visit. Please be sure to schedule the first three to four therapy appointments while you are in the office for your pre-op appointment.

Pre-Operative Planning

Inform your family and friends about your surgery, should you need help during your recovery.

Plan and freeze meals in advance for your recovery time.

Have ice bags available. A large bag of frozen peas or corn wrapped in a towel works well. Gel ice packs work well also. Have pillows available to position the limb and elevate the arm as needed.

Stop taking Herbal supplements, Aspirin and aspirin-like drugs such as: Advil, Motrin, Aleve, Daypro or Naprosyn, 7-10 days prior to surgery. Refer to our list “Medications to avoid 10 days prior to surgery”.

The Day of Surgery

Do not eat or drink anything after midnight the night before surgery!

You may brush your teeth, provided you do not swallow ANY water. You may brush your teeth provided you do not swallow ANY water. Remove all jewelry. Remove nail polish.

Have someone to drive you to and from the hospital. You will not be allowed to drive yourself home from your surgery.

Get your prescriptions filled before your surgery day but do not start to take until after your surgery.

Put crutches in the car.

Wear loose fitting, comfortable clothes to the hospital.

If you wear contact lenses, remove them and wear glasses to the hospital.

Post-Operative Instructions

Medications: Take your medications as prescribed after surgery. If you have questions regarding your medication, please call Dr. Reznik's office at (203)-865-6784.

Fluids: Drink plenty of fluids while you are taking pain medication as it can cause constipation; Increasing your fluid intake will help prevent this problem.

Driving: You may not resume driving until you are seen by the physician. Dressing/Showering: The dressing is to remain clean and dry. After 48 hours, you may remove the dressings, leaving the small yellow Xeroform "steri-strips" on if present. These will be removed along with any stitches you may have, at your first post-op visit. You may shower today. Pat the incisions dry, don't rub the scabs off. Cover each incision with a plan Band-Aid. Do not use creams or ointments on the incisions.

Ice: Use ice bags for 24-48 hours post-op to reduce pain and swelling. Alternate ice bags 20 minutes on and 10 minutes off. Never place ice bag directly on skin as this can cause frostbite, always wrap ice in a towel.

Stop smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body's white blood cells.

Blood Clots: Patients at high risk for blood clots include:

  • Those with long car or train commutes
  • May be overweight (*BMI>30)
  • Have a history of cancer
  • Females on birth control pills
  • Males over the age of 40

These patients should be taking 1 aspirin per day for 6 weeks after surgery unless allergic to aspirin
*BMI or body mass index is a number calculated from a person’s weight and height. BMI provides a reliable indicator of body composition. The index is used to screen for weight categories that may lead to health problems: To determine your BMI: http:/www.cdc.gov/nccdphp/dnpa/bmi/

Deep Breathing: Be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after anesthesia.

Call Dr. Reznik immediately if you develop a fever, experience stomach upset, or notice excessive redness, warmth, or swelling at surgical site or if you have excessive bleeding or odorous drainage from surgical site.

When sleeping, place 1or 2 pillows under the operative side elbow to keep the arm in place. Some patients find it more comfortable to sleep in an upright position.

Copyright © 2011, AMReznik All rights reserved.
Revised 3/11/11

Tibial Plateau Fractures – Surgical Repair

Alan M. Reznik, M.D.

The knee has several weight bearing surfaces. The primary loads (weight) in the knee pass from the femur (thighbone) to the tibia (shinbone), with the curved surface of the femur resting on the relatively flat surface of the tibia. Like a mountain with a flat top, this flat surface is called the Tibial Plateau. This is a very sturdy surface, yet it is vulnerable to trauma and can break (fracture). The most common injuries result from a side blow to the knee. This can occur in sports, like skiing and football, or from trauma, like a fall or a car accident. The fracture below occurred when a large dog accidentally knocked its owner over from the side. The stress applied to the outer side of the knee can cause one of two injuries: rupture of the medial ligaments (medial collateral ligament sprain or tear) or collapse of the lateral plateau as seen here. You can imagine how the femur acts as a hammer as it hits the plateau in this type of injury.

There are many types of plateau fractures. These involve the outer (lateral) side, inner (medial) side or both sides (bi-condylar) of the plateau. If the surface is depressed or the sides of the bone are cracked, the plateau can no longer support the femur. This is made even worse if there is a ligament injury associated with the fracture. The unstable knee will be painful, unstable, swollen and often grossly deformed after the injury. The fracture can be detected by checking the medial and lateral stability of the knee, getting plain X-rays and performing CT scans (as in the CT generated image below in Fig 1). When there is instability during the exam or the fracture is significantly depressed (pushed down into the bone), it should be surgically repaired to preserve knee function.

