# Shoulder Code:  Greater tuberoplasty



## Desperate Denise (Jan 16, 2010)

Hey guys!!!

Just when I thought I was getting somewhat of better grip on shoulder coding - I get this one - any help will be greatly appreciated.  Here is the opnote:


 PREOPERATIVE DIAGNOSIS:  Right shoulder rotator cuff arthropathy.

 POSTOPERATIVE DIAGNOSIS:  Right shoulder rotator cuff arthropathy, labral tear/fraying, massive rotator cuf tear (supraspinatus and subscapularis), impingement syndrome/bursitis, chondromalacia

 OPERATION PERFORMED:  Right shoulder evaluation under anesthesia.
 Right shoulder glenohumeral arthroscopy.
 Chondroplasty.
 Debridement of labrum.
 Partial synovectomy.
 Debridement of full-thickness rotator cuff tear.
 Subacromial decompression.
 Greater tuberosity plasty.


 INDICATIONS FOR PROCEDURE:  The patient is a 77-year-old male who is right- hand  dominant.   Has  been  having  right  shoulder  pain  refractory  to nonoperative  management.  X-rays and MRI revealed a chronic rotator  cuff tear  and  some  changes  consistent with rotator cuff  arthropathy.   The
 patient  actually had excellent range of motion and had pain, and  surgery
 was  indicated  for pain purposes.  He deferred any type of  rotator  cuff
 tear,  and  given the appearance on the MRI this was actually  a  relative
 contraindication  given  the chronicity and  the  atrophy  and  the  fatty
 infiltration as well as he deferred any kind of arthroplasty.   He  wanted
 to  try  a  more  minimally  invasive procedure  for  pain  purposes.   He
 understood  the limitations of surgery, understood the risks and  benefits
 as well.  The patient signed a consent form, was medically deemed suitable
 for surgery by is cardiologist and primary care doctor.

 DESCRIPTION  OF PROCEDURE:  The patient was taken to the  OR.   The  
 shoulder was identified as the correct operative extremity by the patient.
 This site was signed by the surgeon.  One gram of vancomycin was given  90
 minutes prior to incision.  The patient was placed supine on the OR table.
 After  adequate  general  anesthesia  was  obtained,  right  shoulder  was
 examined  under anesthesia, had full passive range of motion.   There  was
 subacromial  crepitus  noted.  The patient was then  placed  in  the  left
 lateral  decubitus  position.   All bony  prominences  were  well  padded.
 Axillary  roll  was placed.  The right shoulder was placed in  45  degrees
 abduction, 20 degrees of forward elevation and with 10 pounds of traction.
 The  right  shoulder was then prepped and draped in the standard  surgical
 fashion.   A timeout was performed indicating a right shoulder arthroscopy
 as  the  correct operative procedure.  Local anesthesia was injected  into
 the  subacromial space approximately 20 mL.  A stab incision was  made  in
 the posterior portal site.  Arthroscope was inserted.  There was noted  to
 be  a  significant amount of __________ chondromalacia as well  as  labral
 fraying  and  a  full-thickness rotator cuff tear.  There  was  an  absent
 biceps tendon.  The greater tuberosity was exposed.  There was noted to be
 massive  tear  involving the supraspinatus tendons.   Using  the  anterior
 superior  portal  made from the inside-out technique, a total  debridement
 was  performed, a synovectomy was performed, debridement of the labrum was performed.  Chondroplasty was performed with a 4.5 curved incisor as  well as  an ArthroCare wand.  The subscapularis was noted to be partially  torn in  the  upper  aspect.  There was no evidence of any Bankart  lesion,  no evidence  of  any loose bodies.  Attention was directed to the subacromial
 space.   Using a direct lateral portal 3 cm off the anterior ledge of  the
 acromion  a  portal  was  made.   A complete  subacromial  bursectomy  was
 performed.  The coracoacromial ligament was left intact but just carefully
 peeled  off  the anterior ledge of the acromion for exposure purposes  for
 the AC joint.  Again, the rotator cuff was viewed from the bursal side and
 again  noted to be a full-thickness retracted tear to the glenoid.  Again,
 there  was  noted  to  be  an  absent biceps.  Good  hemostasis  with  the
 ArthroCare  wand.  The remainder of the rotator cuff was debrided  with  a
 4.5  curved incisor.  The acromioplasty was performed with an acromionizer
 making  a  type 2 acromion to a type 1.  A greater tuberosity  plasty  was
 performed as well taking the prominence of the greater tuberosity off  the
 surface  of  the  anterior lateral aspect of it.  The  AC  joint  was  not
 addressed  for  the  surgical procedure.  The rotator  cuff  was  grasped,
 however, excursion was very limited, therefore the rotator cuff repair was
 not even attempted at this time, and the patient understood this prior  to
 surgery.  


THANKS FOR YOUR HELP!!!


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