1. Rotator Cuff Repair: Difficult Post op Patients Derek Cuff, M.D. Suncoast Orthopaedic Surgery and Sports Medicine Gulfcoast Orthopaedic Rehab Conference-August 22 nd 2015

2. Goals Discuss potential problem patients Identify risk factors

3. Difficult Post Op Patient Post-op management very important Therapy vital component Deviation from post-op protocol can result in failures

4. Difficult Post op Patients Disregarding post op immobilization Not attending therapy sessions Not complying with post-operative restrictions

5. 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

6. Difficult Post op Patients Disproportionate pain – Excessive narcotic use – Unable to comply with PT – Failure to push themselves – Often histrionic

7. Difficult Post op Patients Workers Compensation – Many have secondary gain issues – Not much incentive to improve – Some don’t want to return to work

8. “Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims” Cuff et al. JSES 2012

9. 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

10. 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

11. Results- ASES Score

12. Results- SST Score

13. Results- VAS Score

14. 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

15. Results- ASES Score

16. Results- SST Score

17. Results- VAS score

18. Difficult Post op Patients To summarize – Work comp= high degree of noncompliance – Not all bad – Have to be careful and document everything

19. 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

20. 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.

21. Materials and Methods 277 cuff repairs over study period 181 patients (101 males, 80 females) Avg. age 63.3

22. 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.

23. 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

24. Materials and Methods Intra-op factors – Tear size ( partial, small, medium, large ) – Number of anchors used – Repair technique (single row vs TOE)

25. 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

26. Subjective Pain Tolerance 7.3

27. Results Other factors affecting post op pain – Pre op narcotic use – POD #1- 8.7 – POD #7- 6.1

28. Results Other factors affecting post op pain – POD #7 – Smokers – Younger decade of life

29. Results Factors that did not correlate: – Tear size – # of anchors used – Work comp claims – Pre op VAS – Gender – Single or double row

30. 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

31. Difficult Post op Patients Pre-op narcotic use – At risk for hyperalgesia – Consultation with pain management specialist pre-op for these patients

32. 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

33. Summary You will encounter these patients Understand which may present a challenge helps Patient education helps Do your best to help them

34. THANK YOU