The $30 approach for optimizing perioperative nutrition for patients having shoulder surgery

50% of patients having rotator cuff repair, shoulder arthroplasty, and fracture surgery are deficient in Vitamin D. While 10% of patients having shoulder surgery are protein deficient before surgery, as many as 40% have insufficient protein reserve to mount the necessary healing response.  Insufficient Vitamin D and protein place the patient at increase risk for complications including delayed healing and infection.

For this reason we provide our patients scheduled for surgery with the following letter:

"Dear Patient

Good nutrition plays an important role in how your body heals after surgery. Unfortunately, many people don't get optimal levels of key nutrients through diet alone, especially during recovery from an operation when you need extra support.

To give your body the best chance to heal well, I recommend two simple supplements starting 2 weeks before your surgery and continuing for 4-6 weeks afterward:

Vitamin D: 4000 IU daily

Most people have low vitamin D levels, particularly in the Pacific Northwest. Vitamin D supports bone healing and may reduce infection risk. This dose is safe and well below levels that could cause any problems.

Protein Powder: 25-30 grams daily

Your body needs protein to heal surgical wounds, maintain muscle mass, and recover strength. A scoop of whey protein ensures you're getting enough even if your appetite is reduced after surgery. Use a plant-based alternative if you prefer.

You can find both supplements at any pharmacy or grocery store. Generic or store brands work fine—you don't need expensive formulations. The cost of this program is usually only $30 - a great investment in your recovery.

When to start: 2 weeks before surgery if possible

How long to continue: 4-6 weeks after surgery

If you have kidney disease, are on blood thinners, or have concerns about these supplements, please let me know.

Taking these simple steps won't guarantee a perfect outcome, but they address common nutritional gaps that can interfere with healing. Think of this as giving your body the raw materials it needs to do its job.

Please email me if you have any questions."

Thanks to Hafiz Kassam for making this plan doable for patients.

See also

The "Secret Sauce" for Optimizing Rotator Cuff Outcomes: Biologics or nutrition?

and

The "secret sauce" for optimizing arthroplasty outcomes: nutrition

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Coming of age as a shoulder surgeon

Thanks to Dr. Scott Sigman for this podcast.

https://www.youtube.com/watch?v=Jmo94BOB2lM

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Can Benzoyl Peroxide-Miconazole Nitrate cream reduce Cutibacterium in the deep tissues of the shoulder?

 Acne Cream Reduces the Deep Cutibacterium Acnes Tissue Load before Elective Open Shoulder Surgery: A Randomized-Controlled Pilot Trial

These authors point out that Cutibacterium is the main pathogen in periprosthetic shoulder infections (PSI) and that in acne vulgaris therapy, Benzoyl Peroxide and Miconazole Nitrate cream reduces the superficial Cutibacterium burden of the skin. 

The goal of their study was to investigate the efficacy of a topical acne vulgaris cream (Benzoyl Peroxide; Miconazole Nitrate - 50 mg/g BPO and 20 mg/g MN,) in reducing subcutaneous and capsular Cutibacterium in individuals with Cutibacterium skin colonization in open shoulder surgery.

They conducted a prospective randomized pilot trial, allocating 60 adult patients (1:1) between a 7-days-preoperative application of a commercial acne cream (Benzoyl Peroxide; Miconazole Nitrate) on the preoperative skin (intervention group) versus no cream (controls). The cost of one-week therapy with the cream was about $11.

One week before surgery, and before the first application of the cream, the superficial skin over the planned shoulder incision was swabbed (sample 1) for microbiological cultures. The same skin swabbing (sample 2) was repeated in the operating room immediately before disinfection with povidone-iode, isoprophyl-alcohol and ethanol. The perioperative antibiotic prophylaxis comprised cefuroxime 1.5g intravenously tid for 24 hours. During surgery, two deep intraoperative biopsies were obtained from the subcutaneous (sample 3) and capsular tissue (sample 4).

Sixty patients (mean age 59 years, 55% females) with primary open shoulder surgery were included. 

At baseline, Cutibacterium was present on the skin in 60% (18/30 in the intervention group; 19/30 in the controls. 

