The Surgical Experience

• First and foremost, smoking cessation is one of the most important factors in postoperative recovery.
• Additionally, among diabetic patients, achieving and maintaining a Hemoglobin A1C < 7 has been shown to significantly improve patient outcomes following surgery.
• Medication optimization is another important aspect of surgical preparation that you and your primary care physician can evaluate.
• In addition, physical prehab can aid in maintaining joint mobility and muscle mass through something as simple as isometric exercises.
• The final component is nutritional readiness which the following will address.

Both injury and surgery are huge stressors on the body. This stress increases cortisol levels in the body. Cortisol, known as the “stress hormone”, prompts the body to enter a catabolic state, where the body is breaking down fuel stores and thus loosing mass. The body is basically using all of its energy stores (carbohydrates, fats and protein) as fuel in this heightened metabolic state. This in contrast to an anabolic state where the body is building muscle mass.

Therefore, carb loading prior to surgery is a good idea. This is similar to what athletes do before a big race or competition. From a metabolic standpoint, surgery or injury is very similar to such a race or competition from a metabolic standpoint. The main way that we store glucose is through a molecule called glycogen, which is one of the fuels we burn for energy. Carbohydrate loading will thus increase glycogen stores in your muscles and liver, ensuring the body has plenty of fuel to aid in the recovery process following surgery or injury. It has been shown that carb loading 3 days prior to surgery resulted in reduced loss of muscle strength and a quicker return to pre-operative energy levels.[1}. The main nutritional focus during this time should be high carb and low-fat foods such as bananas, Quinoa, sweet potatoes, rice, fruit smoothies, pasta and cereals. There are apps available to count the carbs and calories, such as MyFitnessPal.

• ERAS (Enhanced Recovery After Surgery) recommends 100 grams of carbs the day prior to surgery. Athletes will often consume 4grams per pound 3 days prior to a competition.
• If you have diabetes this carb loading will need to be done carefully to not increase your blood glucose level- your primary care physician can provide guidance in this regard.

A high protein diet is critical. The increased cortisol levels seen after surgery or injury results in reduced protein synthesis and an increase in protein breakdown. When increased protein breakdown is coupled with immobility, skeletal muscle loss will occur. An example is total knee replacement but this happens in almost all orthopaedic surgeries. It has been demonstrated that this muscle mass loss is measurable within 5 days averaging 1% per day in total knee replacement [2]. To combat this and provide your body with the protein and amino acids needed to heal from an orthopaedic or musculoskeletal surgery, you need to be on a high protein diet a week before and at least 6 weeks after surgery. I would actually advocate 3 months after surgery.

The following is a guideline for a high protein diet:

• At least 1.5 grams of protein per kg of bodyweight. If you know your weight in pounds, just divide that by 2.2 and you will have your weight in kilograms. Considering that an egg is about 6 grams of protein and a chicken breast is about 50 grams, you will probably need to supplement with extra protein. This extra protein can come from powder collagen or whey protein isolates which can be mixed in a smoothie. The fruit smoothie will also provide you with low-fat carbs. These protein supplements are available at bulk stores such as Costco and Sam’s but also at nutrition stores. There are also great protein supplement drinks such a Fairlife which are lactose free.

There are several other important supplements for surgery that include the following:

Vit D– At least 60-70% of Americans are deficient in vitamin D. Everyone is familiar with the importance of vitamin D in bone health but it is also a very important immunomodulator. There are receptors for vitamin D on both T cells and B cells, crucial players in the body’s immune response, and this affects both the innate and adaptive immune functions. The importance of vitamin D in immune function was highlighted with the COVID 19 pandemic where deficiency was associated with disease severity and supplementation with recovery. The healthy range of vitamin D is 30-80ng/ml. You need to be sure that you are well within the normal range:

• In general, 3000-5000units of Vit D3 daily will get you in the normal range but you need to have a blood test to determine your actual level before you start supplementing.

Vitamin C is critically important in musculoskeletal healing as it is integral to the crosslinking of collagen. Various types of collagen form bone, tendon and ligament tissue and cartilage. One thousand milligrams per day after surgery is recommended. Vitamin C is a water soluble vitamin so that which you don’t use will be expelled by the body.

