cclarson
Guru
This looks like an open subacromial decompression (23130), but I'm not sure how to code the acromial fragment removal? would it be bundled? I would love some advice, thank you!
POSTOPERATIVE DIAGNOSES: Left shoulder lateral acromion fracture, with subacromial impingement.
PROCEDURES PERFORMED: Left shoulder excision of lateral acromion fragment and subacromial decompression.
INDICATIONS FOR PROCEDURE: The patient is a 57-year-old female who was injured at work about 4 months ago. Now, she fell and landed directly onto her left shoulder. She was treated initially through the urgent care facility. She underwent physical therapy. She continued to have pain and dysfunction. I recommended getting an MRI to evaluate her lateral acromion fracture. I make sure she did not have any rotator cuff tears. Once we obtained good quality MRI, it is confirmed that she had fragment off the posterolateral aspect of her acromion with some subacromial impingement. Her rotator cuff itself was intact. Given her failure of conservative treatment and persistent pain and dysfunction, I recommended surgical intervention. I recommended open approach to the posterolateral shoulder. I recommended removing some of the malunited posterior acromion fragment and then smoothing off the undersurface of the acromion to perform a subacromial decompression type of procedure to prevent impingement on her rotator cuff. The risks, benefits, and alternatives were discussed with the patient including the risks of bleeding, infection, continued shoulder pain and dysfunction, and possible need for more surgery. The patient understood these and agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified and marked in the preoperative area. We marked her area of maximal tenderness to palpation on the posterolateral corner of the acromion. Her consent form and H&P were signed and updated. She was taken to the operating room and intubated without complication. She was placed in the beach-chair position. Her left upper extremity was prepped and draped in a normal sterile fashion. Preoperative antibiotics were given. After a surgical time-out was performed, we started by making an incision about 3 cm in length over the posterolateral aspect of the acromion. We dissection through the skin and subcutaneous tissues with a knife and Bovie electrocautery.
I did identify the deltoid fascia. I split this in line with its fibers and then made our way down to the posterolateral acromion. I did not find any true loose fragments; however, with palpation on the underside of the acromion, I could feel where part of the acromial fracture had scarred in place and was causing some subacromial impingement. I used a combination of a rongeur and a rasp to remove this and smoothed out the undersurface of the acromion. We made sure to irrigate the subacromial space thoroughly and did not find any loose fragments here. Once we had worked with the rasp and a rongeur, I felt like we had a good smooth undersurface of the acromion out to the deltoid insertion. I did not feel like it was necessary to excise any cortical fragments that were embedded in the soft tissue that were not causing this impingement. We thoroughly irrigated again with saline solution. We closed with a running Vicryl suture in the fascia layer and then subcuticular Vicryl sutures and nylon suture for the skin. Sterile dressings were applied. The patient's arm was placed in a sling. We did inject local anesthetic before closure. She was awakened from anesthesia and taken to the recovery area in stable condition.
POSTOPERATIVE DIAGNOSES: Left shoulder lateral acromion fracture, with subacromial impingement.
PROCEDURES PERFORMED: Left shoulder excision of lateral acromion fragment and subacromial decompression.
INDICATIONS FOR PROCEDURE: The patient is a 57-year-old female who was injured at work about 4 months ago. Now, she fell and landed directly onto her left shoulder. She was treated initially through the urgent care facility. She underwent physical therapy. She continued to have pain and dysfunction. I recommended getting an MRI to evaluate her lateral acromion fracture. I make sure she did not have any rotator cuff tears. Once we obtained good quality MRI, it is confirmed that she had fragment off the posterolateral aspect of her acromion with some subacromial impingement. Her rotator cuff itself was intact. Given her failure of conservative treatment and persistent pain and dysfunction, I recommended surgical intervention. I recommended open approach to the posterolateral shoulder. I recommended removing some of the malunited posterior acromion fragment and then smoothing off the undersurface of the acromion to perform a subacromial decompression type of procedure to prevent impingement on her rotator cuff. The risks, benefits, and alternatives were discussed with the patient including the risks of bleeding, infection, continued shoulder pain and dysfunction, and possible need for more surgery. The patient understood these and agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified and marked in the preoperative area. We marked her area of maximal tenderness to palpation on the posterolateral corner of the acromion. Her consent form and H&P were signed and updated. She was taken to the operating room and intubated without complication. She was placed in the beach-chair position. Her left upper extremity was prepped and draped in a normal sterile fashion. Preoperative antibiotics were given. After a surgical time-out was performed, we started by making an incision about 3 cm in length over the posterolateral aspect of the acromion. We dissection through the skin and subcutaneous tissues with a knife and Bovie electrocautery.
I did identify the deltoid fascia. I split this in line with its fibers and then made our way down to the posterolateral acromion. I did not find any true loose fragments; however, with palpation on the underside of the acromion, I could feel where part of the acromial fracture had scarred in place and was causing some subacromial impingement. I used a combination of a rongeur and a rasp to remove this and smoothed out the undersurface of the acromion. We made sure to irrigate the subacromial space thoroughly and did not find any loose fragments here. Once we had worked with the rasp and a rongeur, I felt like we had a good smooth undersurface of the acromion out to the deltoid insertion. I did not feel like it was necessary to excise any cortical fragments that were embedded in the soft tissue that were not causing this impingement. We thoroughly irrigated again with saline solution. We closed with a running Vicryl suture in the fascia layer and then subcuticular Vicryl sutures and nylon suture for the skin. Sterile dressings were applied. The patient's arm was placed in a sling. We did inject local anesthetic before closure. She was awakened from anesthesia and taken to the recovery area in stable condition.
