# rotator cuff revision  help!



## karieb70 (Jan 12, 2018)

INDICATIONS FOR PROCEDURE:  The patient is a 55-year-old, white female,

who injured her right shoulder, had a primary right shoulder rotator

cuff repair arthroscopic assisted over 8 months ago back in April 2017,

however, re-injured her shoulder and also had continued to smoke when

she was counseled regarding smoking cessation.  Followup MRI revealed a

propagation and retear of her rotator cuff tear.  It was explained to

the patient the options and alternatives.  Revision surgery was

indicated. The nature of procedure was discussed with the patient, which

would be an open revision rotator cuff repair with an augmentation.  The

patient was explained the importance of smoking cessation, however, the

patient continues to smoke, although she shows me that she will quit

smoking.  She was explained the risks and potential complications

include, but not limited to death, infection, blood clot, fracture,

neurovascular injury, pain, stiffness, scarring, bleeding, inability to

repair, retear, reaction to the graft, failure of repair, poor outcome,

deltoid insufficiency.  The patient signed informed consent.


PROCEDURE IN DETAIL:  The patient was taken to the OR.  Right shoulder

was identified as the correct operative extremity by the patient.  This

site was signed by the surgeon.  2 g of IV Ancef given preoperatively

within 1 hour of incision.  The patient received a right interscalene

block in the holding area by Anesthesiology.  The patient was placed

supine on the OR table.  After adequate general anesthesia obtained, the

patient's right shoulder was examined under anesthesia, had full range

of motion.  No evidence of any instability.  The patient was placed in a

semi-beach chair position with a spider attached.  All bony prominences

were well padded.  Right shoulder was then prepped and draped in a

standard sterile surgical fashion.  Time-out performed indicating an

open revision right rotator cuff repair with augmentation as a correct

operative procedure.  Using a standard open approach to the rotator cuff

repair starting at the just lateral to the coracoid in line with

Langer's line extending to the lateral aspect of the acromion at the mid

point between the anterior and posterior acromion, this site was

preinjected with local anesthetic.  Incision was then made with the

scalpel.  Thick flaps were then raised.  The deltoid was then split

starting at the anterior acromion extending distally, not more distally

than 5 cm from the acromion.  This was tagged with a #5 Ethibond.

Retractors were then placed.  Good hemostasis obtained with the Bovie

cautery.  At this time, the rotator cuff tear was identified.  There was

no evidence of any biceps tendon.  The rotator cuff tear appeared to

involve just the supraspinatus tendon and had a V-shaped tear and it was

nonretracted, which already of the tendon remained attached to the

greater tuberosity.  All suture anchors remained in place.  The sutures

were then removed, however, the suture anchor was left in place, given

that these were imbedded in bone and not prominent and would be

technically difficult to remove without significant bone loss.  The

greater tuberosity was then prepared with a rongeur and preparing a bony

trough from the articular margin of the humeral head to the greater

tuberosity.  At this time, a side-to-side repair was performed, given it

was a V-shaped tear and a release was performed to the coracohumeral

ligament.  The rotator interval was also intact.  At this time, the side-

to-side repair was done to the supraspinatus tendon with #2 FiberWire

sutures in a figure-of-eight fashion from the level of the glenoid

laterally to the greater tuberosity.  At this time, a 2.8 Q-Fix was

placed at the articular margin and then these sutures were passed in a

simple fashion to the anterior and posterior leaf and again to the

anterior and posterior leaf.  Another 2.8 Q-Fix suture anchor was placed

at the lateral aspect of the footprint of the greater tuberosity and

then these were passed in a horizontal mattress-type fashion, one in the

anterior leaf and then one in the posterior leaf.  At this time, a

matrix HD RTI Biologics graft was then trimmed.  The rotator cuff tear

appeared to be about 2 cm in width, which made a medium size tear.

Therefore, the sutures left from the anchors were then passed through

the graft in a similar type fashion and then the sutures were then tied.

The Q-Fix anchor in the more lateral aspect of the greater tuberosity.

Sutures were then tied to themselves and then an another Q-Fix anchor

was placed at the lateral aspect of the greater tuberosity distal to the

insertion of the rotator cuff insertion and then these were passed in a

simple fashion in the anterior and posterior aspect of the graft and

then these sutures were then tied to the more lateral footprint 2.8 Q-

Fix anchors.  The sutures were then cut.  The medial Q-Fix anchor

sutures were also cut.  Secure repair was performed.  The shoulder was

examined and had no evidence of any impingement.  The previous

acromioplasty had already been performed.  There was no active bleeding.

A previous bursectomy was also performed.  Therefore, only a minimal

open bursectomy needed to be performed.  There were minimal adhesions in

the subdeltoid region.  These were also released.  The axillary nerve

was protected with the suture and then at this time, the incision was

copiously irrigated.  The deltoid was then repaired to the acromion with

#2 FiberWire sutures in a figure-of-eight fashion and the deltoid split

was closed with #2 FiberWire sutures in a figure-of-eight fashion.  A

secure repair of the deltoid was performed to the acromion.  The

incision was then closed with 2-0 Vicryl suture in inverted fashion and

the incision was closed with 3-0 Monocryl sutures in a subcuticular type

fashion.  Steri-Strips was then applied and a sterile dressing was

applied.  Right upper extremity placed in UltraSling.  The patient

tolerated the procedure well and was taken to recovery room in good and

stable condition.


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## AlanPechacek (Jan 17, 2018)

This case is very complicated from both the history and diagnosis aspects, as well as the procedure done for repair, and there are a lot of questions I would have based on the terminology used in the documentation as presented (too many, in fact, to go into all of them).  I would "condense" this into an *Open Repair of a Chronic Rotator Cuff Tear with* *Graft Augmentation/Supplementation*.  There is no code for this, particularly with the complexity of having been repaired before and the graft.  I am not sure I would use the term "revision" in the procedure as he didn't take anything apart and repair it again differently.
     My best suggestion would be *23929: Unlisted procedure, shoulder*, and pair it with *23420: Reconstruction of complete chronic rotator cuff tear* as I think that based on the procedure as described this most closely "equates" the complexity of both.  What he did was beyond *23412: Open Repair of chronic rotator cuff tear* alone in complexity.  A lesser coding alternative would be *23412* with *Modifier 22: Increase Procedural Services.*

It will be interesting to see what others offer or recommend.

Respectfully submitted, Alan Pechacek, M.D.


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## daedolos (Jan 29, 2018)

Could the mini open bursectomy be coded as well?  The documentation is skimpy on it though.

Peace
@_*


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## AlanPechacek (Jan 31, 2018)

I would say *no* in that in this case the "bursectomy" was an integral element of the procedure to help isolate &/or debride and prepare the rotator cuff for repair.

Sincerely, Alan Pechacek, M.D.


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