This post is bought to you by the letter 'P'

Hello again. Today is Wednesday 26th April 2017, three weeks since my rotator cuff repair with GraftJacket. I'm tending to post weekly at the moment as each week I'm permitted to add something else to my list of rehab movements, so that gives me something to write about.

I'm still wearing the sling most of the time, removing it to shower and dress and of course, do my limited exercises. Last week I started doing pendulums, a couple of days ago I added the pulley to my routine, plus I am now able to do some passive movements - so I guess this post is bought to you by the letter 'P'.

P is for:

- Pendulums - I spoke about these in my last post. They are sometimes referred to as Codman exercises, after the surgeon Ernest  Codman who was the first surgeon to perform a repair of the rotator cuff and one of the pioneers of modern methods of outcome monitoring using data gathered from real patients. You can read all about the man and his work here.

 

- Pulley - I cannot recommend an exercise pulley enough for helping to regain range of motion in the early stages. A simple exercise pulley costs little and provides and almost completely passive way to raise and lower the arm through it's main arc of movement. It's not really effective for rotational range, but for abduction (out to the side) and flexion (out to the front), it is highly effective.

- Passive - I am using passive movement to gently push my external and to a lesser extent, my internal rotation. I lie on my back with my elbow at 90degs, rested on a cushion near to my side. I grasp my wrist (or you can use a stick as in the picture) and gently rock it to invoke internal and external rotation of the shoulder. As this is only 3 weeks since surgery, little or no force is used and we stop at pain. Doing this 4 or 5 times a day, I'm seeing small improvements in range each time.

So that's all good stuff. I'm not getting any clicking or unduely painful sensations, although there is still some residual pain from the surgery and it doesn't feel strong nor normal - it's early. However, there are some things we should avoid:

Cross-body movements - stretching the arm accross the body (e.g. scratching the opposite shoulder) is out until at least 6 weeks. This is becasue the supraspinatus (and infraspinatus) is stretched to it's limit by cross-body movement.

Full rotation - whilst I'm getting some rotation back, forcing full external or internal rotation is ill advised as it stretches the deltoid and rotator cuff. Internal rotation is particularly risky early on and I'm waiting until 6 weeks before exploring this to any extent.

A word on progress:
For some people reading this, the progress I'm making may seem fast, to some it may seem slow. If you have had a similar procedure and you are worried about your progress, please do not compare yourself with what you read here as we are all different. I would say the GraftJacket implant allows for a robust-enough repair to begin gentle penulums and to start increasing ROM at 2-3 weeks. Some surgeons still allow this with conventional repairs, especially where a double-row fixation like a speed-bridge has been used, but this is not always the case. It is true that the earlier movement can begin, the less stiffness is likely to persist and the quicker full movement will return. However, you may be kept immobilised by your surgeon for longer and for good reason. Listen to them and follow your protocol, as I am doing.

Incisions, incisions

Today is two weeks and one day from surgery and things are still going ok I guess!

I reported in my last post that the allograft felt pretty comfortable and I wasn't aware of anything scratching or scaping around inside. Not that I would as I'm immoblised in a sling (!!) but I can't say I can feel this thing.

During the last couple of days my rehab plan has permitted me to start some gentle pedulum exercises 3 or 4 times a day. These are simple exercises to mobilise the joint without causing the muscles to fire significantly. The joint feels very smooth with no clicks or bumps and no snapping or popping.

These exercises have felt ok although the first time I did them I did get a few twindges, as one might expect. However, having been though these recoveries before, I am acutely aware that every new thing you do for the first time since surgery HURTS....and can hurt for a while afterwards.

Most of the pain is around the incisions and this makes senese if you consider the healing that's going on around them. I have two arthroscopic and one open incision. They still feel a bit tender and moving the joint feels like it's aggravating the tender tissue around them. Still, this is not a bad thing. staying completely immobile for six weeks would result in adhesions and scar formation that would be even more painful to break up when you first move it, so there's no avoiding the initial pain.

At least that 'old' pain from when my rotator cuff was torn is absent.

What does this thing feel like?

Today is day 7 from surgery and I feel this is probably the first day where I can offer some kind of idea of what the GraftJacket in my shoulder feels like; now that some of the latent pain of the surgical incisions is beginning to abate.

This is not to say I can 'feel' it as such. I don't have a sense that any 'thing' is there - not at the moment anyway - but I do get a sense that the joint feels more solid and connected than it did. It aches, but the pain is very different from what I had before - plus it's changing as it's healing. I've spoken with a few people who've had these kinds of graft operations. Some of them have been out of a sling within a week and encouraged to start using their arm quite quickly. I'm in a sling for six weeks - so what's different here?

My particular operation was perfomed 'fully' open. This means splitting the fibres of the deltoid and detatching some of them from the acromion - like lifting the cylinder head off an engine - to gain access to the medial (inner) portion of the rotator cuff. The deltoid is reattached and closed afterwards and has to heal in the same way the repaired rotator-cuff has to. So, early mobilisation of the joint is not really an option here. Some of the other people I spoke with had this done without deltoid detachment, but my procedure required it because my cuff defect started much further into the medial cuff tendon - where it meets the muscle. So what can I look forward to? Well, I'm hoping that the solidity of the cuff repair means that I will progress more quickly than with a conventional repair, once I'm out of the sling. I can start pendulums at two weeks, passive exercises at three, then fully active from six. Strengenting will probably start after week eight - with conventional cuff repair, this is normally around week twelve. I can't say whether the deltoid detatchment will complicate things - one hopes not, but the human body can be very mysterious!