In these patients with Cutibacterium skin colonization, application of acne cream resulted in an apparent reduction of the number of positive intraoperative capsular samples (0/18 vs. 4/19). However two of our statistical colleagues pointed out that this study used the Chi Square test to consider the significance of this difference of p 0.04. The Chi Square test is not appropriate with a count of 0. A Fisher's exact test is more appropriate and yields a p value of 0.105, i.e. not significant. The intervention resulted in a significant reduction of the overall number of positive intraoperative samples compared to the control group (8/18 vs. 16/19; Fishers exact p=0.02).

One patient showed an adverse reaction to the cream and was excluded from the per-protocol analysis.

It is recognized that systemic antibiotics cannot eliminate Cutibacterium from shoulder surgical wounds and carry the risk of creating resistant germs. Standard preoperative skin preparation is also ineffective in eliminating Cutibacterium from shoulder surgical wounds.

Benzoyl Peroxide (BPO) is known to have a bactericidal effect on Cutibacterium, but carries the risk of skin irritation.  Miconazole Nitrate (MN) is an imidazole derivative that interferes with lipid synthesis and membrane permeability. The author suggest that the synergistic MN favors the penetration of BPO into the bacterial cells and ultimately supports a better tolerability of the topical combination therapy. See Efficacy and tolerance of a miconazole-benzoyl peroxide cream combination versus a benzoyl peroxide gel in the topical treatment of acne vulgaris, which concluded that this combination supports a better tolerability of BPO.

Further study will be needed to clarify the value of this combination of agents in reducing the load of Cutibacterium in the deep tissues of the shoulder,

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Complications of shoulder surgery.

This week provided a sobering reminder of the fact that shoulder surgery can be associated with major complications.

We were referred the following cases

1. Cutibacterium periprosthetic infection after shoulder arthroplasty

2. Secondary arthritis after a LaTarjet procedure

3. Secondary arthritis after shoulder repair using metal suture anchors placed on the glenoid articular surface.

4. Loose posteriorly augmented glenoid component.

5. Major brachial plexopathy after a reverse total shoulder.

6. Multiple failed attempts at arthroscopic rotator cuff repair leading to cuff tear arthropathy.

Comment: As we seek to improve the care of patients with shoulder disorders, we must thoroughly analyze such complications and from them learn how they can best be prevented.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Is topical Betadine effective in reducing Cutibacterium levels in open shoulder surgery?

Subcutaneous tissue disinfection significantly reduces Cutibacterium acnes burden in primary open shoulder surgery

These authors point out that Cutibacterium is one of the major pathogens responsible for infection after shoulder surgery and that surgical dissection of the dermis may expose Cutibacterium from sebum producing hair follicles. Because of contact with the surgeon’s gloves and instruments, further spread occurs throughout the surgical field. 

Their goal was to determine whether subcutaneous tissue application of povidone-iodine could reduce the Cutibacterium culture rate in primary open shoulder surgery through a deltopectoral approach.

108 patients were prospectively enrolled in a 2-arm, randomized, single-blinded clinical trial:treatment (n = 70) and control (n = 38). The 2 groups did not show any significant difference in terms of sex, age, body mass index, or occurrence of diabetes. 

In all patients, a skin swab of the operative field was taken prior to standard surgical skin preparation. After application of sterile drapes, the remaining skin was covered with an iodine-impregnated adhesive drape. A standardized deltopectoral approach was used. The skin and subcutaneous tissue were incised in 1 layer down to the deltopectoral muscle fascia using the ‘‘outside scalpel blade.’’ At this point, the intervention (disinfection) group exclusively received an additional preparation of the whole subcutaneous layer with povidone-iodine solution (Betadine). Only thereafter were retractors placed, and the dissection of the deltopectoral interval was carried out with the ‘‘inside scalpel blade.’ Once the proximal humerus was completely exposed, 5 swabs from different sites were taken for microbiological examination. All cultures were incubated in aerobic and anaerobic conditions for 14 days.

The subcutaneous application of Betadine significantly reduced the positive culture rate of the operating field for all germs combined (P .036) and specifically for C acnes (P  .013). The reduction of positive swabs for C acnes was significant for the surgeon’s gloves (P  .041), as well as the retractors (P  .007).

