Joint PREP Class Shoulder Replacement T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine Center

Goals for you and your family Recognize shoulder replacement is a reliable operation to improve quality of life Describe what to expect of the shoulder replacement procedure. Discuss the risks of shoulder replacement surgery.

Goals of Your Shoulder Replacement Improve your quality of life by: Relieve your pain Improved motion Improved strength Better function

Shoulder Joint Replacement Indications Bone on bone osteoarthritis Intact rotator cuff tendons

Shoulder Arthritis Loss of cartilage leads to narrowing of the joint space

Shoulder Arthritis As the cartilage wears, bone spurs form and the shoulder becomes stiff

Surgical Technique of Total Shoulder Replacement Replaces the worn bony surfaces with metal ball and plastic socket (glenoid) Restores shoulder motion and stability

Implant Materials A plastic socket A Metal ball attached to a stem -Non-cemented press fit into the humerus or - Bone cement is used to cement the stem into the humerus.

Implant Materials A plastic socket is cemented into the glenoid. A metal ball and stem goes down into the humerus.

Hemiarthroplasty A metal ball and stem goes down into the humerus. No plastic socket is placed.

Reverse Total Shoulder Indications Completely torn rotator cuff with severe arthritis Complex fractures Previous failed shoulder replacement

REVERSE TOTAL SHOULDER Socket and ball are reversed - Humeral head (ball) becomes the socket - Glenoid (socket) becomes the ball

Surgical Technique Incision The incision is made in the front of the shoulder Your surgeon will make the incision long enough to see the joint area Your surgeon will use techniques to spare muscle Surgical techniques continue to improve as technology advances

Day of Surgery Your surgeon will meet you in SurgiCenter to initial your shoulder and answer final questions. Family can wait with you in SurgiCenter. You will go to the Operating Room (OR) Surgery lasts 2 hours. You will then go to the recovery room for 1-2 hours.

After Surgery in the Hospital Physical & Occupational Therapy is critical for a good outcome Therapy starts the day after surgery - Wear an arm sling immobilizer full time for 4 weeks - No forceful contraction of muscles such as pushing up out of chair or bed. - Follow the exercise program set up for you 4-5 times a day for 4-6 weeks.

Shoulder precautions Do not overdo it! Early overuse may result in severe limitations of motion Do not lift anything heavier than a glass of water for the first 6 weeks Do not participate in contact sports or any repetitive heavy lifting after your shoulder replacement. Avoid placing your arm in any extreme position for the first 6 weeks

Other Doctors in the hospital Additional Doctors take care of non-orthopedic issues (such as high blood pressure or diabetes). If you have an Internal Medicine doctor here, they will see you after surgery. If your regular doctor does not see patients in the hospital, a Hospitalist will see you after surgery. If you are not getting a medication you think you should, please ask.

Blood Clot Prevention Enteric coated aspirin 325 mg twice a day while in hospital to prevent blood clots. Continue at home for 3 weeks. TED hose worn for 3 weeks after surgery, you may remove these at night. SCDs (calf squeezers) are on in the hospital whenever you are in bed. Exercising your legs and being up and walking promotes blood flow.

Risks of Surgery Anesthetic Complications Anesthesia providers meet with you the day of surgery. They discuss anesthetic options including nerve blocks for postoperative pain relief. Nausea and vomiting are common but more serious side effects or complications may occur. Please tell the anesthesia provider of any past experience with anesthesia.

Risks of Surgery Blood Clots Lower risk for blood clots with total shoulder replacement Clots can go to the lungs and be fatal Your risk is reduced to <1% if treated with medication (aspirin) and TED hose Being active and walking helps to prevent blood clots

Risks of Surgery Infection You will get antibiotics at the time of surgery and for 24 hours after surgery. Surgeons, assistants and scrub techs wear “spacesuits”. Using all precautions, risk of infection is ~1%. Infection may occur months or years after surgery. Infection may mean removal of your implants.

“ Spacesuits worn during surgery”

Risks of Surgery Blood loss Bony surfaces bleed during surgery. There may be some bleeding after surgery. Your surgeon may use a drain in the shoulder Your blood count will be checked each morning after surgery. If you have symptoms from a low blood count, you may need a blood transfusion.

