Complications in Shoulder Surgery My Secretary Says the Patient is Mad with Pain After Cuff Repair: It's A Failure - "I Never Got Better Doc…" John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics Chief of Shoulder Surgery Vanderbilt University Medical Center V A N D E R B I L T S P O R T S M E D I C I N E
Two Issues Here to Discuss Angry Patient Failure of Surgery V A N D E R B I L T S P O R T S M E D I C I N E
Avoiding Unhappy Patients • 1994-2017 • 23 years in Practice • So far----Malpractice Actions Brought-0 V A N D E R B I L T S P O R T S M E D I C I N E
Kuhn’s Principles Patient’s Don’t Sue their Friends • Every patient has a story- know it and use it at every visit-Make them your friends • I give every surgical patients my email • I give every complication my cell phone number V A N D E R B I L T S P O R T S M E D I C I N E
Kuhn’s Principles Own your Work • Medicine is an Art and Science • Surgery is an ART • This is your work, you own it • “Are you looking after my shoulder?” V A N D E R B I L T S P O R T S M E D I C I N E
Kuhn’s Principles Treat Patient’s Like Family • Every patient will see me. I don’t have them see PA or NP without me. • Late patients are seen that day and worked in • Patients who call with concerns are called and usually offered an appt the next day if they want V A N D E R B I L T S P O R T S M E D I C I N E
Kuhn’s Principles The Golden Rule V A N D E R B I L T S P O R T S M E D I C I N E
Diffusing the Angry Patient • Spend Extra Time • Show Empathy-Acknowledge their anger • Focus on the Patient • Communicate verbally and nonverbally • Apologize • Keep your Cool • If you were upset, how would you want your physician to act? V A N D E R B I L T S P O R T S M E D I C I N E
Why are they not Better? • Discussion of Pain • Discussion of Expectations • Discussion of What to Do Next V A N D E R B I L T S P O R T S M E D I C I N E
PAIN and the ROTATOR CUFF • You made the assumption that the cuff was the source and that fixing the cuff would take away the pain…..... • The patient believed this... V A N D E R B I L T S P O R T S M E D I C I N E
PAIN and the ROTATOR CUFF • Cuff tear anatomy does NOT correlate with – Pain severity – Duration of Symptoms – Activity Level – Or Surgical Success....... V A N D E R B I L T S P O R T S M E D I C I N E
Error in Managing Expectations • Patient Expectations Drive Outcomes…. – Did the patient really know the risks? – Did he understand the time it would take to get better? – How do you do informed consent? V A N D E R B I L T S P O R T S M E D I C I N E
For Atraumatic Tears • Did you exhaust non- operative treatment first? • If you did and failed, surgery is more palatable to the patient… • This also give you time to get to know the patient and discover their expectations V A N D E R B I L T S P O R T S M E D I C I N E
Postop Rotator Cuff Repair Pain • What is the source? – Infection – Stiffness – Scapular Dyskinesis – Biceps – Cervical Radiculitis – Other V A N D E R B I L T S P O R T S M E D I C I N E
Infection • Rare • Cause Failure of Repair • P. acnes – More common than expected (30% of revision scopes) – Hard to diagnose V A N D E R B I L T S P O R T S M E D I C I N E JSES 2015
Stiffness • Convince your patient that Stiffness is GOOD! – 43 patients, 23% stiff at 6 weeks – At 1 year all had normal ROM, but Stiff patients had higher healing rates V A N D E R B I L T S P O R T S M E D I C I N E
Ignored Scapula • Scapula dyskinesis • Scapula Assistance Test • Scapula Retraction Test • Review their Rehabilitation! V A N D E R B I L T S P O R T S M E D I C I N E
Did you Address the Biceps? • Biceps is a Known Pain Generator V A N D E R B I L T S P O R T S M E D I C I N E
Referred Pain • Stop, Listen, Examine and Think… V A N D E R B I L T S P O R T S M E D I C I N E
Is More Testing Needed? • Before you order a test know what you would do if positive and/or negative….. • Do you want an MRI? V A N D E R B I L T S P O R T S M E D I C I N E
Is More Testing Needed? • Use Local Anesthetics to Rule in or out the Location..... V A N D E R B I L T S P O R T S M E D I C I N E
In My Experience • Continued pain after rotator cuff surgery is due to stiffness • Patience and PT are the cure…. V A N D E R B I L T S P O R T S M E D I C I N E
If the Cuff is Re-torn • Don’t be quick to surgery again • Many do well with re-tears • Again figure out the source of the pain – Is it best treated with rehab? • Stiffness • Scapular Issues – Is it best treated with surgery? • Infections • Biceps • Irritants in the SA Space… V A N D E R B I L T S P O R T S M E D I C I N E
Second Opinion • If you recommend it- YOU WIN! • No one knows everything • We all have our biases…. • Who would you see in your community if you had a shoulder problem? V A N D E R B I L T S P O R T S M E D I C I N E
Thanks! V A N D E R B I L T S P O R T S M E D I C I N E
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