What is the recommended postoperative care for a patient after right shoulder rotator cuff repair with balloon arthroplasty?

Postoperative Care After Right Shoulder Rotator Cuff Repair with Balloon Arthroplasty

Implement a multimodal pain management protocol starting with interscalene brachial plexus block, paracetamol, NSAIDs, and IV dexamethasone, followed by structured rehabilitation beginning with immediate passive range-of-motion exercises to prevent stiffness while protecting tendon healing. 1, 2

Pain Management Protocol

Pre-operative and Intra-operative Interventions

• Administer paracetamol and a COX-2 inhibitor pre-operatively or intra-operatively and continue postoperatively for baseline analgesia 1

• Give a single dose of IV dexamethasone to prolong the duration of regional anesthesia, reduce analgesic requirements, and provide anti-emetic effects 1

• Perform interscalene brachial plexus block as the first-choice regional technique (Grade A evidence), either as continuous catheter or single-shot injection 1, 2

  • If interscalene block is contraindicated, use suprascapular nerve block with or without axillary nerve block as an alternative (Grade B evidence) 1, 2

Postoperative Pain Control

• Continue paracetamol and NSAIDs/COX-2 inhibitors throughout the postoperative period as the foundation of systemic analgesia 1

• Reserve opioids strictly for rescue analgesia only when other modalities are insufficient 1, 3

• Avoid superficial cervical plexus blocks, as they do not adequately cover the glenohumeral joint or deep shoulder structures and lack evidence for efficacy 2

Rehabilitation Protocol

Phase 1: Immediate Postoperative/Protective Phase (0-6 weeks)

• Begin immediate passive range-of-motion exercises rather than prolonged immobilization to minimize stiffness risk 4, 5

  • Studies show resistant postoperative stiffness occurs in only 1.5% of patients with immediate passive motion protocols versus 4.5% with 6-week immobilization 5

• Protect the repair with sling immobilization between exercise sessions during the first 6 weeks 4

• Monitor for early stiffness development, which occurs in approximately 10% of patients but typically responds to conservative management 5

Phase 2: Progressive Strengthening Phase (6-12 weeks)

• Transition to active-assisted and active range-of-motion exercises at 6 weeks postoperatively 4, 6

• Initiate progressive strengthening exercises focusing on rotator cuff and scapular stabilizers 4

• Continue home-based rehabilitation program with structured exercises, as compliance during this phase is critical for successful outcomes 6

Phase 3: Advanced Conditioning (12+ weeks)

• Progress to advanced strengthening and return-to-activity exercises after 12 weeks 4

• Assess tendon healing with MRI at minimum 2 years if clinical concerns arise, as healing rates with balloon spacer protection show 81.3% tendon integrity 7

Special Considerations for Balloon Spacer

• The subacromial balloon spacer provides mechanical protection during early healing, allowing tensionless repair with acceptable healing rates 7

• Expect significant pain improvement, with studies showing pain reduction from mean NRS 6.8 preoperatively to 0.8 at final follow-up 7

• Anticipate functional improvement, with ASES scores increasing from mean 39 preoperatively to 89 at 2-year follow-up 7

Critical Pitfalls to Avoid

• Do not use opioids as first-line analgesics instead of the recommended multimodal approach, as this increases side effects without superior pain control 1, 8

• Do not immobilize for extended periods (>6 weeks), as this significantly increases the risk of resistant postoperative stiffness requiring capsular release 5

• Do not neglect regional anesthesia techniques, as inadequate pain control can impair early rehabilitation and compromise long-term outcomes 1, 8

• Do not delay intervention for resistant stiffness; if stiffness persists beyond conservative management (occurring in 3.3% of cases), arthroscopic capsular release successfully restores range of motion 5

Monitoring and Follow-up

• Assess pain scores, range of motion, and functional outcomes at regular intervals using validated measures (ASES, NRS) 6, 7

• Recognize that healed tendons (Sugaya I-III on MRI) achieve significantly better functional outcomes (ASES 93) compared to non-healed repairs (ASES 74) 7

• Monitor for complications including infection, nerve injury, and deltoid dysfunction, though these remain uncommon with arthroscopic technique 1