Risks of Surgery Medical Complications Surgery is a stress to your body. Heart and lung problems, stroke, stomach problems, constipation - all may occur. A physical with your regular doctor and an EKG are required before surgery. Despite precautions, unforeseen medical complications may still occur.

Risks of Surgery Dislocation This is an artificial joint and may slip out of joint. If it does dislocate, this often requires a trip to the hospital to have the shoulder put back in place. You may be required to wear a brace if it dislocates. Multiple dislocations may require revision surgery to fix the problem.

Risks of Surgery Need for Revision We encourage patients to wait as long as possible before replacement. Implants wear with time.. Wear rate is about 1% a year Revision surgery may involve changing the plastic or changing one or all metal parts. Revision surgery is more challenging with a more difficult recovery.

Recovery time 3-4 months: ‘normal’ activity 6 months: ‘normal’ endurance 12 months: maximal recovery Focus on exercises for movement and then strength Getting back to work is individual- check with your surgeon

Summary Shoulder replacement is a reliable operation to improve quality of life with less pain, improved motion, strength and better function. As with any operation, there are associated risks. All of the precautions we take are to minimize risk and to provide for a “routine” operation

Patient Resource and Education Program Joint PREP Class Patient Resource and Education Program Welcome to the nurse presentation of the patient resource and education program, for the patient undergoing total shoulder replacement. I am ________(1st name) from the Orthopedic center. There is a copy of the slide presentation in your folders for you to follow along with and to take notes if you would like. There is also a space for notes in the back of the Mayo total joint booklet in your folder. Talk with your surgeon or his nurse about any questions or concerns you may have at your next scheduled visit. You may also call them with the questions.

Goals for you and your family Discuss steps to take to get ready for the surgical procedure Discuss what to expect of the surgical experience Recognize why it is important for you to participate in your plan of care Read slide bullets

Plan Ahead Appointments: Your regular doctor for pre-surgery; Blood work, EKG, Physical exam, discuss medications Your surgeon for final discussion and update Stop smoking – talk to your regular doctor to get help Call your surgeon if you get a fever, cold, infection or rash before your surgery date Read slide. Your primary care doctor will examine you to make sure it is safe for you to have surgery. He may have you get fasting blood tests along with an EKG and other tests. Your surgeon will see you back within 1 week of your surgery for a pre-operative examination to prepare you for the surgery. There is a stop smoking brochure in your folder for more information.

Plan Ahead Plan for your return home Identify who will take care of you after surgery; Plan for about 2 weeks Identify who will assist you with shoulder exercises for 4-6 weeks Practice daily activities not using the arm affected by surgery Recovery is a gradual process and will take time after surgery. Plan for your return home before you enter the hospital. Identify who will take care of you after surgery. Plan for about 2 weeks. This is 24 hours every day of the week. If you do not have someone who is able to care for you after surgery social services will discuss options with you. Ask your spouse, children or friends if they can assist you with shoulder exercises for four to eight weeks after leaving the hospital. Before surgery it may be helpful to practice daily activities not using your arm that will be affected by surgery. Anticipate a temporary change in your activity.

Plan Ahead (cont) Simplify meals. Plan for 2 weeks of easy or no preparation meals Pick up throw rugs and other hazards that may cause you to trip. Place frequently used items in convenient locations…not too high or not too low Any planned dental work should be finished about 2 weeks before your surgery date Simplify meals. Plan for 2 weeks of easy or no preparation meals. Pick up throw rugs or any other item that might cause you to trip after surgery. Rearrange your kitchen so that often used utensils are easily accessed. Finish any planned dental work at least 2 weeks before your surgery date. Have your teeth in healthy condition. Bacteria in your mouth may enter your bloodstream and cause infection in the new joint If you have current work being done plan to finish before your surgery.

What to bring to the hospital Loose comfortable clothing to wear home Non skid comfortable shoes Personal items: toiletries, books etc. Medication list, inhalers, C-PAP mask Prepaid long distance calling card (optional) Cell phones are not allowed to be used in the patient rooms Loose comfortable Clothing: Jogging suit or larger button down the front shirt and pants that are easy to put on. (elaborate on position of arm for clothing- front closing bra or strapless) Non Skid Comfortable shoes. Personal items; toiletries like a comb, tooth brush and toothpaste, books, magazines Medication list, inhalers, C-PAP mask Prepaid long distance calling cards (optional) Cell phones not allowed to be used in the patient rooms. If you want to use a cell phone, ask the nurse where you can use the cell phones in the hospital. Your Total shoulder Replacement information folder from this presentation.We will be using information from this folder during your hospital stay.