Consider other supplements that can increase lean muscle mass:

• These include branch chain amino acids or BCAA’s. There are 20 amino acids that make up all of the proteins in our bodies. Valine, leucine and isoleucine are the 3 BCAA’s. Consuming BCAA’s (especially at night) can increase your lean muscle mass.
• Hydroxymethylbutyrate, or HMB, has also been shown in a 3 gram dose to increase lean muscle mass.
• There are other supplemental protein drinks mainly found in health food stores that can increase your protein intake. Those that contain arginine are especially beneficial as arginine has been shown to increase blood flow by converting to nitric oxide but it also boosts your immune system and can help decrease the risk of infection which has been demonstrated in the general surgery literature.

Maximizing your hormonal ability to heal is also important. Androgens like testosterone work in conjunction with growth hormone to potentiate your ability to heal. If you are low in testosterone, then supplementation is an option. There are many ways to boost your native ability to produce testosterone and I encourage you to explore those options. One can also directly supplement testosterone via either transdermal creams, injection or pellets. It is not advised to become supra-therapeutic with testosterone. Instead, you just want to be within your normal age specific range. Supplementation should be discussed with your primary care physician as your past medical history will help determine the safety profile of supplementation.

There are also a number of more intensive methods of improving healing and rate of recovery, including intravenous administration of amino acids and supplements. It has been demonstrated that amino acid supplementation can stimulate protein synthesis by 40% and decrease muscle breakdown by 20%. [3]

Other options include the use of peptides. Peptides are simply chains of amino acids that are less than 100 amino acids long. Typically, peptides are molecules that bind to receptors on target cells and signal that cell to perform an action or produce a bioactive molecule. These peptides can also “turn off” the action of a specific cell. An example would be the reduction in the production of inflammatory mediators, which is beneficial to the recovery process. Additionally, some of these peptides can affect the function of a structure called the mitochondria. The mitochondria are the “energy factories” in each cell that take molecules like glucose and pyruvate and convert them into adenosine triphosphate or ATP. ATP is the currency of energy. Just like the dollar is the currency of the world, ATP is the currency on which our bodies run. We have a few podcasts where you can learn about these peptides and much more. There are experts in town that can set you up with and appropriate peptide regimen designed for you.

References

1. Henriksen MG, Hessov I, et al. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand 2003; 47: 191-199.
2. Dreyer HC, Stryker LA et al. Essential amino acid supplementation in patients following total knee arthroplasty. J Clin Invest. 2013; 123:4654-466.
3. Rittig N, Bach E et al. Amino acid supplementation is anabolic during the acute phase of endotoxin-induced inflammation. A human randomized crossover trial. Clin Nut 2016; 35: 322-330.

1. General

a. The staff of the shoulder and elbow center are dedicated to improving your health and well being. We strive to make your surgical outcome successful. The following outline addresses many common questions.

b. We require someone is with you the night of surgery. Baggy clothing is easier to get in to. Meal prepping easy meals prior to surgery is recommended.

c. Most arthroscopic surgeries are accompanied by pictures and/or a flash drive which you can review at home on your computer.

d. You will receive a postoperative folder that will include your flash drive, pictures, drug prescriptions and other instructions. Please review your flash drive within the first few days after surgery.

e. If you had an open surgery like a shoulder or elbow replacement or fixation of a fracture or other open procedure, then there will not be a flash drive of the surgery but you will probably have some X-rays demonstrating the reconstruction.

f. We have acquired discounted rates at several hotels near Tennova Turkey Creek Hospital, please see attached flyers.

2. Therapy

a. Outpatient home exercises/therapy are specific to the type of procedure performed. Please refer to the applicable therapy protocol which is provided for you in your postoperative folder. In many cases formal therapy is not initiated until your first postoperative visit after surgery. The timing of the initiation of therapy is dependent on the size and type of the repair or reconstruction or replacement and the quality of the tissue. Dr. Spencer will talk to you about your specific therapy protocol after surgery. If you have questions please call Stephanie Johnson (Dr. Spencer’s) secretary during normal business hours at 865 450 1227 as she will have access to operative notes which will describe your specific protocol.

b. In general for rotator cuff repairs, we do not start therapy for a couple weeks. The timing and type of therapy is based on your tear size and quality of tissue.

c. In general for replacements and fracture fixation we start range of motion exercises within and few days after surgery.

