Complications in Shoulder Surgery My Secretary Says the Patient is - - PowerPoint PPT Presentation

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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

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Two Issues Here to Discuss

Angry Patient Failure of Surgery

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Avoiding Unhappy Patients

• 1994-2017
• 23 years in Practice
• So far----Malpractice Actions Brought-0

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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

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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?”

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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

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Kuhn’s Principles The Golden Rule

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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?

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Why are they not Better?

• Discussion of Pain
• Discussion of Expectations
• Discussion of What to Do Next

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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...

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PAIN and the ROTATOR CUFF

• Cuff tear anatomy does NOT correlate with

– Pain severity – Duration of Symptoms – Activity Level – Or Surgical Success.......

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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?

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For Atraumatic Tears

• Did you exhaust non-
• perative 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

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Postop Rotator Cuff Repair Pain

• What is the source?

– Infection – Stiffness – Scapular Dyskinesis – Biceps – Cervical Radiculitis – Other

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Infection

• Rare
• Cause Failure of Repair
• P. acnes

– More common than expected (30% of revision scopes) – Hard to diagnose

JSES 2015

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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

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Ignored Scapula

• Scapula dyskinesis
• Scapula Assistance Test
• Scapula Retraction Test
• Review their

Rehabilitation!

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Did you Address the Biceps?

• Biceps is a Known Pain

Generator

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Referred Pain

• Stop, Listen, Examine and

Think…

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Is More Testing Needed?

• Before you order a test know what you would

do if positive and/or negative…..

• Do you want an MRI?

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Is More Testing Needed?

• Use Local Anesthetics to Rule in or out the

Location.....

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In My Experience

• Continued pain after rotator cuff surgery is

due to stiffness

• Patience and PT are the cure….

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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…

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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?

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Thanks!