What not to bring to the hospital Valuables/Jewelry Credit cards, check book or large sums of money Your medications (except inhalers) -All Valuables/jewelry, even your wedding band if it comes off easily -Credit Cards, check book or large sums of money -Your medications- except inhalers

The day before surgery Review your medications A SurgiCenter nurse will call you to: Review your medications Tell you what medications to take and not take the day of surgery Review eating, drinking and smoking restrictions Give hygiene instructions Tell you what time to arrive at Luther Hospital A SurgiCenter nurse will call you to: Review your medications Tell you what medications to take and not take the day of surgery Review your eating, drinking and smoking restrictions Nothing to eat, chew or smoke after midnight. No mints, hard candy or chewing gum Your surgery may be delayed if you eat anything after midnight May have clear liquids up to 2 hours prior to the time of surgery: Water Clear juices without pulp such as apple juice, Clear broth, Clear Jello, Black coffee or tea, Popsicles Give hygiene instructions Take a bath or shower the evening before or the morning of surgery. Shampoo hair - it may be a while before able to do this after surgery. Tell you what time to arrive at Luther hospital

Day of surgery Take medications at home as instructed Check in at Luther Hospital Registration Desk Read Slide

Day of Surgery (continued) You will be taken to the SurgiCenter You will be asked your name and date of birth by everyone who has contact with you – this is done for your safety Family and Friends are welcome. Try to limit to 2 people on day of surgery Read Slide Family/friends Will be allowed to stay with you until you are taken to surgery.

SurgiCenter Nursing admission in the SurgiCenter- We will ask you many questions and get you ready for your surgery Leg squeezers and TED hose applied Anesthesia visit Surgeon visit Nursing admission in the SurgiCenter- We will ask you many questions and get you ready for your surgery The nurse will put TED hose and SCDs (Sequential Compression Devices) leg squeezers on your legs in the SurgiCenter If you do have jewelry, remove and give to your family/friend. Dentures, glasses and hearing aids may stay in place until you are taken to surgery. Anesthesia staff will: Discuss the type of anesthesia available for your procedure Perform a brief examination Start IV Surgeon will: Review the consent for your procedure and will sign your surgical site Answer your last minute questions.

Leg Squeezers – SCDs This is a picture of the leg squeezers

Going to the Operating Room The Surgery RN will take you to the operating room Family/Friends Will be directed to the main lobby Family Lounge They should register with the volunteer and will be given a beeper and contacted when the surgery is finished

Operating Room (OR) Monitors Anesthesia Surgical scrub Foley catheter Staff will communicate to your family if the surgery is longer than 2-3 hours Staff will hook you up to monitors . Anesthesia will be given to you Once you are asleep: An antibacterial scrub is done to your surgical site; this may leave your skin with a bluish or brownish color that eventually washes off. A catheter will be placed in your bladder If the surgery is taking longer than 2 hours and they do not expected to finish soon, the Operating Room staff will try to call your family in the Family Lounge to let them know of the change in time.

Recovery Room/Post Anesthesia Care Unit (PACU) Your nausea and pain are managed as you awaken When you are ready, you will be transferred to a hospital room Read slide: After surgery you will be moved to the post anesthesia Care Unit PACU. Your relatives will be told when you are in PACU. The most important functions of the PACU is to manage pain and nausea as you awaken from anesthesia. When you are ready and nausea and pain are controlled (not eliminated), you will be brought to your hospital room.

