# Left Shoulder Resection Arthroplasty with Placement Antibiotic Spacer



## Joyce Burchett (Nov 15, 2018)

Post op DX: Septic Arthritis LT Shoulder with chronic anterior shoulder dislocation & glenoid fracture malunion
Pt. has history of septic arthritis LT shoulder that was addressed with irrigation & debridement in July by another surgeon. They have a previous history of fractures about the shoulder including the acromion, glenoid & coracoid. These have resulted in fracture malunion with chronic anterior shoulder dislocation & now recurrent suspicious infection. Op Note: Incision made anteriorly over the shoulder through a standard deltopectoral approach. I was unable to use the previous transverse space surgical scar. The deltopectoral interval was identified & also the cephalic vein & this was preserved throughout the entirety of the procedure retracting it laterally with the deltoid. There was significant scar tissue from her previous surgery & secondary chronic infection. I released the proximal 1 cm of pectoralis major insertion as well as the leading edge of the coracoacromial ligament to facilitate exposure. I identified the biceps tendon & its sheath & began to resect & reflect the subscapularis & underlying capsule just medial to this. I opened it through the rotator interval, exposing the humeral head. Red tinged & slightly turbid synovial fluid was identified. I sent specimens for analysis. The shoulder joint was identified & revealed extensive erosive changes about the humeral head with reciprocal changes about the glenoid consistent with advanced septic osteoarthritis. The rotator cuff was noted to be completely torn & retracted. The humeral head was noted to be chronically anterior dislocated. I released the inferior capsule to facilitate further extraction of the humeral head with combination of adduction, flexion & external rotation & the head was completely dislocated. I then identified a starting point for entry of reamer. I progressively reamed up to 12 mm. I then used the extramedullary alignment guide to fashion a resection of the humeral head in 30 degrees of retroversion using the humeral epicondylar axis & the forearm as a guide. I resected approximately 25 mm of the native humeral head. I removed extensive foul appearing tissue from the metaphysis. I prepared the humerus with broaches up to size 12 & 30 degrees of retroversion. I then assessed the glenoid. There was chronic malunion of the glenoid with significant loss of the anterior substance of the glenoid which would make it unreasonable to try to resurface in the future. I did try to ram down the glenoid using the glenoid reamers & a guide pin & what I thought was the central aspect of the scapula. I did remove foul appearing tissue that surrounded the growth glenoid in particular over the anterior aspect which is felt to be residual hypertrophic scar tissue from the fracture. I thoroughly irrigated the glenoid & humerus with antibiotic irrigation. I prepared the size 12 Prostalac implant. Once the prostalac stem was prepared & hardened it was removed from its casing. The stem was place in appropriate retroversion in the humeral canal. The wound was irrigated & closed. I repaired the capsule & subscapularis to the humeral shaft & repaired the deltopectoral interval.  Need help with how to code-Unlisted or 23470 or 23472 & 11981?


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## ACord (Nov 28, 2018)

*Bump*

I would also like to get others' thoughts on this. My surgeon makes his case that he should be able to bill a 23470 or 23472 even without a total shoulder prosthesis due to the time/skill it takes to mold and insert the Prostolac spacer. He states he is not taking a lump of bone cement and imbuing it with antibiotics. I don't agree as the spacer is not meant to take the place of the joint but only until the infection clears up. The fact that the patient is able to experience greater mobility with the Prostolac and not a traditional antibiotic spacer appears to me to not be relevant to the code selection.

I would tend to lean towards 23195 (humeral head resection) with 11981, as one of the reasons for a resection would be infection. However, I can't locate any information this. I also have other surgeons who are using Prostolacs in staged hip revisions who are making the same argument that they should be able to bill 27134 rather than 27091 and 11981 when they remove the prosthesis and implant a Prostolac.


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