A Coronal and Sagital CT Scan images of a Tibial Plateau Fracture (Below): This reconstructed image (made of many images reformatted by the computer) shows a lateral compression fracture through the lateral tibial plateau. The goal of treatment is to restore the height of the depressed fragment seen here.

side-view-fracture.jpg
front-view-lateral-fracture.jpg

Front view of laterally compressed fracture

Side, sagital, view of the same fracture

arthoscopic-fracture.jpg

Arthroscopic view of the same fracture

Note how the depressed tibial plateau is no longer supporting the lateral meniscus. This explains the lateral knee instability.

Treatment

Surgery is indicated when the surface is depressed or displaced significantly. Many years ago, up to one centimeter of displacement was accepted for surgery. Now, with CT scans and arthroscopic assisted techniques, no more than ½ a centimeter is accepted and, for some doctors, even less than that. If the plateau is injured and the fracture is depressed, the femur will “fall” into the defect, and the knee will be unstable in the direction of the fracture. Walking on the fracture will worsen the condition. Once the plateau is fractured, the patient should be braced or splinted and placed on crutches. A CT scan is used to “see” the displacement, the number of fractures and the location of the pieces. It can also aid in surgical planning if surgery is necessary. At the time of surgery, an open or arthroscopically assisted method may be used to reduce the fracture and re-align the joint. Bone graft, screws and/or a plate with screws will also be used to support the surface. Newer plates with “locking” screws have improved the strength of these repairs, and precontoured “anatomic” plates have also improved our ability to get a good reduction of the fracture with a better restoration of the normal anatomy. The case below shows the use of a pre-contoured locking plate. Remember that even with a perfect reduction, ideal plate fixation and bone grafting, we cannot undo the crushing injury to the cartilage surface at the time of the fracture. Many of the cartilage cells are killed in the initial blow to the knee, and that cannot be reversed.

intra-operative-xray.jpg
arthoscopic-reduced-fracture.jpg
plate-scope-fracture-pins.jpg

Intra-operative X-ray of the scope in place and a trial positioning of the plate with the bone elevated to its normal height.

An arthroscopic view of the reduced fracture while the plate and pins are placed. The meniscus is now supported by the bone below.

The plate is being placed in position, with the scope inside the knee checking the reduction. The fracture and the plate are being held with temporary pins before the screws are placed.

Intra-operative fluoroscopic X-rays:

lateral-incision.jpg
final-view-bone-graft.jpg
side-view-plate.jpg

Side view of the plate in place

Final view of the fracture reduced, the bone graft in place and the plate affixed to the bone with the locking screws to fully stabilize the fracture.

This is the final position of the plate in place with eight screws, as seen through the lateral “lazy S” incision. Four screws are holding the tibial plateau surface up; four are fixing the plate to the shaft of the tibia and the medial side of the knee.

Once the fracture is reduced and fixed in place with the plate and screws, the wound is closed, and the patient is placed in a straight knee brace to protect the knee. He or she may not fully weight-bear for at least 6 to 12 weeks post-operatively, depending on the nature of the fracture, depth of the defect, amount of bone graft used and the surgeon's assessment of the quality of the bone fixation.

Recovery Plan: General instructions for the procedure

Lungs: After surgery, you are encouraged to deep breathe and cough frequently (at least 3-4 times per day). This will reduce mucus from building up in your lungs and will reduce the risk of developing pneumonia.

You must stop all smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia by slowing your body's white cells.

Blood Clots: Those at higher risk of blood clots include those patients who have sedentary life styles, long car or train commutes, have a history of prior cancer, women on birth control pills, may be overweight or males over the age of 40. These patients should be taking an at least a baby aspirin per day (unless allergic or sensitive). Doing the exercises (ankle pumps below), using aspirin and at times compressive stockings will also reduce the risk of blood clots. Patients who have a history of clots in the past or three or more of the above risk factors should ask if they should be on a blood thinner post op for at least six weeks.

Diet: You may resume a regular diet when you return home. Most patients start with tea or broth, then crackers or toast and then a non-spicy sandwich. If you become nauseated, check to see if one of your medications is upsetting your stomach since most narcotics can have this effect. If your stomach feels acidy, try Tums, Zantac or Pepcid AC to settle it and drink some clear liquids.

Pain Control: Take medication as prescribed by Dr. Reznik. Please call our office with any questions regarding your medication. Use ice as needed (never place ice directly on skin). Elevate leg above heart level using 2-3 pillows. Elevating the leg decreases swelling and reduces most “throbbing” pain.

