Rotator Cuff Repair: Difficult Post op

Patients

Derek Cuff, M.D.Suncoast Orthopaedic Surgery and Sports MedicineGulfcoast Orthopaedic Rehab Conference-August 22nd 2015

Goals

• Discuss potential problem patients

• Identify risk factors

Difficult Post Op Patient

• Post-op management very important

• Therapy vital component

• Deviation from post-op protocol can result in failures

Difficult Post op Patients

• Disregarding post op immobilization

• Not attending therapy sessions

• Not complying with post-operative restrictions

Difficult Post op Patients

• Causes of concern- RED FLAGS!!

– No sling at 6 week post op visit

– Showing me how proud they are of arm elevation at 6 weeks

– Early return to work

– Describing sporting activities

Difficult Post op Patients

• Disproportionate pain

– Excessive narcotic use

– Unable to comply with PT

– Failure to push themselves

– Often histrionic

Difficult Post op Patients

• Workers Compensation

–Many have secondary gain issues

–Not much incentive to improve

– Some don’t want to return to work

• “Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims”

• Cuff et al. JSES 2012

Difficult Post op Patients

• Study design

– 42 consecutive WC patients undergoing RTCR

– 50 control patients –Documented sling wear at follow up visits–Documented number of physical therapy

visits attended–Basically evaluating for non-compliance

with protocol

Results- Compliance

• 52% of Work Comp patients with documented episode of non-compliance

• 55% noncompliant to immobilizer• 45% noncompliant to PT• 36% noncompliant to both

• 4% of controls with documented episode

Results- ASES Score

ASES PRE ASES POST0

10

20

30

40

50

60

70

80

90

100

Non WCWC

Results- SST Score

SST PRE SST POST0

2

4

6

8

10

12

Non WCWC

Results- VAS Score

VAS PRE VAS POST0

1

2

3

4

5

6

7

8

9

10

Non WCWC

Difficult Post op Patients

• Not all Work Comp patients were non-compliant

– 52% were

– 48% were not

– There is a subset that wants to get better

Results- ASES Score

ASES PRE ASES POST0

10

20

30

40

50

60

70

80

90

100

Good WCBad WC

Results- SST Score

SST PRE SST POST0

2

4

6

8

10

12

Good WCBad WC

Results- VAS score

VAS PRE VAS POST0

1

2

3

4

5

6

7

8

9

10

Good WCBad WC

Difficult Post op Patients

• To summarize

–Work comp= high degree of noncompliance

–Not all bad

–Have to be careful and document everything

Difficult Post op Patients

• Post op pain after ARTC repair is common

• Challenge to both patient and surgeon

• Highly variable

• Multiple factors may be involved

• Evaluation of Factors Affecting Acute Post-operative Pain Levels after Arthroscopic Rotator Cuff Repair

• Purpose- Evaluate multiple pre-operative and operative factors that may be predictive of and correlate with acute post-operative pain levels after arthroscopic rotator cuff repair.

Materials and Methods

• 277 cuff repairs over study period

• 181 patients (101 males, 80 females)

• Avg. age 63.3

Materials and Methods

• Single shot interscalene block

• Hydrocodone 7.5/325 APAP 1-2 q 4-6 hours

• VAS scoring

• Pain score POD #1, #7 and #90.

Materials and Methods

• Pre-op factors evaluated

– Subjective pain tolerance (extremely high, above average, average, below average, extremely low)

– Pre op narcotic use– Smoking– Gender– Age– Preop VAS– Workers Comp

Materials and Methods

• Intra-op factors

– Tear size (partial, small, medium, large)

–Number of anchors used

–Repair technique (single row vs TOE)

Results

• #1 Factor affecting post op pain:

– Patients subjective pain tolerance

– Those patients rating themselves having “extremely high pain tolerance” had the highest correlation with elevated VAS on POD #1 and #7

Subjective Pain Tolerance

POD #1 POD #7 POD #900

1

2

3

4

5

6

7

8

9

10

Extremely High

Above Avg

Averge

Below Avg

Extremely Low

8.9

7.3

Results

• Other factors affecting post op pain

– Pre op narcotic use

– POD #1- 8.7

– POD #7- 6.1

Results

• Other factors affecting post op pain

– POD #7

– Smokers

– Younger decade of life

Results

• Factors that did not correlate:

– Tear size–# of anchors used–Work comp claims– Pre op VAS–Gender– Single or double row

Difficult Post op Patients

• Why did “extremely high pain tolerance” patients struggle?

– Ability of a patient to judge their pain tolerance not rooted in objective data or fact

– May have a disproportionate view of their ability to tolerate post-op pain

– Now a question on all my pre op assessments

Difficult Post op Patients

• Pre-op narcotic use

– At risk for hyperalgesia

– Consultation with pain management specialist pre-op for these patients

Difficult Post op Patients

• Beware of the patient who says:

– “Hey therapist, I just want you to know that I have a really high pain tolerance”

–Watch out for pre op narcotic users

– Smokers and younger patients as well

Summary

• You will encounter these patients

• Understand which may present a challenge helps

• Patient education helps

• Do your best to help them

THANK YOU