The treatment also changed the relative prominence of the different bacterial species. Of the 190 swabs sampled in the control group, 17 (9%) grew C acnes, 2 (1%) grew Cutibacterium avidum, 2 (1%) grew other commensal germs of the skin, 1 (0.5%) grew Staphylococcus epidermidis, 1 grew Escherichia coli, and 1 grew Micrococcus luteus. One swab showed positive findings for C acnes and E coli. 

Of the 350 swabs collected in the treatment group, 8 (2.3%) grew C acnes; 3 (0.9%) grew S epidermidis; 58 (1.4%) grew commensal skin flora; and 1 (0.3%) grew M luteus, Staphylococcus saccharolyticus, Staphylococcus hominis, and Streptococcus mitis. 

Comment: This is an interesting study suggesting the effectiveness of Betadine applied to the subcutaneous tissue in reducing the levels of Cutibacterium in open shoulder surgical wounds. It would be of interest to know the amount and concentration of Betadine that was used in the application and how it was applied. 

Surgeons often use Betadine lavage before prosthetic implantation, especially in patients deemed to be at high risk for periprosthetic infection. It that application, the wound is often lavaged with saline to prevent potential adverse reaction to the Betadine. These surgeons did not note adverse effects of their application.

It is clear that no approach has been shown to be completely effective in eliminating Cutibacterium from the surgical field. It is possible that multiple steps may reduce the size of the innoculum, including preoperative antibiotics, skin and subcutaneous preparation, Betadine lavage, avoiding contact of the prosthesis and sutures with the subcutaneous tissue, changing gloves before implantation, topical antibiotics and postoperative antibiotics. Determining the effectiveness of each of these steps in preventing periprosthetic infections is a difficult clinical research challenge indeed.

 How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Economics and shoulder surgery - how much will the sea change?

Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures

These authors note that low socioeconomic status and Medicaid insurance as a primary payer have been associated with major disparities in resource utilization and risk-adjusted outcomes for patients undergoing totaljoint arthroplasty.

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database they identified patients who were treated for proximal humeral fractures (PHFs) from 2002 to 2012.

In an effort to minimize confounding variables, each Medicaid patient was matched to a privately insured patient on the basis of gender, race, year of procedure, and age (but notably not to fracture type or type of treatment):

Of the 678,831 patients treated with PHF, 4.9% (33,263) had Medicaid as the primary payer during the 10-year period. Medicaid patients were found to have a significantly higher risk (P < .05) of postoperative in-hospital complications, including postoperative infection (odds ratio [OR], 2.00 [1.37-2.93]), wound complications (OR, 1.69 [1.04-2.75]), and acute respiratory distress syndrome (OR, 1.34 [1.15-1.59]).

They concluded that Medicaid patients have a significantly higher risk for certain postoperative hospital complications and consume more resources after treatment for PHFs.

Comment: It is apparent that our health care system is on the cusp of change with the new administration. Under most any system, however, the observation that Medicaid insurance (which provides relatively low reimbursement) can be a risk factor for an increased rate of complications and for increased per-case expense will continue to create an ethical, social and economic challenge for the providers. This is especially the case if there are penalties for the increased readmission rates that are likely to be necessary to manage the increased rate of complications. Our hope is that broad-based discussion will lead to a well-informed approach so that our patients can get the care they need.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Why are we prescribing so much narcotic medication after surgery?

A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines

These authors reviewed patients undergoing outpatient upper-extremity surgical procedures over a consecutive 6-month period with respect to patient demographic characteristics, surgical details, anesthesia type, and opioid prescription and consumption patterns. Their concern was that inadvertent overprescribing can lead to excess availability of opioids in the community for potential diversion.

They identified 1,416 patients with a mean age of 56 years (range, 18 to 93 years). Surgeons prescribed a mean total of 24 pills, and patients reported consuming a mean total of 8.1 pills, resulting in a utilization rate of 34%. 

