jrs3181
Contributor
PREOPERATIVE DIAGNOSIS: Rotator cuff tear, right shoulder.
POSTOPERATIVE DIAGNOSES:
1. Severe degenerative arthritis glenohumeral joint, right shoulder involving the humeral head and the glenoid. Photographs were taken.
2. Partial tear rotator cuff, less than 50%. No evidence of severe retraction of the infraspinatus as read on the MRI.
3. Biceps tendon tear with inflammation and instability.
4. Impingement, subacromial bursal space.
5. Arthritis AC joint.
PROCEDURES:
1. Right shoulder arthroscopy with joint debridement of free floating articular fragments and loose articular tissue off the humeral head and the glenoid. 29823
2. Arthroscopic release long head of the biceps. 29828
3. Acromioplasty. 29826
4. Arthroscopic resection, distal end of the right clavicle. 29824
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and was given general anesthetic. Prior to surgery, the benefits, alternatives, and risks of this type of surgery were explained to the patient.
The right shoulder was sterilely prepped and draped in the usual manner. Portals were utilized posteriorly, laterally, and anteriorly. The arthroscope was introduced into the shoulder joint. Severe changes involving the humeral head with multiple loose fragments within the joint and loose articular tissue off the humeral head and the glenoid. These were debrided with a full-radius resector. The biceps was unstable at the anchor and flat and inflamed. This was released and the stump debrided with ArthroCare wand. We then inspected the cuff on the articular side. The tear was less than 50%. Photograph was taken on the articular side and on the bursal side. He had severe impingement. We tried to preserve the coracoacromial ligament, but removed the anterior and inferior aspect of the acromion and the subacromial bursal sac. Good decompression was visualized from the posterior portal and lateral portal. Through the anterior portal utilizing the same equipment, ArthroCare wand, full-radius resector, and the acromionizer, we removed the distal end of the clavicle giving good decompression of the AC joint and the subacromial bursal space. The cuff was inspected on the bursal side quite extensively with a full-radius resector of loose debridement of any bursal sac and there was evidence of somewhat of a partial tear, but no significant tear with retraction. We elected to treat the partial cuff tear with debridement. No surgical intervention.
The shoulder was thoroughly flushed with saline. The portals were closed with 3-0 vertical mattress nylon sutures. A sterile dressing was applied with a compression dressing. He left the operating room in a satisfactory condition.
So far... I have
29823
29828
29826
29824
Am I headed down the right path?!?!
Thank you!
POSTOPERATIVE DIAGNOSES:
1. Severe degenerative arthritis glenohumeral joint, right shoulder involving the humeral head and the glenoid. Photographs were taken.
2. Partial tear rotator cuff, less than 50%. No evidence of severe retraction of the infraspinatus as read on the MRI.
3. Biceps tendon tear with inflammation and instability.
4. Impingement, subacromial bursal space.
5. Arthritis AC joint.
PROCEDURES:
1. Right shoulder arthroscopy with joint debridement of free floating articular fragments and loose articular tissue off the humeral head and the glenoid. 29823
2. Arthroscopic release long head of the biceps. 29828
3. Acromioplasty. 29826
4. Arthroscopic resection, distal end of the right clavicle. 29824
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and was given general anesthetic. Prior to surgery, the benefits, alternatives, and risks of this type of surgery were explained to the patient.
The right shoulder was sterilely prepped and draped in the usual manner. Portals were utilized posteriorly, laterally, and anteriorly. The arthroscope was introduced into the shoulder joint. Severe changes involving the humeral head with multiple loose fragments within the joint and loose articular tissue off the humeral head and the glenoid. These were debrided with a full-radius resector. The biceps was unstable at the anchor and flat and inflamed. This was released and the stump debrided with ArthroCare wand. We then inspected the cuff on the articular side. The tear was less than 50%. Photograph was taken on the articular side and on the bursal side. He had severe impingement. We tried to preserve the coracoacromial ligament, but removed the anterior and inferior aspect of the acromion and the subacromial bursal sac. Good decompression was visualized from the posterior portal and lateral portal. Through the anterior portal utilizing the same equipment, ArthroCare wand, full-radius resector, and the acromionizer, we removed the distal end of the clavicle giving good decompression of the AC joint and the subacromial bursal space. The cuff was inspected on the bursal side quite extensively with a full-radius resector of loose debridement of any bursal sac and there was evidence of somewhat of a partial tear, but no significant tear with retraction. We elected to treat the partial cuff tear with debridement. No surgical intervention.
The shoulder was thoroughly flushed with saline. The portals were closed with 3-0 vertical mattress nylon sutures. A sterile dressing was applied with a compression dressing. He left the operating room in a satisfactory condition.
So far... I have
29823
29828
29826
29824
Am I headed down the right path?!?!
Thank you!