Time to get my ducks in a row.

I now have a surgery date, June 17, 2014, a little more than two weeks. That seems like a long time but there are so many things to do. 

My orthopedic surgeon has ordered chest X-rays,  lab work including a MRSA screening (glad to see that), an EKG, a physical with my internist, an appointment with a specialist due to an old non-issue that has to be checked out, a class for people about to have joint replacement surgery (generally hip or knee but shoulders get thrown in there too) and a registration appointment with the hospital. I am sure I have forgotten to mention something.

On the home front, I need to get together appropriate post surgery clothing, rearrange outdoor potted plants so  it is convenient for someone else to water them, fill the freezer with precooked foods that are easy to nuke, grocery shop for canned soups, fruits and veggies, pull some weeds, fertilize some plants, get a haircut, probably color my hair, buy a pair of shoes with Velcro closures, do a thorough house cleaning (it might be a while), fill usual prescriptions so I don't run out at an inconvenient moment, pay bills, balance checkbook, locate living will, OH MY GOODNESS!

I asked Dr. Kai if I would be more handicapped after surgery than I was ten months ago when I fell and broke my arm. He wasn't definite but thought not. Well, I had no preparation then and somehow survived. Maybe I am being a little obsessive compulsive about my list of things to do. Perhaps all I really need is a great surgeon and a supportive family.

Is it worth having something really wrong to be able to say I was really right?

Before I saw my new doctor I didn't know what to hope for. Did I want him to back up my first orthopod and reassure me pain would lessen and range of motion would improve given enough time?Would an MRI and a CT scan vindicate me? Would I have documented evidence of my pain?  Or horrors, would they confirm an unspoken conviction that I was being a drama queen? The worst thing was that conviction was unspoken by me! What if I really was being a wimp about this?

Pain is such a subjective thing. Now everyone asks you to rank your pain on a scale from one to ten, ten being the worst. I hope I never experience the worst pain. Certainly I have not yet so how do I compare what I am experiencing to it? And it's really hard to conjure up past pain no matter how bad it was at the time. If we could, surely there would be no second babies conceived.

Research into classifying pain by facial expression has led to "The Painful Face-Pain Expression Recognition Using Active Appearance Models" study, using appropriately enough patients with rotator cuff injuries. While our physicians might have a hard time accurately interpreting our discomfort by a grimace, a squint or a scowl, a computer program will objectively assess our pain level based on a data bank of human pain expressions. Honestly, do I grit my teeth in pain more if someone is watching me try to hang up my bath towel?  When we call the boss to say we are sick and won't be in today don't we all try to sound just a little more pathetic? Would we be able to fool the software program as easily as we did our moms when we wanted to stay home from school?

I just know my arm hurts a lot less since Dr. Kai said he could now see why it hurts so much. Sympathy is a powerful force.

Willet

What is the plan of action? Copied from the AAOS website.

Reverse Total Shoulder Replacement

Every year, thousands of conventional total shoulder replacements are successfully done in the United States for patients with shoulder arthritis. This type of surgery, however, is not as beneficial for patients with large rotator cuff tears who have developed a complex type of shoulder arthritis called "cuff tear arthropathy." For these patients, conventional total shoulder replacement may result in pain and limited motion, and reverse total shoulder replacement may be an option.

Description

A conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic "cup" is fitted into the shoulder socket (glenoid), and a metal "ball" is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the humerus.

In a healthy shoulder, the "ball" of the humerus is held in the shoulder socket by several muscles and tendons, including the rotator cuff tendon.

A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles to move the arm. In a healthy shoulder, the rotator cuff muscles help position and power the arm during range of motion. A conventional replacement device also uses the rotator cuff muscles to function properly. In a patient with a large rotator cuff tear and cuff tear arthropathy, these muscles no longer function. The reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm.

(Left) Rotator cuff arthropathy. (Right) The reverse total shoulder replacement allows other muscles — such as the deltoid — to do the work of the damaged rotator cuff tendons.

This surgery was originally designed in the 1980s in Europe. The Food and Drug Administration (FDA) approved its use in the United States in 2003.

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Candidates for Surgery

Reverse total shoulder replacement may be recommended if you have:

• A completely torn rotator cuff that cannot be repaired
• Cuff tear arthropathy
• A previous shoulder replacement that was unsuccessful
• Severe shoulder pain and difficulty lifting your arm away from your side or over your head
• Tried other treatments, such as rest, medications, cortisone injections, and physical therapy, that have not relieved shoulder pain

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Preparing for Surgery

Your orthopaedic surgeon will help you plan and prepare for your shoulder surgery.