Note: Tibial plateau patients will have a cooling pad inside the dressing attached to an ice cooler (in the place of using ice packs) for additional pain control.

Remember to Call the Physician If: **You develop excessive, prolonged nausea or vomiting ** You have a fever above 101 degrees F **You develop any type of rash **You experience calf pain **There is excessive bleeding or unusual drainage from surgical site

 

Procedure Specific Post-Operative Care:

Tibial Fracture Patients are to use two crutches for 6 weeks, putting no weight on the foot for the first three weeks and only toe touch for the next three weeks. Then they can increase the weight bearing as tolerated with a knee brace on.

When you wake up in the recovery room, you will be in a long leg immobilizer and have a cold pad connected to an ice machine, wrapped in an Ace bandage on your surgical leg. The knee immobilizer is to be worn full time for six weeks to protect the knee. This includes during sleep. It is to be removed only for physical therapy and showers. When the knee is more stable, you will change into a knee hinged brace.

You may use the ice machine continuously (including throughout the night) the first 48 hours. To prevent frost bite, keep the temperature at 52 degrees Fahrenheit. You may disconnect the machine to go to the bathroom. At your first therapy appointment, the bandages will be changed.

Directions and Important Precautions with Ice Machine Use:

  • Always keep a thin gauze or cloth between the skin and the cooling pad. Do not allow the pad to contact the skin directly as this may cause frostbite.
  • After the first dressing change, inspect the skin regularly. Discontinue use and notify our office if any changes in skin appearance occur.
  • Change the ice and water when you are unable to maintain a temperature of 52 degrees Fahrenheit. Lower temperatures may damage the skin.

Dressing and Bleeding: After plating the fracture, a moderate amount of blood tinged drainage is common (it is mostly Novocain). Sometimes this is brought to the surface of the dressing by bending the first few times or the first few steps at home. You may need

Torn Meniscus – Repair and Post Op Instructions

Alan M. Reznik, M.D.

What is a Meniscus?

The Medial and Lateral meniscal cartilages are gasket like cushions in the knee. Positioned between the femur and tibia, they distribute the weight transferred from the larger femur above to the smaller tibia below. The Menisci also help with the stability of the knee joint. Healthy Menisci convert the relatively flat tibial surface into a more stable shallow socket

Why Do They Tear?

meniscus-tear.jpgMeniscal tears can occur in any age group. In younger people, the meniscus is a fairly tough and rubbery structure. Tears in the meniscus usually occur as a result of a forceful twisting injury or with hyperflexion of the knee. In younger age groups, meniscal tears are more likely to be caused by a sports injury. In more mature individuals, it can occur with squatting down, twisting or a fall. In older individuals, the meniscus can be weaker and easier to tear. Sometimes meniscal tears can occur as a result of a minor injury, even from the up and down motion of simple squatting. Degenerative tears of the meniscus can also be seen as a part of osteoarthritis of the knee, gout and other arthritic conditions.

In many cases, knee pain is the most common complaint and the patient cannot recall one clear associated injury that leads to the meniscus tear. The pain may be felt along the joint line where the meniscus is located. Sometimes the symptoms are much more vague and occasionally they involve the whole knee. If the torn portion of the meniscus is large enough, locking may occur. Locking simply refers to the inability to fully straighten the knee or loss of the ability to move the knee. Locking occurs when a piece of torn cartilage, or meniscus, is stuck between the bones (see the picture above). In other words, the meniscus is caught in the hinge mechanism of the knee. Once stuck, it will not let the knee straighten out or move completely. (To see Dr. Reznik's video, "The Locking Knee", go to Youtube.com/DrAReznik.)

Left alone, over time the locking and/or constant rubbing of the torn meniscus on the articular cartilage will cause damage or degeneration of the knee joint. As a result, the knee may also become swollen, stiff and tight.

Treatment: Meniscal Repair

Once a meniscus is torn, it won’t heal on its own. The tear can be treated safely with an Arthroscopic procedure that Dr. Reznik performs as an outpatient. It is often done under a light anesthetic with a local injection for post operative comfort. When the tear is repaired, Dr Reznik uses the arthroscope to place tiny sutures or stitches to fix the tear. Of the tears below the ones nearest the outer edge are more often repaired, depending on the overall condition of the cartilage. That is where the blood supply is best and the cartilage has the best chance of healing (the first, second and fourth images below). Radial tears (image eight below) can be repaired on rare occasions.

types-meniscal-tears.jpg

Meniscal Recovery Plan

Diet: You may resume a regular diet when you return home. Start with tea or broth and advance slowly with crackers or toast, then a sandwich. If you become nauseated, return to clear liquids.
Pain Control: Take pain medication as prescribed by Dr. Reznik. Please call our office with any questions regarding your medication. Ice as needed (never place ice directly on skin) and elevate leg above heart level using 2-3 pillows. This will also decrease swelling.

