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Shoulder Surgery – Week 2

It’s been a little over two weeks since I had arthroscopic shoulder surgery. At the post-op followup visit with the physician assistant (PA), an x-ray was done and the steri-strips placed across the small incisions were removed. The incision scars are quite small FullSizeRender (3)compared to other surgeries (see photo). There remains a large area of bruising around the front incision where fluids pooled up after the surgery. I was told that the sling was not necessary except to provide relief and to send a message to others not to grab my hand or hug me!

The PA showed me 24 photos of the procedure and explained what was going on in each one. One showed a grinding tool right above the rotator cuff which had some damage from a bone spur right above the tool. The tool was

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bone spur above and rotator cuff below

used to remove both the damaged rotator cuff tendon tissue and the bone spur. In the next photo, the tool is shown working on removing some bone tissue on the end of the clavicle. Finally, a space between the acromium and clavicle is visible after removing about 1/2 – 3/4 inch of the clavicle. The x-ray shows an that there is an open space where the AC joint used to exist. Bone will no longer grind on each other. The x-ray technician asked who did my neck surgery as she “sees all” on the image. The screws and plates are visible on the image.

I was cleared to start physical therapy and was given a prescription. I went upstairs to the PT clinic run by the surgery group and scheduled PT starting February 17 with two sessions each week for six weeks. The goal is the begin stretching and moving to strengthening.

For the present, I’m careful with the shoulder and avoid moving it too much as any movement can cause it the tire easily and become painful. But without being immobilized, I find myself going into usual movements and paying for it later. Overall, recovery from arthroscopic surgery has been much easier compared to open incision surgeries and I’m thankful for this technology.

In the meantime, I still can’t start my new RA treatment, daily Kineret injections, as I’m battling a thrush fungal infection. I see an ear, nose, and throat doctor tomorrow to address the ongoing cough and the thrush infection.

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grinding tool removing bone tissue on clavicle

 

 

 

 

 

 

 

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opening between acromium and clavicle after removing bone tissue

 

 

 

 

 

 

 

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X-ray showing end of clavicle removed. Screws and plates are visible in neck from previous surgery

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It’s the 4th Annual Rheumatoid Awareness Day. Please read Dana Symon’s excellent blog post listing seven important facts about rheumatoid disease. I’ll focus on Fact # 2.

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Upwards of 30% of patients do not respond to current treatments. Lack of response to treatment is called “refractory”. Unfortunately, I’m one of those refractory people. I’m currently getting ready to start RA treatment number 12 (see this article). This treatment, Kineret, is the last RA treatment my rheumatologist said is available for me. If it doesn’t work or the side effects are intolerable, then we’re going to try off-label medications on an experimental basis. The problem is that the Kineret is sitting in my refrigerator while I wait to get over a thrush fungal infection.

Read all the other great blogs written for the 4th Annual Rheumatoid Awareness Day at http://rawarrior.com/rheumatoid-awareness-day-blog-carnival-2016/!

As another way to share awareness, please read the excellent article at Creaky Joints by Dr. Jonathan Krant on the difference between osteoarthritis and rheumatoid arthritis.

Shoulder recovery is going well. I’ll give an update soon.

Warning: This post includes images of surgery incisions. 

I decided to write regular posts describing recovery from shoulder surgery…sort of a diary documenting the experience. Being that this was my 7th surgery with general anesthesia, I began to feel like a “frequent flyer”. In fact, the nurses at the outpatient surgery center remembered me from previous procedures. Fortunately I reported at 7:15 a.m. and I was the surgeon’s second procedure of the day. This means that I didn’t have to go without food or coffee for long and could be back home relatively early in the day. After paperwork, I was escorted to a pre-op room where a nurse went over medications and inserted an IV IMG_1426IMG_1428catheter (see pic). The surgeon came in to answer any questions and he used a permanent maker to write on the correct shoulder. He also asked about how my other shoulder was feeling since he injected it with steroid the previous week. The anesthesiologist also came in to discuss the anesthesia. He gave me a scopolamine patch behind my ear to reduce nausea. I waited about 15 minutes before being escorted to the operating room. It’s a little strange walking into the OR and not being wheeled into the room on a gurney.

