Prednisone and Rotator Cuff Surgery

[CEAGLE]

Hi PMRpro,

Having rotator cuff surgery in two days. I am on 6 1/2 mg of prednisone but surgeon wanted me to discontinue completely but he and the rheumy decided for me to go to 2 1/2 mg. after surgery. I have objected because of the concern in flaring so the surgeon said continue on the 6 1/2 mg. but he is still very concerned of the healing of the tendon to the bone.

What is your opinion and since this is an outpatient procedure what is your opinion of blood tests to check my inflammation markers?

[suzy1959]

I’m no expert, but having just had a hip replacement on 11mgs Pred. I can tell you that the anaesthetist was not worried about me taking it. He did give me a steroid infusion afterwards, but this might have been because it was quite a major operation? My Rheumy says that surgeons are more worried than they should be about the steroids and the kind of oral doses we are on are nothing to worry about.

[CEAGLE in reply to suzy1959]

Thanks so much. This decision has been a nightmare trying to figure out which way to go.

[Ruadh in reply to CEAGLE]

Shoulders depend on ligaments and tendons, that is all they have to hold them in place. Steroids are known to destroy ligaments and tendons, and can be a surgical nightmare in shoulder surgery as this can happen after a patient has had cortisone injections into their shoulders ! Rheumies are too often unable to take this on board and in some instances go on insulting the shoulder with cortisone injections. One or two injections are OK but more can cause too much injury to the tendons and ligaments, then the surgeon is faced with unenviable surgery difficulties. It is very much up to the surgeon which way to play shoulders. Hips and knees do not have anything like the same problems. It is only applicable to shoulders.

It is a wretched decision. But the surgeon has to make the surgery work. As for a replacement... Hope it can go for a rotator cuff repair, or even possibly a Copeland hemi-arthroscopy - though the Copeland is really for arthritis degeneration.

As for second opinions, one of the top shoulder surgeons in the UK, is Professor Leonard Funk, the Wrightington Hospital - that was where the first ever hip replacement took place, under Prof Emeritus Sir John Charnley. Prof Funk has spoken, and written, of degenerative ligaments and tendons in the shoulder due to cortisone injections. Another eminent surgeon, also at the Wrightington, is Prof Ian Trail. You might do well to consult with them.

Heartfelt and sincere good wishes to you, and the best of everything. But this decision really does lie with the surgeon.

[HeronNS]

Your dose, 6.5 mg, isn't even what the body makes naturally so I doubt your surgeon should have any concerns. And, as you know, if your inflammation markers are down that indicates pred is functioning as it should to reduce the inflammation in your body, no more, no less!

[Ruadh in reply to HeronNS]

The problem lies in tendons and ligaments already damaged to an extent that has the surgeon worried. IF Ceagle has had cortisone injections into her shoulders to help with pain and inflammation, then that is the specific scenario I was referencing. Maybe Ceagle has not had such injections but still has degenerative tendons and ligaments, it is these that pin the muscles to the bone in the shoulders, make for the great movement we have in our shoulders. Makes surgery difficult if these are damaged.

[CEAGLE in reply to Ruadh]

Thanks for your comments. My tear happened because of a fall into a bookshelf.

[Ruadh in reply to CEAGLE]

Ouch. That was indeed some horrific fall - a person I know did it falling downstairs on a circular stairway. Fell on an outstretched arm and ripped out her whole shoulder. Presented surgeon with very difficult reconstructive surgery, necessitating a full reverse shoulder replacement. A big surgery, not all shoulder surgeons fully competent to do it.

But a great friend had brilliant reconstructive surgery after a horse she was holding was frightened and took off, with her still holding, but a tree was in the way, horse went one way and she the other. A big surgery, with long recovery and rehab. Brilliant result. Though she still has to be somewhat careful - do not fall on an outstretched arm etc !

Best to you in all aspects.

[PMRpro Ambassador]

Have they thought about your adrenal function during and post surgery? Though that will be the anaesthetist's problem rather than the surgeon's.