Patients undergoing soft-tissue procedures reported requiring fewer opioids (5.1 pills for 2.2 days) compared with fracture surgical procedures (13.0 pills for 4.5 days) or joint procedures (14.5 pills for 5.0 days) (p < 0.001). 

Patients who underwent wrist surgical procedures required a mean number of 7.5 pills for 3.1 days and those who underwent hand surgical procedures required a mean number of 7.7 pills for 2.9 days, compared with patients who underwent forearm or elbow surgical procedures (11.1 pills) and those who underwent upper arm or shoulder surgical procedures (22.0 pills) (p < 0.01). 

Procedure type, anatomic location, anesthesia type, age, and type of insurance were also all significantly associated with reported opioid consumption (p < 0.001).

They concluded that patients are being prescribed approximately 3 times greater opioid medications than needed following upper-extremity surgical procedures. 

They recommend that surgeons consider some general guidelines for prescribing opioids postoperatively after outpatient upper extremity  

10 opioids for hand and wrist soft tissue surgical procedures, 

20 opioids for hand and wrist fracture or joint surgical procedures,

15 opioids for elbow and forearm soft-tissue surgical procedures, 

20 opioids for elbow and forearm fracture or joint surgical procedures, and

30 opioids for upper arm and shoulder surgical procedures.

Comment: We agree that there is a tendency to over use and over prescribe narcotics after surgery. This trend can be seen starting in the recovery room, where the patient is often asked to rate their pain on a 1-10 scale and then be administered narcotics even though they are tolerating the pain. Of course postoperative narcotics can lead to respiratory depression, urinary retention, confusion, unsteadiness, and the expectation that recovery from surgery will be 'painless'. This trend continues after discharge. We have found it preferable inform patients before surgery that we'll be prescribing minimal narcotics and only administer more if the patient finds that pain is substantial and interfering with their recovery. 

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Propionibacterium - it contaminates shoulder surgery in spite of skin preparation and antibiotics

Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics.

These authors studied 50 patients undergoing open shoulder surgery after receiving 2 g intravenous cefazolin 30 minutes before the skin incision. A wide range of shoulder surgeries were included, ranging from Latarjet to reverse total shoulder to AC joint reconstruction to fracture fixation.

The first swab was termed ‘‘pre-prep.’’ This was taken from the skin surface over the intended incision site, after administration of intravenous antibiotics but before skin preparation with ChloraPrep.

The skin was then prepared with 70% alcoholic chlorhexidine.

The second swab was termed ‘‘post-prep.’’ This was taken from the skin surface over the intended incision site, after skin preparation with ChloraPrep once it was dry.

The third swab was termed ‘‘dermal swab.’’ This was taken from the exposed dermal surface within the wound immediately after the skin had been incised.

A tissue biopsy specimen was termed ‘‘dermal biopsy.’’ This was a 3-mm to 5-mm specimen taken from the dermis within the wound using a fresh blade, skin hooks, and forceps were used to harvest the specimen.

Anaerobic cultures were observed for a minimum of 14 days. Colonies were identified as P acnes by matrix-assisted laser desorption/ionization–time-of-flight mass spectrometry.
P acnes was cultured in 21 of 50 prepreparation skin surface swabs (42%), 7 of 50 postpreparation skin surface swabs (14%), 26 of 50 dermal swabs (52%), and 20 of 50 dermal biopsy specimens (40%).  Twelve swabs were positive for an organism other than P acnes . In the pre-prep swabs, 8 Staphylococcus epidermidis , 1 S capitis , and 2 S aureus were cultured. S capitis was also cultured in a dermal swab in a patient who was positive for P acnes.

No difference was found in the incidence of P acnes according to the surgical approach (deltopectoral, posterior, superior, or deltoid split) performed.

Dermal biopsies were positive 6 of 9 revision surgeries vs 11 of 36 primary surgeries (p =1)

There was a significantly higher incidence of P acnes growth from the skin surface (P = .009) and dermis (P = .01) of patients aged ≤50 years old and a trend toward increased incidence of P acnes in men. 

P acnes growth from a prepreparation skin surface swab had a sensitivity of 69%, specificity of 88%, positive predictive value of 86%, and negative predictive value of 72% at predicting subsequent P acnes growth from the dermal swab or biopsy specimen.