The OR are always kept quite cool. There were two assistants/nurses and the anesthesiologist in the room and they all said hello. There is music playing and I asked who got to pick out the music – the anesthesiologist! They had me lay on a weird table and I was strapped in around the waist and compression leggings were put on. Being that this was my 7th experience, I was not nervous. I was hooked up to a blood pressure cuff and pulse/ox probe. The anesthesiologist mentioned that he was going to use a nerve block to help control pain after the surgery. A mask was placed over my mouth and nose and I started breathing oxygen. Within a few minutes they started the IV and gas anesthesia. This time I experimented fighting it and staying awake as long as I could. It didn’t take long and I said “goodnight” :)

I woke up to the post-op nurse calling my name and I felt pretty good. An injection of the narcotic fentanyl was given to help with pain. After 30 or so minutes, I was moved to another room anIMG_1429d my wife and pastor came back. The surgeon met with my wife and told her that he cut off of end of the collar bone, cleaned up the AC joint bone spurs, and repaired the rotator cuff which was right under the AC joint and was damaged by the bone spurs. The biceps tendon was fine. I was given two oral oxycodones and a hydroxyzine which is an antihistamine to help with narcotic side effects. I was given post-op instructions. After dressing, I was taken to my car in a wheel chair. I asked my wife to stop at Starbucks and pick up a grande, two pump chestnut praline latte – yum. After getting home, a breakfast of toast and eggs filled an empty stomach. The shoulder felt pretty good because of the nerve block but I took the oxycodone and a hydroxyzine on a regular 4 hour interval. Dear friends came by with some delicious fried rice and a coconut cream pie – my favorite!

IMG_0110I found that only shirts with button or zipper fronts could be used as there’s no way to slip one over the head without moving the shoulder. Sleep was awkward but I found I could lie on my back or left side. At most 3-4 hours of sleep would be had at a time and I would get up to take oxycodone and eat a little food to avoid nausea. A very thick bandage was placed on the shoulder in the OR and I was instructed to remove it on day 2. The orange must be betadine or something similar for sterilizing the area. There were 3 incisions – two on the front and one of the side – where the surgeon inserted arthroscopic instruments and a camera. I replaced the bandages and attempted to ice the area as much as possible. As long as I don’t move the shoulder, the pain levels are very tolerable. Using my left arm for daily functions works well and I well experienced in this after having surgery on my right elbow last year. I’m thankful for arthroscopic surgery as opposed to open incisions. I watched several videos of similar procedures to get an idea of what to expect.

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I am surprised how well I feel today. This was certainly not the case with neck and sinus surgeries. A follow-up visit will take place next week and physical therapy will start in six weeks.

On a side note, it was very sad to hear of the death of music legend Glenn Frey from RA. It’s not clear what exactly happened but this drives home the point that RA can impact much more than joints and dramatically increases mortality.

On Monday I will be having a right shoulder acromioclavicular joint (AC) resection. The AC joint is at the top of the shoulder and is the site where the clavicle (collar bone) meets the highest point of the shoulder blade called the acromion. When athletes have shoulder separations, the ligaments holding the clavicle tear. It’s common for this joint on both shoulders to become damaged in RA patients (AAOS). I have have had symptoms on both shoulders for several years. The right has always been the worse probably because that is my dominant arm. Two steroid injections on the right side provided little relief. I received an injection on the left side this week.

Using x-ray and MRI, the surgeon found that the joint was damaged to the point that no cartilage remained, bone was rubbing on bone, and bone spurs were protruding into other tissues. The MRI image posted below shows the damaged joint. There should be a clean line of demarcation between the two bones with 5-10mm of cartilage in between. The image shows a tangled mess of bone spurs. The rotator cuff lies directly under this joint and he said that there was some fraying of this tendon but it wasn’t too bad. A question remains about the nature of the biceps tendon which also runs into this area. There is a possibility that visual inspection of the area during surgery will result in other soft tissue repairs.

The procedure will be conducted via arthroscope which involves several small incisions to the shoulder from various angles to allow access for cameras and tools. This will avoid larger incisions through tissue. This is the first arthroscopic surgery I’ve had on a joint (my sinus surgery was endoscopic) and hopefully this will result in less pain and faster recovery. If no other soft tissues are repaired, the recovery will involve wearing a sling for a week or so, refraining from any heavy use of the shoulder, and starting physical therapy after six weeks. Updates will be posted in the coming weeks.