Day 6

Day 6. A little residual bruising lower down the arm which is, from what I've read, normal and due to blood escaping from the surgery site under gravity. This was open surgery (with arthroscopic examination and debridement first) so to be expected really. Pain has improved somewhat in the last couple of days. Still taking meds at night. Changing these breathable dressings daily, till the weekend (day 10) I reckon. Confined to the sling most of the time. Following a simple daily routine that includes: Change the sling each day after showering - I have two slings and don't remove it for showering. Lie flat on back, loosen sling and flex the elbow with my other hand holding my forearm - about four times a day Gentle shoulder-shrug exercises - 3 or 4 times a day

Surgery Done

Ok, so the procedure was yesterday; Weds 5th April 2017. All seems to have gone to plan. I have a GraftJacket implated in my right shoulder. Sling for the next six weeks.

The surgeon identified a medial tear extending down toward the footprint of the supraspinatus. This has been closed and the GraftJacket applied over the entire tendon, including the margin of the infraspinatus. The GraftJacket is held in place with sutures in bone-tunnels, as opposed to anchors. The procedure was done open with deltoid detatchment and subsequent reattachment - major work.

Pain is under control, but I definitely feel it!! The nerve-block has now worn off and I am taking regualar pain medication including paracetemol, codene and naproxen.

Didn't sleep much in the hospital last night. This is my first night back in my own bed. Should be fun!

I hope to be off the pain meds within the next two days - so tomorrow is Friday and I hope Saturday will be the last day I need them.

What is an Allograft?

In my previous posts, I have mentioned something called an Allograft. It's a piece of donated human skin tissue. It's treated, dried and packaged and is rehydrated at the time of surgery. Think instant freeze-dried skin - no, really.

Who cares? Well, you might do if you've torn your achilles tendon, suffered major skin trauma (like burns) or you have a chronic or massive rotator cuff tear in your shoulder that is difficult to repair. Surgeons have been trialling different tissue grafts for many years. Skin grafts are nothing new, but their applications in tendon repair are newer. Injuries like achilles rupture and rotator-cuff tear - that are always dificult to recover from due to poor healing - are now more readily treatable with the augmentation of the tendon using a tissue graft. Note the word 'augmentation'.

If you're a shoulder patient and you are reading this, then you may be one of the many people with a massive or irrepairable rotator-cuff tear. For you, an 'augmentation' is impossible, because, if your tendon cannot be repaired, the repair cannot be augmented. Fortunately, in recent years, surgeons have been begun to treat these kinds of tears by using an allograft as an 'interposition' graft. This means using the graft to replace the missing tendon tissue, effectively bridging the defect between what is left of the tendon and it's attatchment site on the bone.

There is a big difference between augmentation and interposition grafting, in particular, the surgical complexity and patient eligability. There are many fewer surgeons doing interpositions than there are doing augmentations. In the UK, after a 12 month search to find someone who could do this procedure - including at least six consultations with different surgeons - I discovered the number of surgeons doing interposition allograft surgery in the UK was roughly distributed as follows:

   - London - 0
   - Cambridge - 1
   - Leicester - 4

That's right, no one in London. No one I saw in London knew of anyone doing this kind of operation in London! There maybe others in places like Birmingham, Manchester or Edinburgh, but as I live in the south-east of of the UK, my search did not cover these areas.

Anyway, if you've read this far, you may be interested in this article published by the team from Leicester. It describes the interposition procedure, outcomes and recovery protocol.

Note: if you are from outside the UK, interposition grafts are being performed in the US, Europe and other continents. I would recommend a thorough Google search including the words "Shoulder Allograft Interposition".

Two days until surgey

Today is a Monday and on Wednesday I travel to Leicester for surgery to repair the chronically torn rotator-cuff in my right-shoulder. This should be a repair with an allograft - as mentioned in my first post.

This is not the first rotator-cuff repair I have endured - in fact, it's not my second either. Since 2009, I have endured numerous shoulder operations, some painful but effective, some just painful!

As I write, I am comtemplating another six weeks in a sling, which means:
   - Pain
   - No driving
   - Boredom
   - Lack of sleep
   - Limitation to daily tasks like cooking (which I enjoy) and showering/bathing
   - Little or no exercise, other than walks I must force myself to take
   - No work (see boredom above)

At least the weather's getting better here in the UK - it's the start of spring.

I've spent the last ten days running around like a mad chicken getting "things done". There's nothing like six weeks of being laid up to focus the mind on one's to-do list:
   - Attend to a rat infestation in my loft/attic (great timing there rats)
   - Install a new shower
   - Jet wash the patio
   - Re-seed the lawn
   - Oil the wooden floor and deep-clean the carpets
   - Prepare enough frozen meals for a space mission to Mars!

The thought of having none of these things left to do and not knowing when I will have the energy or enthusiasm for any of them again of kind of scary.