Medical Evaluation

Most patients must have a complete physical by their primary care doctor before surgery. This is needed to make sure you are healthy enough to have the surgery and complete the recovery. Many patients with chronic medical conditions, like heart disease, must also be evaluated by a specialist, such a cardiologist, before the surgery.

Medications

Be sure to talk to your orthopaedic surgeon about the medications you take. Some medications may need to be stopped before surgery. For example, the following over-the-counter medicines may cause excessive bleeding and should be stopped 2 weeks before surgery:

• Non-steroidal anti-inflammatory medications, such as aspirin, ibuprofen, and naproxen sodium
• Most arthritis medications

If you take blood thinners, either your primary care doctor or cardiologist will advise you about stopping these medications before surgery.

Home Planning

Making simple changes in your home before surgery can make your recovery period easier.

For the first several weeks after your surgery, it will be hard to reach high shelves and cupboards. Before your surgery, be sure to go through your home and place any items you may need afterwards on low shelves.
When you come home from the hospital, you will need help for a few weeks with some daily tasks like dressing, bathing, cooking, and laundry. If you will not have any support at home immediately after surgery, you may need a short stay in a rehabilitation facility until you become more independent.

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Your Surgery

Before Your Operation

Wear loose-fitting clothes and a button-front shirt when you go to the hospital for your surgery. After surgery, you will be wearing a sling and will have limited use of your arm.

You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be taken to the preoperative preparation area and will meet a doctor from the anesthesia department.

The components of a reverse total shoulder replacement include the metal ball that is screwed into the shoulder socket, and the plastic cup that is secured into the upper arm bone.

You, your anesthesiologist, and your surgeon will discuss the type of anesthesia to be used. You may be provided a general anesthetic (you are asleep for the entire operation), a regional anesthetic (you may be awake but have no feeling around the surgical area), or a combination of both types.

Surgical Procedure

This procedure to replace your shoulder joint with an artificial device usually takes about 2 hours.

Your surgeon will make an incision either on the front or the top of your shoulder. He or she will remove the damaged bone and then position the new components to restore function to your shoulder.

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Surgical Complications

Reverse total shoulder replacement is a highly technical procedure. Your surgeon will evaluate your particular situation carefully and discuss the risks of surgery with you.
Risks for any surgery include bleeding and infection. Complications specific to a total joint replacement include wear, loosening, or dislocation of the components. If any of these occur, the new shoulder joint may need to be revised, or re-operated on.

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Recovery

A typical follow-up x-ray of a reverse total shoulder replacement.

After surgery, your medical team will give you several doses of antibiotics to prevent infection, and pain medication to keep you comfortable. Most patients are able to eat solid food and get out of bed the day after surgery. You will most likely be able to go home on the second or third day after surgery.

Rehabilitation

When you leave the hospital, your arm will be in a sling. Your surgeon may instruct you to do gentle range of motion exercises to increase your mobility and endurance. A formal physical therapy program may also be recommended to strengthen your shoulder and improve flexibility.

You should be able to eat, dress, and groom yourself within a few weeks after surgery.
Your surgeon may ask you to return for office visits and x-rays in order to monitor your shoulder.

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Do's and Dont's After Surgery

• Do follow the home exercise program prescribed by your doctor.
• Do avoid extreme arm positions, such as behind your body or your arm straight out to the side for the first 6 weeks.
• Don't overdo it.
• Don't lift anything heavier than 5 lbs. for the first 6 weeks after surgery.
• Don't push yourself up out of a chair or bed, as this requires forceful muscle contractions.
• Don't participate in repetitive heavy lifting after shoulder replacement.

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Long-Term Outcomes

After rehabilitation, you will most likely be able to lift your arm to just above shoulder height and bend your elbow to reach the top of your head or into a cupboard. Reverse total shoulder replacement provides outstanding pain relief and patient satisfaction is typically very high.
Early studies of the results of this surgery have been very promising, but currently no long-term studies exist. This is an area for future research.

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Last reviewed: September 2010

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist" program on this website.

Is it a Pseudonym or an alias?

It's kind of fun to think about renaming my doctors for the purpose of privacy here. I renamed my primary care physician Dr. Kildare after TV's Richard Chamberlain from the 1970s. Sympathetic, reassuring, confident and calm. Of course, my first orthopod was not named Evel Knievel. I dubbed him that because of his love for riding motorcycles. And my new orthopod, Dr. Kai, is not an Hawaiian ukelele player. He loves the ocean and the waves.