Arrival in your Hospital Room You will have… Oxygen An IV Your affected arm will be in a shoulder immobilizer after surgery (May) have a foley catheter A pulse oximeter – a device that fits on your finger to measure blood oxygen level Read slide You will be encouraged to cough and deep breathe frequently for the first few days after surgery Respiratory therapy will evaluate your breathing needs. (Pulse Oximeter is on next slide)

Pulse Oximeter This is a picture of the pulse oximeter monitoring your oxygen level

Arrival in your Hospital Room (continued) We will check on you, take your vital signs You will be able to start drinking and eating when ready Activity as you tolerate Help you with control of pain and nausea. When settled in your room, the nurse will listen to your heart and lungs check color, movement, and feeling in your surgical arm tell you about your room and equipment used for your care. Nutrition - Sips of water and/or ice chips --- then clear liquids if not nauseated progressing to regular foods Activity: May be up and around as tolerated as your doctor orders. Do not get up by yourself. ASK for Help! We will continue to help you with control of pain and nausea

Pain Management It is normal to feel pain or discomfort after surgery. Your pain may not be totally relieved but pain medication can be given to make you more comfortable. Read slide You may begin to take your pain pills by mouth when you are able to drink fluids. Ask your nurse for pain medicine before your pain becomes too intense While you have an IV in you may have a Pain pump. This allows you to safely give yourself pain medication through your IV. Only the patient should push the button for pain medication.

After Shoulder Surgery The nurse will check your bandage on your shoulder Report any soreness, numbness or tingling in your arm or fingers to the nurse Ice will be applied to your shoulder to reduce pain and swelling Read slide. Tell the nurse if any irritation occurs under your immobilizer . It is important to keep your arm supported to reduce any tension in the area of your operation. Ice will be applied to your shoulder to help reduce swelling and discomfort around your incision.

You are a Partner in your care! Post operative day You will have…. Blood work Medication For pain control Aspirin 325 mg for blood thinning to prevent blood clots Activity – Occupational and/or Physical Therapy You are a Partner in your care! Blood work - Blood will be drawn Medication for Pain Control – Continue using pain scale to rate pain Anticoagulation or blood thinning with a full strength aspirin Catheter and drain will be removed if present Activity Physical therapists and Occupational therapist will begin working with you Call for assistance/Do not get up by yourself! White Board Plans for each day in the hospital will be on a white board in your room so you know what to expect each day. It will also be used as a communication tool for the nursing staff, Physical Therapy, Occupational Therapy and you and your family. About ½ of the people having total shoulder replacement will go home on the day after surgery. !/2 will go home the 2nd day after surgery.

Discharge Planning You will be discharged home from the hospital when: Your medical condition is stable You are able to manage safely at home with assistance You are able to do your exercises safely Your pain is under acceptable control About half the patients go home on day one and the other half go home on day two. Read slide.

Post operative day/Discharge day The person who will be taking care of you after you go home needs to come to the hospital to learn about: The person who will be taking care of you after you go home needs to come to the hospital for about 2 hours to learn: Safety in your home Activity and exercises for home from Physical and Occupational Therapy When and how to use your immobilizer or sling No lifting or holding weight until given permission by your surgeon No heavy lifting as defined by your surgeon for the rest of your life You should not lie directly on the surgical shoulder You may have problems with constipation that can occur as a side effect of pain medications and as a result of decrased activity. Eat high fiber foods such as fresh fruits/vegetables and whole grains and drink 6-8 glasses of water daily unless instructed otherwise. You may need a stool softener. Safety Exercises – Therapy When and how to use shoulder immobilizer, sling Lifting restrictions

Day of Discharge cont’ Prepare for discharge to home or transitional care Receive discharge instructions for: Incision care/bathing instructions to keep incision clean and dry Icing and how to keep swelling down How to take pain medications correctly Continuing aspirin 325 mg at home for blood thinning for 3 weeks Wearing TED hose for 3 weeks When to contact your Surgeon Day of Discharge Prepare for discharge to home or transitional care unit. The person who will be taking care of you after you go home also will learn about and get discharge instructions for: Discharge Instructions - Staff will go over discharge instructions Incision care: we will provide you with a kit to take home with all the supplies you will need. Ask for this if you do not get it.(Show Kit) Applying ice to your shoulder may provide added comfort as well as help keep the swelling down. Medications: You will be given a list of medications you will take at home You may want to take a pain pill at each meal (to prepare for therapy exercises ) and at bedtime You will be taking an aspirin 325 mg for 3 weeks at home for blood thinning to prevent blood clots. Being up, walking and being active at home will also help prevent blood clots. After 3 weeks you will go back to doing whatever you did prior to surgery i.e. baby/low dose ASA of nothing. Also to prevent blood clots you will be encouraged to wear your TED hose for 3 weeks. You will be instructed of when and how to contact your surgeon for concerns

To control swelling and pain at home Apply ice to your shoulder after exercises (do not apply heating pad) for 4-6 weeks as directed Pain medication as directed especially before exercises Physical therapy/exercises as directed Elevate and support your hand and arm on pillows above the level of the heart when at rest You may experience shoulder discomfort and swelling for several weeks following surgery. use ice on your shoulder AFTER exercise, Use the pain medication as instructed to help you complete your exercises effectively and increase your activity. Support your arm on pillows so the swelling in your hand and arm can flow back to the body by gravity. Do this when you are sitting or lying in bed. Many people are most comfortable sleeping in a recliner for a few weeks.