Our summary of their data is shown below.

Comment: This is an important article in that it demonstrates a high degree of correlation between positive skin surface cultures and dermal cultures carefully harvested after antibiotic prophylaxis in patients having a variety of shoulder surgeries through different open approaches. Their findings are similar to those we presented for patient having primary arthroplasty, some of which had positive deep cultures for Propionibacterium despite preoperative antibiotics and in another publication that Propionibacterium persist in the dermis of normal volunteers despite skin surface preparation.

Taken together, these findings suggest that the dermis is often not sterilized by common antibiotics and surgical preparation and that the bacteria in the opened sebaceous glands can inoculate the wound after  skin incision, injection, or arthroscopic surgery.

These data suggest that preoperative epidermal skin swabs may be a way to identify individuals at higher risk for Propionibacterium infection.

Here is an article summarizing what we think we know about Propionibacterium.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Propionibacterium acnes in primary shoulder surgery - a surprising result

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

These authors assessed Propionibacterium in intraoperative samples of different tissue layers in 118 consecutive patients (mean age, 59.2 years; 75 men, 43 women) undergoing first-time shoulder surgery.
Patients in this study had either an anterolateral approach for open rotator cuff reconstruction/open subacromial decompression or a deltopectoral approach for shoulder arthroplasty or open anterior shoulder stabilization. Patients were excluded if they had tumors or systemic inflammatory diseases or if they had received systemic or topical antibiotics or anti-inflammatory medications within 6 months before surgery. Patients with subacromial injection before the surgery were identified.

Preoperative antibiotics were withheld until the final intraoperative sample was collected. Intraoperative samples were correlated to preoperative subacromial injection, the type of surgical approach, and gender. One skin, one superficial, one deep tissue, and one test sample were cultured for each patient.

Samples were cultured on Columbia agar, chocolate agar,Schaedler agar, and Schaedler kanamycin-vancomycin agar plates and inoculated in thioglycollate broth. Cultures were observed for 14 days.

The cultures were positive for P. acnes in 36.4% of cases. 35 of the 75 men were Propionibacterium–positive , while  8 of the 43 female patients were Propionibacterium–positive.

Subacromial injection was not associated with bacterial growth of Propionibacterium other bacteria. 

Skin samples were positive for Propionibacterium in 8.5%, superficial samples were positive in 7.6%, deep samples were positive in 13.6%, and both samples (superficial and deep) were positive in 15.3% of cases (P < .0001). 

Propionibacterium was detected in the anterolateral approach in 27.1% of cases and in the deltopectoral approach in 9.3% of cases.

Two patients in this study had a postoperative infection requiring revision surgery. During the revision, intraoperative samples confirmed the presence of Propionibacterium in both cases. The patients were both male and were positive for P. acnes in all tissue layers (skin, superficial, and deep) at the index operation.

One segment of the Discussion was of particular interest: " Our data demonstrate that P. acnes colonization of intraoperative samples is predominantly a male problem, confirming reports from shoulder revision surgery and topical skin testing. Men have more sebaceofollicular glands with a greater volume, resulting in a greater P. acnes load. A strong positive correlation has been reported between male sex, pore size, and sebum excretion.White men reportedly have a sebum average of 3 mg/cm2 of skin surface (with large interindividual variability), whereas white women have only 0.7 mg/cm." 

Comment: This is a very well done and important study. The authors were very careful with their methodology, even using test samples to check for contamination (none of the 118 were positive for Propionibacterium). 

Their results strongly suggest that primary surgical wounds are routinely contaminated with Propionibacterium,  most likely from the patient's own skin and that this contamination is not prevented by careful surgical preparation and draping. In view of the fact that Propionibacterium is adept at forming biofilms on implants and is known to be associated with delayed implant failure, three actions seem in order: (1) patients having shoulder surgery, especially males, need to be informed of the risk of Propionibacterium colonization,  (2) thorough irrigation and careful handling of implants should be exercised to reduce the effects of the contamination, and (3) infection with Propionibacterium should be suspected when  shoulder procedures are followed by unexpected pain, stiffness or component loosening, even if the onset of symptoms is delayed substantially beyond the index procedure.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Getting in shape for surgery - making shoulder surgery safer. A safety check list.

