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Professor Jonathan L Rees

Brief Outline: Professor Jonathan Rees graduated from St Mary’s Hospital Medical School, London, in 1992. He trained in orthopaedics in Oxford and has specialist fellowship training in routine and complex shoulder and elbow surgery. His was appointed as an Academic Consultant Orthopaedic Surgeon to the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences in 2005 and was made a full Professor at Oxford University in 2014 becoming a Professor of Orthopaedic Surgery and Musculoskeletal Science. He continues to specialise in shoulder and elbow surgery and runs this surgical service at the Nuffield Orthopaedic Centre (NOC), Oxford.
Background: Professor of Orthopaedic Surgery and Musculoskeletal Science; Academic Consultant Shoulder & Elbow. Botnar Institute of Musculoskeletal Sciences. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford.

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A doctor explains what subacromial shoulder surgery is?

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Well, it has a big, long name. It’s called arthroscopic subacromial decompression or ASD for short. But that’s basically keyhole surgery of the shoulder, usually performed through two keyholes, one for the little camera, one for the little instruments. 

And what the surgeon, and what we’re really trying to do at that point is to shave a spur or little prominence of bone from the roof of the shoulder, which has been catching on some tendons in your shoulder and causing the pain that you get when you lift your arm up.
 

A doctor talks about the risks of subacromial shoulder surgery.

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Well, I think with keyhole surgery, the risks are generally a lot lower than with other types of surgery. Because it’s normally done as a day case, so you’re in and out of hospital quickly. It’s keyhole, so the wounds generally tend to heal a lot more speedily as well. But no operation comes without any risks, so there’s still a small risk of infection. It is small. Most surgeons and most hospitals would probably quote about a 1 in 300 chance of getting a problem with the wound or possibly a more serious infection deeper in the shoulder. 

About 1 in 100 people can get some stiffness that develops in the shoulder after keyhole surgery. And that’s classically called a frozen shoulder. It’s not a dangerous problem, because it does get better. But it’s a real nuisance, because it can last for several months before it gets better. And you definitely wouldn’t thank your surgeon or your team until you got better from that. So that’s a bit of a frustrating one. It’s about 1 in 100 people. I personally think that actually one of the main risks is that you might not get better from that operation. You know, it doesn’t come with 100 per cent guarantee, but most surgeons and most teams will quote a success rate of about 90 to 95 percent. 

So that, you know, and while there are many people who will focus on that, that does mean some people will still have some ongoing pain and may not get the result that they were looking for. And perhaps over about ten years we’ll probably see a few people coming back with the same sort of problem. It’s more common with every decade of life. So the younger you are when you get it, you might get it again. The older you are when you get it, the less likely.

And if someone does have a frozen shoulder, how is that treated?

Well, actually it does just get better on its own. So probably the most common treatment in the UK is to do little with it except make the right diagnosis, reassure your patients. But it is a really painful condition in some people. So sometimes it does need an injection into the joint, of some anti-inflammatory Cortisone and some local anaesthetic. But generally speaking it’s one that gets better on its own. I suppose ironically a few people do come back and ask for a keyhole operation to free up their frozen shoulder. Which has a little irony, because it was the keyhole operation that maybe caused it in the first place.
 

A doctors talks about recovering from subacromial shoulder surgery.

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Most surgeons and most teams would probably say to their patients that 90 to 95 per cent of people will improve with this operation. But they can improve over a 6 to 9 month period. So for some people it can be quite slow improvement and for others it’s quite rapid improvement. 

But generally speaking you’ll go home, you’ll be in a sling. But you don’t need to stay in the sling. Once the nerve block has worn off and the arm has come back to life, you can start moving the shoulder pretty much as you want. And for some patients, they find they’re able to move it very quickly, within a few days. For others it might take up to a week. 

Most people are off driving for 7 to 10 days. You need to be out of the sling and have a reasonable range of movement back in your shoulder to be able to drive. I think most people on average take about 2 weeks off an office job after this sort of surgery. Manual work, it’s often 6 weeks before you really feel able and comfortable to go back to do your job. Many people have to go back sooner than that. You probably can’t really damage what the surgeon has done. But you can make your shoulder sore and that can eventually slow things down. 

So how much movement can people expect? So in the first few days they...

Within the first few days they’ll need to take some painkillers. And if you take some painkillers, you expect your shoulder to get to the point where perhaps you’re getting your arm up to your face, you’re able to eat and drink again normally. But it might be 2 weeks before you’re getting to the stage where you can get your arm above shoulder height. And for many patients, that could even be 6 weeks before they’re able to achieve that. So it does really vary. But I think the important thing to remember is you can’t really damage or do any harm to the shoulder. So if it’s feeling okay, you can just get on and move it.
 

A doctor explains why a nerve block is given and how the shoulder and arm feel immediately after surgery.

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So an important part of surgery is having no pain afterwards. And traditionally people would wake up perhaps in pain, given painkillers and so forth. Now the anaesthetic teams that work with the surgeons are very motivated to ensure the patients are as comfortable as possible, so they use a nerve block. And that involves having some local anaesthetic put in at the side of the neck, which pretty much numbs the shoulder. But it can numb the entire arm.

So some patients do wake up and, while they’re completely comfortable, they find it quite an alien or weird experience because their arm is dead and they literally can’t feel it. And I think certainly one or two patients when I talk to them, they even have to look down quickly to make sure their arm is still there. Because they just can’t feel it and it is a bit of a dead weight up to about 24 hours. But on balance most patients usually report back that they’d rather have a pain-free, comfortable shoulder, even though it might feel like a bit of a dead weight of an arm for a while.
 