After Discharge A person to care for you will need to be available 24 hours a day to: assist you at home the first two weeks drive you to appointments encourage you in your home exercise program Change your incision dressing every day Wear the immobilizer sling for 4 weeks, according to your surgeon’s directions Read slide above…

Bathing 1. You may shower when your incision is dry (no drainage) Support your arm as directed by therapy 2. Place a plastic barrier over the incision, taped in place, prior to showering 3. Wash under arm, dry thoroughly and place dry padding to absorb moisture 4. Place a new dressing on the incision after shower You may shower as soon as your incision is dry, with no drainage on your dressing. Place a plastic barrier over the incision taped in place to prevent water on the incision. Wash under arm, dry thoroughly and place a dry padding to absorb moisture under the arm. Pat the incision area a dry and then remove the plastic barrier. Place a new dressing on the incision from your dressing packet. Do not submerge the incision in a bathtub, pool, hot tub, etc, until the incision is completely healed

Driving No driving. Talk with your surgeon about when you will be allowed to drive again After permission you must : Be off narcotic pain medicines to drive Able to sit in car comfortably Drive in a safe area Read slide Being able to use blinker, shift lever. Do not rush back into driving.

A Follow-Up Appointment with your surgeon will be made 10-14 days after surgery At your appointment: - X-ray will be done of your shoulder - Your stitches will be removed - We will give you care instructions about your: incision, bathing, exercises, and a handout titled ‘Joint Replacement- Dental Procedures and Antibiotics’ You will see an Occupational or Physical Therapist Read slide Ask for refills of medications if needed. You will get a form to remind you and your dentist that you will need antibiotics before any dental procedure for the next two years

Total Shoulder Replacement Therapy Services: Focusing on Function

Purpose To discuss what to expect in therapy the first days after surgery To identify Total Shoulder motion precautions To discuss home exercise program To identify what you need to do to achieve the best outcome

After Surgery You will wear a sling except when performing self-cares and exercises You can move your elbow, wrist and fingers You should not move your shoulder until you have assistance from nursing or a therapist

Therapy is important for a good outcome! After Surgery Therapy is important for a good outcome! Therapy starts the day after surgery You will learn motion precautions for your healing shoulder You will learn how to move your arm safely when: Taking care of yourself Taking sling on/off Walking/moving about

Therapy After Surgery Therapy Goals: PASSIVE range of motion of surgical shoulder (Maximum: 0-140 degrees flexion, 40 degrees external rotation) Control pain and swelling Be independent in taking care of yourself and moving your shoulder Prepare for a safe return to home

Activity limitations Limit shoulder elevation to 140 degrees flexion Limit shoulder external rotation to 40 degrees

Therapy for home You will learn a home exercise program that includes: Passive range of motion for your shoulder (no muscle flexing) Active range of motion for your elbow, wrist and fingers (moving them on your own) Techniques to control swelling and pain It is recommended that a person be available at home to assist you

At home you will: Continue with range of motion exercises Wear immobilizer/sling Practice your total shoulder precautions Call the therapy department with questions or concerns Comment: Do not baby the arm. You may lose muscle mass. Strengthening and moving your shoulder will always make your shoulder feel better in the long run.

You are a Partner in Your Care! Make your plans… Start getting ready for surgery!