Stop smoking: Smoking slows the healing process by interfering with the making of new DNA. Smoking also increases the risk of infection and pneumonia after surgery by slowing your body's white blood cells.

Deep Breathing: Be sure to regularly take a deep breath and blow it out. This helps to clear the lungs after anesthesia.

Knee Immobilizer: Meniscal Repair patients are to wear the knee immobilizer full time for the first 3 weeks to protect the repair for the first phase of healing. This includes while you are sleeping. It is to be removed only for physical therapy directed exercises and showers.

Note: Patients should not flex the knee past 90 degrees for the first 3 weeks even if you therapist says it is okay. After 3 weeks, you will change from the immobilizer to a knee hinged brace. This is normally done by the physical therapist; if you or your therapist is unsure about what to use or when to change your brace call Dr. Reznik’s office. Under guidance, you can then start bending the knee from 90 degrees to a maximum of 120 degrees. When first switching to the knee hinge brace, you may need to use two crutches again for a short time to help with balance if needed.

Crutches: Patients are to use two crutches for the first week, putting light weight on the operative leg with each step with the immobilizer on. Remember to put the involved foot flat on the ground. Most patients can be fully weight bearing by the end of the first week while continuing to wear the immobilizer. After the first week, you may then increase weight as tolerated and advance to one crutch for a few days and then a cane if needed. Meniscus (cartilage) Repair patients cannot do twisting, pivoting, squatting, deep knee bends or impact activities for four months. It is vital that meniscus repair patients do not squat for at least four months after the repair.

Return to Work: People with light work (like desk or computer work with no squatting, lifting or kneeling) can return to work within a week to ten day with the brace on. The exception is for people who may have long commutes. By staying still with the leg down for long periods, increases the risk of a BLOOD CLOT in the leg. Patients with active office work or very light labor with variable tasks can sometimes go back to work at two or three weeks, depending on lifting requirements and if their employer will make accommodations for light duty. Heavy work, (lifting or unprotected heights) cannot usually return before 6 weeks. Most will need to be cleared by their physical therapist. The heaviest of labor, working in unprotected heights would naturally take longer. Driving: Right knee patients and left knee patients with a standard transmission car cannot drive until out of the knee immobilizer, off all pain meds and can fully weight bear without pain. Left knee surgery patients can drive after 3 weeks if they have no pain and you are off pain all pain medications comfortable walking without crutches.

Blood Clots: Those at higher risk of blood clots include those patients who have sedentary life styles, long car or train commutes, have a history of prior cancer, women on birth control pills, may be overweight or males over the age of 40. These patients should be taking an at least a baby aspirin per day (unless allergic or sensitive). Doing the exercises (ankle pumps below), using aspirin and at times compressive stockings will also reduce the risk of blood clots. Patients who have a history of clots in the past or three or more of the above risk factors should ask if they should be on a blood thinner post op for at least six weeks.

Call the Physician If:

  • You develop excessive, prolonged nausea or vomiting
  • Fever above 101
  • You develop any type of rash
  • You experience calf pain

Post-Operative Exercises: Start doing exercises while still in the recovery room. Dr. Reznik or your nurse will instruct you on what to do. At home, while resting in bed after surgery do the following every hour or with each set of TV commercials.

ankle-pump.jpg

Ankle Pumps: Pump your ankle up and down for 1 minute (like pressing on the gas pedal). This will increase circulation and reduce the risk of developing a blood clot. If watching TV, do this during every commercial.

straight-leg-raises.jpg

Straight Leg Raise: Tighten your quads (muscle in the front of your thigh) with the knee immobilizer on and raise your leg 8 to 12 inches off the bed. Do at least three times a day.

Add other exercises as your therapist gives them to you.

Knee bends/heel slides: With your heel on the bed, bend your knee while sliding your heel toward you. Start with bending 30-45 degrees and work toward 90 degrees during the first week.

If you are in bed for extended periods, move your arms regularly. Use light weights for upper arm exercises and keep muscle tone for using crutches.

Copyright © 2011, AMReznik All rights reserved.
Revised 3/7/11

Elbow-Arthroscopy Surgical Video