We have posted often on the "4 Ps" that contribute to the outcome of a shoulder surgery: the problem being treated, the characteristics of the patient having the procedure, the procedure itself and the physician performing the procedure.

Most shoulder surgery is elective; this means surgery should not be undertaken until everything is optimized. In this post we present the concept of "prehabilitation", that is, steps the patient can undertake before  surgery to make it safer and more effective.

Here is a 'risk calculator' which estimates the surgical risk related to some important characteristics of the patient. What is important to note is that the risk factors outlined here and elsewhere are, in many cases modifiable by the patient.

Here are some steps for the patient considering surgery that can reduce the risk of surgery. Consider it a 'pre flight check list'.

Habits:
__Engage in three hours of aerobic exercise per week if your primary care physician deems it safe.

__Avoid smoking or use of any nicotine-containing products for three months prior to surgery.

__Avoid any narcotic medications stronger than hydrocodone for three months prior to surgery. If heavier narcotics have been used, tapering off under physician supervision should be accomplished three months before the surgery.

__For three months before surgery, restrict alcohol consumption to one drink per day for women and two drinks per day for men

Planning:
__ A plan for patient care after discharge needs to be in place well in advance of surgery, recognizing that the shoulder may be less useful for a period after surgery than it was before. Understand the limitations on their activities after surgery, such as restrictions on driving, as well as the need for someone to be with you for days or weeks after the procedure. The need for a skilled nursing facility should be identified and discussed with your surgeon well in advance of the procedure. Some patients find that they are more comfortable sleeping in a recliner for several weeks after surgery; you may wish to consider having one available.

__Identify a primary care physician who can manage non-surgical concerns and medications after surgery.

__Understand and plan for the rehabilitation program after surgery as well as the plan for followup with the surgeon.

Physical and emotional health
__Optimize dental hygiene, including gum care. Dental concerns need to be tended to at least 2 weeks before surgery.

__Identify any skin lesions anywhere on the body, especially on the arm of the intended surgery. These need to be completely healed at least two weeks before surgery. Be particularly careful to check the skin in the arm pit and under the breasts.

__Assure that any infections are completely resolved and antibiotics discontinued at least 6 weeks prior to surgery.

__Optimize control of sleep apnea, anxiety, depression, diabetes, hypertension, heart conditions, as well as urinary tract function.

Communication with the surgical team
__Discuss the surgeon's personal experience with the problem and the procedure along with possible risks, alternatives and anticipated outcomes

__Notify the team if prior experience suggest that it will be difficult to establish an intravenous (IV) line for surgery or has been difficult for an anesthesiologist to establish an airway or if you have had any problems with prior anesthetics, or if it has been difficult to control your pain after surgery.

___Let the team know if you or any family member or blood relative ever had a serious problem with anesthesia, and if so, what was the problem?

__Discuss with the surgeon heart conditions, strokes, kidney disease, liver disease, lung disease, bleeding tendencies, prior surgical complications, reactions to anesthetics, seizures.

__Document and communicate all medical allergies, especially allergies to antibiotics and latex.

__Could you be pregnant? If so, we would recommend that you have a pregnancy test performed before coming for surgery, and if you are pregnant, that you not undergo elective surgery until after delivery.

__Compile and share complete list of all prescription and over-the-counter medications.

__Anti inflammatory medications and blood thinners ( for example, aspirin, Advil, Coumadin, Warfarin, Plavix, Ibuprofen) will increase the risk of bleeding and their use may need to be modified well in advance of surgery. If you are taking drugs to prevent blood clotting, you should consult with the pre-anesthesia clinic at least 10 days in advance to obtain instructions regarding when these medications need to be stopped, or modified.

__Identify and discuss any legal issues regarding the shoulder problem well in advance of surgery.

__Verify insurance coverage needs to be verified well in advance of surgery. This is especially important for patients living outside of Washington.
You may also be interested in the Strong for Surgery concept explained here.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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