# Latarjet with  remplissage open



## trose45116 (Feb 5, 2016)

WOULD YOU CODE AS 23466???


PREOPERATIVE DIAGNOSIS:	Left shoulder instability, anterior/posterior.

POSTOPERATIVE DIAGNOSIS:	Left shoulder instability, anterior/posterior.

PROCEDURES PERFORMED:	1.	Left shoulder arthroscopy.
Left shoulder open Latarjet procedure.
Left shoulder extensive synovectomy.
Left shoulder glenoid chondroplasty.
Left shoulder remplissage.

ASSISTANT:	Robert Hutchison, P.A.-C.

ANESTHESIA:	GET.

COMPLICATIONS:	None noted.

ESTIMATED BLOOD LOSS:	Minimal.

INDICATIONS:  The patient comes in with chief complaint of left shoulder instability.  He had multiple shoulder dislocations he estimates may be somewhere between 30 to 50.  He did have seizure disorder.  This has been corrected.  He was having instability anteriorly as well as he had a reverse Hill-Sachs.  I did obtain a CT scan showing evidence of decrease in anterior bone loss.  I was concerned that a soft tissue procedure would not be adequate for him.  I did recommend Latarjet procedure.  He understood this.  He was in agreement.  I also described to him that we would evaluate his posterior instability.  It did sound like positionally he was more anterior and had more apprehension anteriorly.  Risks and benefits of surgery were described in detail including but not limited to infection, bleeding, damage to vessels or nerves, continued pain, and possible repeat surgery.  All questions were answered.

OPERATIVE PROCEDURE:  The patient was taken to the operating room after appropriate side was marked and consent obtained.  The patient was transferred to OR table, and anesthesia was successfully induced.  He was placed in the beach-chair position.  Head and neck were stabilized throughout.  Left upper extremity was prepped and draped in the usual sterile fashion.  Timeout was performed.  Antibiotics were given prior to skin incision.  We did examine the shoulder.  He did have instability anteriorly as well as posteriorly.  He did not have inferior instability.  He was not MDI.  Left upper extremity was prepped and draped in the usual sterile fashion.  Timeout was performed.  Antibiotics were given prior to skin incision.  Standard posterior portal was created.  I went into the joint.  He had extensive synovitis about the interval as well as the rotator cuff.  This was debrided with a shaver.  There was no evidence of a SLAP tear.  He lost approximately 30% of the anterior glenoid.  I felt that a Latarjet would be most appropriate for him.  There was no labral tissue in the complete periosteal stripping anteriorly.  

There was no evidence of a SLAP tear.  Biceps was intact.  No evidence of biceps subluxation.  Subscapularis was intact.  Supra and infraspinatus were intact.  Evaluation posteriorly showed no evidence of bone loss; however, there was labral issue.  Again, he had extensive synovitis about the posterior aspect of the shoulder and this was debrided with a shaver.  We then turned our attention anteriorly.  We made a deltopectoral incision just medial, cut through the skin and subcutaneous tissue sharply.  Deltopectoral interval was identified and developed.  02:45 ______ was taken laterally.  We then took the coracoid and took down the pectoralis minor.  The conjoint tendon was obviously left attached.  We then took an osteotome and a rongeur.  The osteotome in the coracoid was harvested.  Care was taken to prevent injury to the musculocutaneous nerve.  The coracoid was then prepared.  The conjoint tendon was still in line, and the inferior aspect of the coracoid would be associated with the glenoid.  Two drill holes were placed.  We then turned our attention toward the subscapularis.  We did a subscapularis split.  We then teed the capsule which was a humeral based T capsule.  We then took a Bovie and the tissue anteriorly was removed.  This was poor quality tissue.  We then took a bur and decorticated the glenoid.  This was fashioned in order to fit the coracoid piece.  We then placed the coracoid piece at approximately 5 o’clock.  This was just slightly recessed.  We placed two screws, size 36 screw and a 34 screw, and this secured the piece quite nicely.  We were very pleased with this.  Excellent fixation was achieved.  We did use a washer inferiorly.  Both screws were fully threaded.  Excellent compression was achieved.  We then examined the shoulder.  He had excellent stability anteriorly; however, he still had issues posteriorly.  We went back in the joint.  He had a sizeable Hill-Sachs lesion; however, this was not engaging at this point.  I felt that we could ink previous posterior stability as well as make the Hill-Sachs extraarticular with remplissage procedure.  We placed two 55 Corkscrew anchors adjacent to the articular surface about the posterior aspect.  We then placed total of four sutures through the capsule.  These were subsequently tied down.  We performed the remplissage.  We were very pleased with this.  He examined with significantly increased stability.  Prior to tying down the remplissage, we gently decorticated the Hill-Sachs lesion in order to get a good bleeding bed to accept this tissue.  The subscapularis was closed with #1 Vicryl.  Subcutaneous tissue was closed with 2-0 Monocryl.  Skin was closed with 3-0 nylon in a baseball stitch fashion as were the portals.  Xeroform, 4 x 4’s, ABDs, and a sling were applied.  The patient was taken to the recovery room in stable condition.  There were no apparent complications.


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## shecodes (Feb 8, 2016)

This is usually 23462


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