Not that I really know, but I can't see what difference it makes now - the damage is there (maybe) and stopping oral pred acutely won't change that, especially as you will probably go back to a higher dose post-op and stopping it will almost certainly lead to a flare which may then lead to an even higher dose being required so you can mobilise and do the physio. The greatest tendon effects are due to injections into the joint - which is why they should be limited to occasional use and that is the basis for Ruadh's excellent post.

[Daylily2000]

My Rheumatologist assured me that steroids will enhance healing after surgery. Maybe tendon-bone attatchment presents a special consideration? Something to discuss with the medical team.

[Ruadh in reply to Daylily2000]

The problem lies in damage to tendons and ligaments by injection of cortisone into the joint capsule to bring down inflammation and pain, before surgery. As for using pred to facilitate recovery of tendons and ligaments following shoulder surgery - and, I would assume pred by mouth as opposed to injections of cortisone into the joint capsule (!) - one would need to discuss this fully with the surgical team.

[artfingers]

I had surgery on both my shoulders last year and this year, the left was rotator cuff done this past December (but nowhere near as extensive damage as what it seems you are suffering). At the time of surgery, the aenesthesiologist did give me a "boost" to my adrenals (not sure what but they knew my full history) and I stayed on oral prednisone before and after both surgeries and stayed at my full dose. At that time I believe I was also at 6 1/2 mg prednisone. I was lucky in that my orthopedic surgeon did a stint working with a rheumatologist so he was very in tune with PMR and other auto immune issues. If you have had your surgery by now, I hope it went well. I agree with PMRPro in not reducing your pred dose. Good luck!

[CEAGLE in reply to artfingers]

Can’t thank you enough for responding artfingers. Had surgery this afternoon and am typing with left hand. Surgeon did a stem cell while in surgery to help aide with the healing.

I refuse to go down to the low dose 2 1/2 since I am alternating 6 ....6 1/2 mg. That’s where you were at and sounds like you have healed fine

Thanks again

[artfingers in reply to CEAGLE]

Oh so glad that surgery is over. My friend wanted to have the stem cell as she heard great things about it but she couldn't afford it. I am so glad you are on the mend! Yes, glad you are sticking with the dose you were on - rest up it sure is a lot to put our bodies thru, right? I recall I also had the nerve block and that sure was funny - my arm seemed like someone else's arm, a dead weight for about a day. Anyway, thanks for the update! Heal well!

[CEAGLE in reply to artfingers]

Artfingers. Did your shoulder surgery involve a tear that required healing tendon to the bone while you were taking prednisone?

[CEAGLE in reply to CEAGLE]

Yes. I wondered if yours involved a tear as well. My tear was around an inch and a half.

[artfingers in reply to CEAGLE]

It was a small ligament, yes had to be re-attached, but not a large one I don't think. I didn't really ask, but it did take a LOT longer to heal than the other shoulder which did not require any re-attachment. Sore longer but I was swimming (in Florida) about 5 weeks after surgery and mid-way thru physical therapy. I tried to swim sooner but was scolded for that so stopped. Now, this summer, am swimming up to 2 hours (breast stroke, side stroke, not the crawl) in our lake. I trusted my surgeon to know what to do and my aenesthesiologist whom I told every little detail of my "journey", exactly how much and what kind of pred I was taking. I hope all goes well for you. So have you had the surgery yet? Keep me posted. I found it well worth it and am so glad I had it done!

[CEAGLE in reply to artfingers]

Had my surgery yesterday and he did a stem cell injection using my bone marrow to aid in the healing. I can tell he is still concerned about the healing since he wants me to wear the immobilized sling for 6-8 weeks.

I just hope this tendon attaches after all of this

[Ruadh]

A good and concerned surgeon Ceagle, and, a good medical team. The tendon will reattach, but will need time. Keep to the sling, and follow instructions from physio, and surgeon. Go easy on yourself and take care.

[CEAGLE in reply to Ruadh]

Thanks for the encouragement