3. Wound Care

a. You may remove the dressing the day after surgery. The steri strips or mesh under the dressing, are applied with superglue or cyanoacrylate adhesive & are waterproof. Therefore, you may shower and allow water to run over the steri strips or mesh, and then pat them dry. No further dressing is needed. Try to keep those strips or mesh on as long as possible. Do not soak or immerse the wounds in a bath or hot tub. If you have a splint or a cast, do not remove the splint or cast until you are seen in the clinic at your first postoperative visit. Do not get the splint or cast wet and keep the area elevated above your heart as much as possible. If you have a cast or splint, you will be given an impervious sleeve that should be placed on the involved extremity to keep it dry while bathing. The splint should be kept dry until seen in clinic.

b. If you develop drainage from the wounds, fever greater that 101, bleeding or uncontrolled pain please call Dr. Spencer’s PA (Physician’s Assistant), Jeff Jarnagin, at 865 254 2023 during normal business hours. If after normal business hours please call the PA on call at 865 558 4400.

c. Sutures (if present) will be removed in the office in 10-14 days at the first postoperative visit.

4. Activities of Daily Living

a. You may drive as long as you are not taking pain medication and you feel safe. The operative arm should be kept on the bottom of the steering wheel.

b. To perform axillary (arm pit) hygiene simply bend over at the waist and allow the arm to dangle away from the body. The exposes the axillary region but does not require active use of the operative shoulder. This is exactly how to perform a pendulum exercise as well.

c. Use of the extremity depends on the specific procedure that you had performed. Typically you will be allowed to perform waist level activities such as typing and writing and texting but the elbow should not come out away from the body. Typically you should not reach out away from the body. Dr. Spencer will review with you or a family member what you will be able to do after surgery.

5. Pain Control

a. Take pain medication about 60 minutes prior to performing therapy either at home or with the therapist.

b. Placing a heating pad on the shoulder or elbow 30 minutes prior to therapy will also help with mobility.

c. May use ice pack or cryocuff on the affected area after surgery and is wonderful for pain control. Alternate ice/cryotherapy 30 minutes on and 30 minutes off. KOC does sell cryocuffs. Your insurance would not cover these, the cost is $175 and you can call our DME specialist at 865-769-4574.

d. Enough pain medication is usually given at the time of surgery to get you through until the first postoperative visit. For additional pain medication requests please call our medication line during normal business hours at 865-558-4400 and follow the prompts to the prescription line.

e. If you had either local anesthetic or an interscalene block (numbing medication in the neck prior to surgery to numb the arm) please take oral pain medication as soon as you start feeling some pain. As soon as you start regaining sensation in the arm or start feeling pain at the surgical site, start taking oral pain medication as directed. You want to stay ahead of the pain for the first 48 hours and then start decreasing the amount of oral pain medication as your pain decreases. You do not want to get behind the pain as it will be very hard to catch up.

f. In General we use 3 ways to control pain: *N SAID’s *Narcotics *Ice *Start taking NSAID & narcotics before the block wears off. In general it is more comfortable to sleep in a recliner or reclined position after shoulder surgery. It is ok to have the sling off with arm resting on some pillows while in Recliner.

6. Braces

a. Some patients will be in a brace after surgery. Personal demonstration will be provided regarding how to adjust and remove the brace.

b. Most patients will be in a simple sling that should be worn most of the time except for bathing unless otherwise instructed by Dr. Spencer. It is a good idea to wear the sling while sleeping until seen in the office at the first postoperative visit.

7. Other

a. It is very common to experience nausea with general anesthesia and with narcotic pain medication. You will be given medication for nausea (usually either Phenergan or Zofran) to take if that occurs. Itching can also occur and over the counter Benadryl can help significantly. If the Benadryl does not work Zantac can be combined to block more histamine. Constipation is a very common problem and we encourage patients to start taking stool softeners immediately after surgery. Over the counter medications such as Dulcolax, Senakot and Mirlax can be helpful.

Additionally, check out the flash drive with your surgery video if you got one. They’re great educational tools and help ensure our patients are just as invested in their care as our team!

Trouble watching your surgery video? Follow the link below to download the VLC Media Player.

https://www.videolan.org/vlc/index.html

We are honored that you have chosen us to be a part of your care.