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Many RA patients receive an excellent response from their RA treatments. But a substantial portion of us, perhaps as many as 30%, struggle to find effective treatments. Roth and Finckh (2009) found that 20-40% of RA patients failed to respond to the popular TNF inhibitors. In one recently published study in China, only 25% of patients achieved remission status (Lu, Li, Zhao, & Li, 2013).1 Such cases are called “refractory” or resistant to treatment. According to Webster’s Medical Dictionary,

“Refractory disease is defined as failure to attain a predefined target, which is now accepted to be remission or, at least, a low disease activity state.” 2

I seem to be such a refractory case and have even been labeled as such by my rheumatologist. I’ve been on 15 different RA medications since being diagnosed in early 2009 (see list below).

Read the rest of the article at https://rheumatoidarthritis.net/living/already-shot/

Busy as a (Sick) Beaver

It seems that every day brings about a bevy of appointments or medical related task keeping me busy as a beaver. The past month has been a whirlwind of medical related activities sandwiched around the holidays. Here’s a list from my calendar.

  • Office visit with rheumatologist.
  • Phone calls from the speciality pharmacy and doctor’s office in order to process a new prescription for Kineret – my new RA drug (last RA drug to try).
  • Routine office visit with primary care doctor.
  • Office visit with pulmonologist.
  • Sputum lung test at lab.
  • Bronchoscopy at the hospital to check lungs for RA involvement and/or infection.
  • Multiple office visits with two different orthopedic surgeons.
  • X-ray of the left hip and lower back.
  • Physical therapy on left hip twice a week.
  • Steroid injection into left hip trochanter bursa.
  • Ultrasound guided steroid injection into the left hip socket.
  • Steroid injection into the right acromioclavicular (AC) joint.
  • MRI of the right shoulder (see below).
  • Scheduling of shoulder surgery.
  • Various blood tests.
  • Visit to dentist for regular cleaning plus an x-ray of inflamed left jaw.
  • Multiple phone conversations and paperwork with Human Resources department and insurance company for processing long term medical leave and disability.
  • Paying multiple medical bills online and via mail.
  • Submitting reimbursement claims for out of network providers.

I’ve been very busy but being off work right now has been a blessing and given me some much needed rest and time to complete these tasks.

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A bit of good news…ChronicPainDisorders.com named my blog as one the best RA blogs for 2016! I’m honored to be included with such great company.

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A Puddle on the Floor

4399013159_421680f3ca_bI want to be strong. I want to exude positivity. I want to be a superhero in the fight against RA. But those attributes don’t seem to describe me at this time. Rather, the reality is that I’m a like puddle on the floor. Spilling into the cracks and across the floor. Spread thin. Hard to collect back into the vessel. Evaporating into air. Reduced in volume. Heading towards the drain.

Ok, enough embellishment. But the lack of posts here speak to the general situation. After 2 1/2 years I stopped taking Rituxan infusions after it was clear it wasn’t working. I started taking Xeljanz, stopped for a while when non-stop migraines ensued, and started back up recently. But any impact on pain and energy is not yet realized. I resorted to a steroid dose-pack last week.

To add insult to injury, the past 4-5 months have been a coughing bonanza which a pulmonologist is trying to figure out. Thus far a lung function test showed some abnormalities but x-rays and CT scans did not reveal any visible issues. A week on an Advair inhaler (steroid and bronchodialiator) resulted in another week of non-stop migraines so that was halted. After breathing in a nebulizer for 20 minutes while locked away in the doctor’s office, I was able to hack up a sputum sample. That was sent to the lab and culture results await.

In addition, steroid injections into the left hip and right shoulder didn’t help knock down pain and swelling. An ultrasound-guided injection deep into the hip joint is scheduled for December 30. Imaging of the shoulder showed bone damage and active inflammation around the acromio-clavicular (AC) joint which is where the collarbone meets the shoulder. The orthopedic doctor mentioned that the long-term solution is to surgically remove the tip of the collarbone.

At times I’ve probably stuck my head in the sand and ignored the mounting impact of RA on the ability to work and engage in regular life activities. To that end, an exploration into applying for disability is underway. While raising a whole other set of issues, it’s probably for the best in order to help the puddle from spreading too thin.

Creative Commons Photo credit – John McGarvey
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