A doctor explains what happens at the pre-operative assessment.

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I think that pre-operative assessment probably has a couple of roles. One is you get to meet the surgeon or the surgical team again to go through things in more detail in regard to the operation. Sometimes you don’t quite get all the information you need as a patient when you’re in a busy Outpatients. So the pre-assessment gives you an opportunity to speak to the surgical team again. Usually that’s when your consent form is signed. So you get to talk about the risks and the benefits of that operation. 

But the other main role of the pre-admission is sort of a bit like having an MOT, where the nursing staff, the junior doctors will just make sure that you’re fit enough to have that operation, there’s no heart or chest problems, there’s no other illnesses that might have an impact. So it’s all about trying to make sure that, when you come in for your operation, things run as smoothly as possible.

And what sort of tests could patients expect to have at the pre-op assessment?

Well, they’ll usually have an examination of their heart and their lungs. They’ll have a tracing of their heart and they’ll have some routine blood tests done. Those are the standard things. It’s possible during those simple tests that the doctors may pick up something that requires further, more complicated tests. And occasionally that might slow down or delay your operation. But it’s all generally done with your best interests at heart.

Some patients mentioned filling out a questionnaire. Is there usually a questionnaire as well?

I think that will vary from hospital to hospital. There are something called Patient Reported Outcome Measures, or PROMs for short, these days. And it’s a big drive by the Health Service and the government to ask patients to complete scores about how painful or how much trouble they’re having, whether it’s their shoulder or their knee or their hip. And those can be repeated after the operation as well. And it’s really aimed at trying to identify how they’re improving, how quickly they improve and making sure that they’re getting a good benefit from their treating centre.
 

A doctor explains what happens at follow-up and who to contact if there are shoulder problems after that.

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This [follow-up] will vary throughout the country. Certainly in our own region, our own centre, most patients after this type of shoulder operation will come back to Outpatients at 6 weeks. And at 6 weeks they’ll either see one of the surgical team or perhaps more importantly they’ll see the physiotherapist. Because after surgery, it’s usually down to the rehabilitation and the physiotherapy. So they may not see their surgeon again. If they see the physio and they’re doing well and they’re happy with their exercises, they may not see the surgeon. If they’re not doing as well, the surgeon is usually called in to say hello and to have a look at them as well. 

And generally speaking most patients aren’t discharged from hospital care until they’ve got the result that they want. So it’s not usually an issue of struggling to get back in contact. That line of contact should be open until they’re better. But otherwise obviously their GP is a great source of information and can usually get back in contact with the hospital team if needed.

And when they attend the follow-up appointment, what happens at the appointment? Some people wondered if they’d have x-rays. What usually happens?

So after this particular type of operation, where a little bit of bone has been trimmed from the shoulder, nothing has been put in, so x-rays aren’t usually required. It’s all about ensuring that the pain is improving, the range of movement is improving. So it’s really about physiotherapy and exercises. And that’s what is looked at and that’s what is checked. And the physios may then modify or change the rehabilitation or the exercises that need to be done by that patient. 

Many patients ask about physiotherapy after this operation. And actually again that will vary throughout the country. Many patients won’t see a physiotherapist during those first 6 weeks. And that’s because most people after this operation can just get on with their own exercises, their own rehabilitation. And they get checked at the 6-week mark with the physiotherapist. Those that are doing well can probably just carry on as they are. Those that are struggling a little are usually picked up by the physios at that point and may need some more concerted input.

So patients can do gentle exercise, or if they feel able to move on to something a bit more challenging, that’s okay?

Again I think the important thing to remember after this operation is you can pretty much let your shoulder tell you. If your shoulder is feeling comfortable, you can increase the level of activity and do more and more things without worrying about harming your shoulder. If it gets sore, it probably means you did a bit too much and you just need to cut down things a little, and then try again a week or two later. 
 

A doctor talks about the telephone consultations used to assess patients.

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So I think for many patients, they’ll be aware traditionally that a referral to the hospital really was about their GP writing a letter, sending it through to the hospital and then the patient would be seen in an Outpatient clinic. And generally speaking that’s changed throughout the UK at the moment. And there’s a sort of an intermediate service or triage service which has been put in place between GPs and the hospitals. And that service or that triage hub generally receive the letters from the GP and then look at those letters and make a decision about whether that letter is passed through to the hospital or not. 

And although I think some patients get quite frustrated by that, because the feeling will be, “Well, the GP has made the referral. I should be seen”, what these intermediate services are doing is perhaps identifying that maybe some more physiotherapy or perhaps another injection into the shoulder might be the right type of treatment at that point for that patient. 

So some referrals are passed through. Some are delayed. And then that often involves a telephone consultation as well, just to talk through those aspects about whether the referral is passed through. But it’s not something that the hospitals have put in place. But it’s something that’s pretty much in place throughout the country at the moment, sitting between General Practice and sitting between the hospitals.

So when a patient gets one of these calls, who will generally be making that call? Or can that vary?

It will vary. It may be a nurse, it may be a physiotherapist, it may be a doctor. But that would vary throughout the country. It is different in different regions at present. In our own area, it’s usually a physiotherapist.

So it would be a health professional?

It usually is, but I don’t think it necessarily is throughout the country. 
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