Knitting Together a Surgical Strategy
Medical team devises plan enabling woman with lung disease to undergo shoulder surgery for rotator cuff repair
After knitting just one, purling just two, Pamela Van Mill had to put her needles down. "My right shoulder was in constant pain," she recalled. She wasn’t able to do her favorite hobbies -- knitting, crocheting, embroidering and other crafts that require delicate handwork.
Back in March 2012, Van Mill, 59, was eating lunch at a table in her back yard on a beautiful spring day when she leaned back and her chair toppled over. She landed on her shoulder.
"I thought I had only badly bruised it," Van Mill said. Still in pain a month later, she visited her family doctor who treated her shoulder with a cortisone shot. The medicine helped for three months but then the discomfort came back. An MRI revealed a torn rotator cuff. When the pain got worse after a month of physical therapy, a local orthopaedist recommended surgery.
But Van Mill had concerns. Diagnosed with pulmonary hypertension while in her thirties, she didn’t know if she could safely undergo a surgery. Patients with this chronic disease have high blood pressure in the arteries of their lungs. The condition forces the heart to work harder in order to move blood through the lungs, eventually damaging and weakening the heart. Even minor surgical procedures in these patients can be dangerous.
Collaboration and Careful Planning
Van Mill turned to University of Chicago Medicine cardiologist Stuart Rich, MD, for help. A nationally known expert in pulmonary hypertension, Rich has been caring for Van Mill for 22 years. She could have surgery, he told her, but only with careful planning and monitoring by a team of specialists.
Rich collaborated with sports orthopaedic surgeon, J. Martin Leland III, MD, to initiate the care strategy. "As with all of my patients, I recommended conservative therapy first," Leland said. "Anti-inflammatory medications, steroid injections and physical therapy often get patients to where they want to be for comfort and mobility. With Pam’s underlying medical issues putting her at higher risk for surgery, we needed to exhaust all non-operative therapies before considering the procedure."
But Van Mill’s shoulder discomfort still did not improve after a second round of medical and physical therapy. "She couldn’t sleep at night," Leland said. "Not doing surgery and leaving Pamela in pain was not an option. We wanted to get this done for her."
Because of her cardiac condition, Leland suggested the surgery be done using regional anesthesia, which would involve a nerve block directly to the affected area rather than putting Van Mill to sleep during the operation. Rich agreed the plan offered a safe and effective solution.
Taking extra attention and precautions, the surgery took place in an operating room adjacent to an intensive care unit rather than in an outpatient surgery suite where arthroscopic procedures would normally be performed.
Using a tiny catheter inserted in Van Mill’s neck, anesthesiologist Tariq Malik, MD, blocked the nerves in the rotator cuff area. "We normally inject 20 to 30 ml of medicine to block the nerve, but this amount can affect the heart in patients with her condition," Malik explained. "Using the catheter technique, we were able to numb the shoulder with only 7 ml of medicine injected very slowly."
Leland made four tiny incisions for insertion of the arthroscope and the surgical instruments. Rich was on call, ready to intervene in case of a cardiac emergency. "We all felt that Pam was at minimal risk but at the same time, we were ready for anything," Leland said.
Van Mill was awake and alert during the entire two-hour operation. "I remember saying to the anesthesiologists, 'You guys must be bored.' And they answered, 'We like bored.'"
According to Leland, the surgery and recovery went perfectly and "without a blip." Van Mill was brought to the intensive care unit for post-operative monitoring but moved to a regular hospital room and was soon discharged. The catheter stayed in place for several days after she went home, delivering anesthetic to numb the surgical site and control pain. "We wanted to be sure she was comfortable so as not to stress the heart from pain," Malik said.
"I never took any strong medicine for discomfort," Van Mill said. "And I had no issues with my lungs before or after the surgery."
Physical therapy was challenging, but Van Mill slowly regained movement in her shoulder. In her sessions with her physical therapist, she marked many milestones: lifting a glass, picking up her Bible, pouring a cup of coffee and curling her hair. By early May 2013, she started knitting, crocheting and cross-stitching again. Her goal is to knit a dozen sets of hats, scarves and mittens by Christmas to donate to needy families.
"You don’t know how glad I am," Van Mill said. "I was afraid I’d have to live with this pain for the rest of my life and not do what I love to do. Now there are days when I don’t even think about it. I am doing so well."
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