Social Services and Case Management

Roles of Social Services and Case Management in Your Care Social Workers and Nurse Case Managers work in teams to assist with: Insurance Counseling/support Transition planning Advance Directives for Healthcare

Insurance Before surgery, you will need to notify your insurance company of your surgery plans Once you are in the hospital, your Nurse Case Manager will monitor your approved stay days and be a contact person for your insurance company for any questions or concerns INSURANCE Notification of elective surgery is NOT required for those who have only Medicare as their insurer. Medicare rules do not require pre-authorization of elective surgery. Many Medicare Advantage plans and private insurance companies do require notification of elective surgery by both the surgeons office and the patient themselves. Although this is not the case for every Medicare Advantage plan and private insurance plan, play it safe by notifying your Medicare Advantage plan or private insurance plan yourself about your surgery plan. Prior authorization for surgery can take anywhere from 15-30 days to process, so call your insurer as soon as you know your scheduled surgery date. If for any reason your insurer denies your prior authorization request, the hospital will be notified and we will contact you to let you know your request was denied.

Counseling and Support Surgery and hospitalization are stressful Meeting your emotional needs is important to all staff at Luther-Midelfort If you have any concerns about your care or are feeling “out-of-sorts”, please feel free to discuss these things our Social Services staff

Discharge Planning A Social Worker or RN Case Manager will meet with you to discuss your transition plan to home or a transition facility. You, your family, your doctor and your therapist all will help determine what transition plan is best for you.

Options at Discharge Home with family to care for you Home with outpatient services Home with or Home Care Skilled Nursing Facilities Transitional Care Units or Swing Beds TRANSITIONAL CARE OPTIONS Home with outpatient services is an option for the person who is generally in good health, has someone available to stay with them the majority of the time for a few weeks, has progressed sufficiently in therapies during hospitalization, and is self-motivated to perform their exercises at home on a consistent basis. Home with Home Care services is an option for the person who has a skilled nursing need such as complex dressing changes or IV antibiotics. Physical Therapy is available through home care agencies but because of the shortage of therapists, generally the maximum amount of home therapy they can provide is 2 times a week. In addition to having a skilled nursing or skilled therapy need, home care also requires that you are “homebound”, meaning leaving your home requires a great deal of effort. Skilled Nursing Facilities are area nursing homes that offer short term rehabilitation stays along with their long term care. This is an option for the person who requires more assistance to ambulate or care for themselves than their family or friends can safely provide. It is also an option for the person who lives alone and may not have someone that can be available to them at all times during the day, or the person who needs the extra motivation and skill of a trained therapist. Remember, for the best recovery, therapy needs to start early and be consistent. Transition Care Units or Swing Beds are located in a rural hospital and your care is provided by the hospital staff and a hospital physician will assume your care while you are receiving services at the Swing Bed. This is an option for the person who has a more skilled nursing care need, examples would include complex dressing changes or difficult to control blood sugar levels or a pre-existing medical issue such as cardiac disease. Swing Beds can also provide more intensive rehabilitation therapies than the Skilled Nursing Facilities.

Advance Directives for Healthcare What are Advance Directives? What are the 2 types of Advanced Directives? ADVANCED DIRECTIVES FOR HEALTHCARE Advanced Directives are written documents that tell your Doctor what you want for care when you are unable to speak for yourself. They allow you to describe the type of medical treatment your would like to receive or not receive. They allow you to identify the person you wish to be your decision maker if you are unable to make your own health care decisions. There are 2 types of Advance Directives, Declaration to Physicians or Living Wills, and Power of Attorney for Health Care.

Declaration to Physicians or Living Wills Describes the kind of life-sustaining care you would want only if you had a terminal condition or were in a persistent vegetative state Living Wills direct your physician regarding life-sustaining treatment or a feeding tube Living Wills do not give authority to anyone to make health care decisions on your behalf

Power of Attorney for Health Care Your agent can tell your physician what kind of care you would want in all types of health decisions, not just concerning life-sustaining treatment You appoint an agent to make all health care decisions for you in collaboration with your physician In most cases, going to court to appoint guardianship can be avoided POWER OF ATTORNEY FOR HEALTH CARE This document is recommended because it is much more flexible than the Living Will and gives health care providers a person to discuss your wishes with.

Who Can Help you Complete an Advance Directive? Luther Hospital Social Services-no cost Luther Hospital Chaplaincy-no cost Your personal attorney-attorney fee

Safekeeping of Advance Directives Store the original document in a safe place Give a copy of the document to family members Give a copy of the document to your Physician so that it can be kept in your medical record

To complete an Advance Directive or for any questions Call Social Services Department at 838-3278, or Ask for a Social Worker or Chaplain when you are admitted to Surgi Center the day of your surgery.