Coding Case Study:
Coding for Shoulder Revision
Published on Thu Apr 01, 1999
Case Description
A bipolar arthroplasty of the left shoulder has failed. A surgeon and an assistant surgeon perform a revision bipolar arthroplasty.
The most common problem that warrants revision is instability. For example, the shoulder prosthesis may dislocate repeatedly. The arthroplasty also would be called a failure if excessive scarring caused reduced range of motion. (On rare occasions arthroplasties also fail because of infections or neurovascular damage.)
Procedure
Before reviewing the operative notes below for this specific case, its helpful to understand the difference between a total shoulder revision and a hemiarthroplasty. In a total shoulder revision, the surgeon removes and replaces the surface of the humeral head and the glenoid. In a hemiarthroplasty, only the humeral surface is replaced. But in the following case study, all of the glenoid and only part of the humeral component were replaced; hence, the term bipolar.
Operative Note
The previous incision was utilized. Subcutaneous tissue was divided. The skin was very friable and would tear at the slightest pressure. The deltoid was retracted. The cephalic vein was free but during the procedure it was torn in a manner that required ligation.
The anterior shoulder capsule was exposed and the subscapularis and capsule were removed in one layer. The entire bipolar head was dislocated anteriorly. It was also noted that there had been loss of the superior half of the glenoid. After long tissue dissection and freeing of retractures, the bipolar head was delivered into the wound and removed.
Due to the tightness of the tissue as well as the scarring and friability, long-term mobilization was carried out to regain the ability to expose the glenoid. The glenoid was inspected. The patient was noted to have loss of the superior 30 percent. This was from chronic superior dislocation of the bipolar prosthesis. This was evaluated and options were considered including bone grafting. Because of this patients compromised immune state, it was not felt that this was a viable alternative. It was felt it would be in his best interest to fashion a methyl methacrylate support for the glenoid prosthesis. The glenoid was then sequentially prepared to accept the custom glenoid component. This was quite lengthy in time because of the bulk of the custom implant required to prevent superior migration.
After extensive soft tissue manipulation and lengthening the exposure distally and proximally, the trial was placed. Some modification in the glenoid component was carried out with an Anspach saw to remove areas which were causing impingement. The glenoid was then completed as far [...]