Are there some "doctor" names that bring such an emotional response to them that a young medical student might rush to change his surname?  Dr. (Henry) Jekyll or Dr. (Hannibal) Lecter would turn heads if paged in the hospital. Dr. (Yuri) Zhivago or Dr. (Ben) Casey might turn a few hearts.  Dr. (Richard) Kimble would have us looking for a one-armed villain and Dr. (Frasier) Crane would just be way too stuffy, even for a psychiatrist. (Trapper) John McIntyre and Benjamin Franklin (Hawkeye) Pierce would leave the surgery in stitches. And would young Dr. Howser automatically be nicknamed  Doogie?

Does the name make the person or does the personality make the name what we associate with it?

By the way, what was Dr. Kildare's first name?

Willet (is it a nom de guerre or a nom de plume?)

I do need a reminder but...

I'm trying to figure out when doctors' offices started calling to remind us of our upcoming appointments and why.

 Was it because we patients got so busy we couldn't remember to show up? Did we become so inconsiderate that we didn't think twice about standing up our physician for our "date?" Think twice? We didn't think about it at all.

Does a fifteen minute vacuum in the day's schedule forebode some kind of medical practice apoptosis? Or has the doctor's budget gotten so tight that a missing patient here or there threatens financial collapse?

Whatever the reason, the telephone answering machine certainly made it efficient. First, it was just a pleasant voice with a brief message, "we are calling to remind Willet of her appointment with Dr. Welby at 10:00 tomorrow." OK, got it. I can usually remember something from one day to the next.

But recently a message was left five days prior to my appointment.  I'm not sure how much of a help that is. Does the recorded messenger  know it is talking to a machine when it says "to confirm this appointment, please press 1." When I listen to the message late Monday night I have to assume my machine did not press 1. So does that mean I need to call the office Tuesday morning to confirm? Or can I call during the evening hours and leave a message on the doctor's machine? Or can I presume they know I am a frugal person who would call to cancel rather than incur a $30.00 missed appointment fee?

Taking appointment reminders to the next level, I recently received an email reminder for a doctor appointment, a first for me. The email was sent April 30th reminding me of my appointment June 27th.  Now, they are giving me more credit than I deserve for being able to use the Calendar Alert system on my iPad.

At any rate, right now there is no  way I will forget my upcoming appointment. Too much hinges on it. I wonder if the doctor needs a reminder?

     Just feeling a little stressed right now.


Things I wonder about...



Is your surgeon an orthopedic doctor or an orthopaedic doctor?


I say rumor, neighbor, color, flavor
You say honour, humour, harbour, labour.
Is It just that British English thing or is there more to it?

Nicolas Andry de Bois-Regard (1658 – 13 May 1742) was a French physician and writer. He was a pioneer in the early study of both parasitology and orthopedics, the name for which is taken from Andry's book Orthopédie. Orthopedie is a neologism, that's a newly coined word, and since Andry made the word up he could spell it anyway he wanted. But that annoying little french accent aigu, a diacritical mark, made the middle E sound like an A so the Brits stuck an A in to remind them how to pronounce it. As the profession moved across the pond Americans tended to drop the accent aigu and the middle A. But traditionalists, even in the US, still use the English version.

So whether your doctor uses the French spelling with the little accent or the British spelling with the A in the middle or the Americanized version with no accent and no A doesn't say so much about his speciality as it does about his literary persuasion.

It has been ten months since my accident.  Dr. Evel Knievel,*, my first orthopod , released me at five and a half months post fracture even though I still had considerable pain and very limited range of motion. He said the bone was healed and the pain would diminish with time. Although he never said it, I felt as if he thought I was being a wimp  about the discomfort.


At nine months post injury I went to my primary care physician, Dr. Kildare*. I told him I was in considerable pain and could only sleep in one to two  hour stretches. Bless his heart, he took me seriously and sent me for an MRI, the first and  only one since the fracture.

The MRI shows a full thickness tear of the supraspinatus ligament, a partial tear of the subcapsularis tendon, and vascular necrosis of the posterior humeral head and neck. There is extensive deformity of the humeral head and neck.

So here I am ten months post fracture with a new orthopod, Dr. Kawika Kai*, who has ordered a CT scan and says there will be no improvement without surgery. We will talk about options on my next appointment.

What is a girl to do?


*Names have been changed to protect the guilty, the innocent, and mostly me from getting sued.