D.R.
Networker
2nd opinion needed on this please. Doc wants both 29807 & 29806 billed, what are your thoughts? Thanks in advance
PREOPERATIVE DIAGNOSIS: Left shoulder instability Bankart superior labral tear
OPERATION PERFORMED: Left shoulder arthroscopic extensive glenohumeral debridement, labral repair,
capsulorrhaphy.
ANESTHESIA: General
OPERATIVE SUMMARY: The patient was brought to the operating room and placed in a supine position. Once general
anesthesia, left scalene block and IV antibiotics were administered, the left upper extremity was examined under
anesthesia and the left shoulder was found to have normal glenohumeral motion with grade 2 subluxation anteriorly with
abduction external rotation. The patient was then placed in a beachchair position with all bony prominences well-padded
and the left upper extremity was prepped and draped in the normal sterile fashion. A posterior viewing portal allowed
needle localization of an anterior working portal for an instrumented diagnostic arthroscopy which demonstrated abundant
synovitis and a severely torn superior labrum, anterior inferior labrum and anterior labrum which was avulsed and is here
to the subscapularis which with itself scarred capsule and anterior humeral ligament, intact articular cartilage.
An extensive debridement of the glenohumeral joint removed frayed labrum and synovitis anterior posterior inferior
superior quadrants, anterior glenoid labrum was elevated and debrided to bone to create a healing response. An anterior
inferior labral tear was identified and elevated off the medial neck of the glenoid with the periosteal elevator the inferior
capsule was stimulated with a rasp to create a healing response. The bone of the glenoid neck was debrided and
prepared for a Bankart capsulorrhaphy repair. This was performed through an anterior 8 mm portal with 3 anchors on the
face of the glenoid at 6:30, 7:30 and 8:30 respectively on this left shoulder. The most inferior of which was used for
capsulorrhaphy and the 2 superior anchors used to create a stable labral repair. The stability of the repair was confirmed
with a probe. There was a large tear in the superior labrum constituting a type II tear with an unstable biceps anchor this
was further debrided to remove torn labrum and superior glenoid bone in preparation of a superior labral repair. SLAP
repair was performed through an 8 mm anterior cannula with 2 anchors placed one anterior and one posterior to the bicep
tendon and the stability of the repair was confirmed with a probe.
Sponge needle and instrument counts were correct, meticulous hemostasis was confirmed, the portals were closed
primarily, Marcaine with epinephrine was injected into the subacromial space, a sterile bulky dressing and a sling was
applied and the patient was stable en route to recovery room. There were no complications.
PREOPERATIVE DIAGNOSIS: Left shoulder instability Bankart superior labral tear
OPERATION PERFORMED: Left shoulder arthroscopic extensive glenohumeral debridement, labral repair,
capsulorrhaphy.
ANESTHESIA: General
OPERATIVE SUMMARY: The patient was brought to the operating room and placed in a supine position. Once general
anesthesia, left scalene block and IV antibiotics were administered, the left upper extremity was examined under
anesthesia and the left shoulder was found to have normal glenohumeral motion with grade 2 subluxation anteriorly with
abduction external rotation. The patient was then placed in a beachchair position with all bony prominences well-padded
and the left upper extremity was prepped and draped in the normal sterile fashion. A posterior viewing portal allowed
needle localization of an anterior working portal for an instrumented diagnostic arthroscopy which demonstrated abundant
synovitis and a severely torn superior labrum, anterior inferior labrum and anterior labrum which was avulsed and is here
to the subscapularis which with itself scarred capsule and anterior humeral ligament, intact articular cartilage.
An extensive debridement of the glenohumeral joint removed frayed labrum and synovitis anterior posterior inferior
superior quadrants, anterior glenoid labrum was elevated and debrided to bone to create a healing response. An anterior
inferior labral tear was identified and elevated off the medial neck of the glenoid with the periosteal elevator the inferior
capsule was stimulated with a rasp to create a healing response. The bone of the glenoid neck was debrided and
prepared for a Bankart capsulorrhaphy repair. This was performed through an anterior 8 mm portal with 3 anchors on the
face of the glenoid at 6:30, 7:30 and 8:30 respectively on this left shoulder. The most inferior of which was used for
capsulorrhaphy and the 2 superior anchors used to create a stable labral repair. The stability of the repair was confirmed
with a probe. There was a large tear in the superior labrum constituting a type II tear with an unstable biceps anchor this
was further debrided to remove torn labrum and superior glenoid bone in preparation of a superior labral repair. SLAP
repair was performed through an 8 mm anterior cannula with 2 anchors placed one anterior and one posterior to the bicep
tendon and the stability of the repair was confirmed with a probe.
Sponge needle and instrument counts were correct, meticulous hemostasis was confirmed, the portals were closed
primarily, Marcaine with epinephrine was injected into the subacromial space, a sterile bulky dressing and a sling was
applied and the patient was stable en route to recovery room. There were no complications.