talitha82
Guest
My ortho surgeon just did an arthroscopic repair of the subscapularis, but then decided that the supraspinatus and infraspinatus could not be repaired arthroscopically, and so decided to convert to open. I've never had an instance where they actually repaired one portion via arthro and then decided to do the rest via mini open, and now I am stumped. I want to describe the work done arthroscopically, but I am not sure if I can do that?? I know that generally, if a diagnostic scope procedure is done, and then you convert to open, you only code the open...but what do you do in this situation?? Here is the pertinent portion of the op note:
The posterior portal was entered in the usual fashion. Immediately, we could see that the biceps was still attached but it was laying in the inferior aspect of the joint consistent with the upper two thirds of the subscapularis being torn. In addition, the subscapularis was torn and retracted. The interval tissue was still connecting it and the supraspinatus, and there was actually also a flap of tissue from the biceps tendon sheath that was keeping it from becoming more retracted. The anterolateral portal was established under arthroscopic vision, and the shoulder was inspected. The glenohumeral joint was actually in excellent condition. The labrum had some mild fraying. The supraspinatus, infraspinatus, and subscapularis were all as above. The teres minor was still attached and the inferior pouch was intact.
An accessory anterolateral portal was established, and to get the biceps out of the way so that we could do the repair of the subscapularis, it was looped and released and the suture pulled out through this anterolateral portal. This anterolateral portal was also used to create the bleeding bed on the lesser tuberosity. Once that bed was created, FiberTape was passed in a reverse mattress fashion to make a good bridge over about 2 cm of the leading edge of the subscapularis with the bite of the suture approximately 1.5 cm separated. This gave good purchase of the subscapularis. The accessory tissue that was still attached from the sheath of the biceps tendon was then released, and this gave full mobility of this flap. Using a swivel lock with a self-tapping tip, the FiberTape was pulled down into the bleeding bed and the repair was excellent. The shoulder was put through a full arc of external and internal rotation in neutral, and there were no signs of gapping. Probing showed it to be quite stable and pulled well into the bleeding bed. Attention was then turned to the supraspinatus bleeding bed, which was debrided. This was done both through the anterior and the anterolateral portal. The shoulder was then drained, instruments removed, and then the subacromial space was entered.
There was a fair amount of bursa present, and this was debrided. Then the very significantly thickened periosteum on the undersurface of the acromion was removed with the ablation device up until the edge of the acromion and the insertion of the coracoacromial ligament. As suggested on x-ray, it was part of the coracoacromial ligament that was calcified, but fortunately it was far enough medially that I felt that that part did not have to be debrided. However, the lateral acromion and the anterior acromion were quite pronounced and very hooked and they were debrided and taken back to a type 1 shape. A total of about 8 mm were removed anteriorly and about 4 mm removed laterally. This gave good access.
The rotator cuff was then further inspected. There was no way that we could get the anterior half of the supraspinatus into its original footprint with arthroscopic techniques. This being the case, although I was not sure I would be able to get there with open techniques either, I felt a mini open approach was necessary. The subacromial space was drained after placing two traction sutures in the rotator cuff. Then attention was turned to the mini open approach.
The incision was parallel to and just lateral and anterior to the anterolateral acromion. Once through the skin and dermal tissue, the subdermal fat was elevated off the deltoid fascia, and then the deltoid fascia was opened in line with its fibers to allow placement of retractors. This brought us right onto the defect. The bleeding bed preparation had been quite good. Attempts to mobilize the anterior half of the supraspinatus were found to be unsuccessful. We were able to get the posterior half and all of the infraspinatus back into its original bleeding bed. This being the case, to gain coverage and to help with support of the frayed rotator cuff, the small dermal graft was brought in and prepared in the usual fashion. It was marked appropriately so that the appropriate side would be against the soft tissue. Then three 5.5 bioabsorbable suture anchors with suture tape were placed along the medial border of the bleeding bed. Each of these three suture tapes were then passed through the overlying supraspinatus and infraspinatus, receptively. With pulling them into position, the infraspinatus and the posterior half of the supraspinatus came into the original beds in good contact. The anterior part of the supraspinatus did not. The anterior-most suture anchor also had its #2 FiberWire used to suture the biceps down into the bleeding bed. This gave good mattress style closure and reduced it beautifully into the groove. Then the dermal graft was brought in with the appropriate side down, and the three suture tapes were passed through the dermal graft in such a way that it gave another flap on top of the rotator cuff repair. It was pushed all the way down to the leading edge of the rotator cuff to make sure there was no laxity. Then two arms from each of the two FiberTapes were passed through each of three self-tapping swivel locks. The middle suture was passed to the anterior- and posterior-most suture. The posterior suture was passed to the posterior-most swivel lock and then to the middle suture. The anterior suture tape was passed through the anterior swivel lock and then one onto the middle swivel lock. This gave excellent double row fixation and pulled the rotator cuff beautifully into the bed as well as the dermal graft into the bed and held it into position. The anterior-most swivel lock was actually a little bit anterior to the biceps, so this gave even additional closure of the biceps into the groove. The shoulder was then put through arc of motion of 60 degrees under observation, and there were no signs of undue tension or gapping or laxity within the repair of the infraspinatus and the posterior half of the supraspinatus, and the anterior half of the supraspinatus was covered well by this dermal graft. The wound was then irrigated and attention turned to closure.
WHAT DO I DO??? ANY IDEAS? Thanks so much!!!
The posterior portal was entered in the usual fashion. Immediately, we could see that the biceps was still attached but it was laying in the inferior aspect of the joint consistent with the upper two thirds of the subscapularis being torn. In addition, the subscapularis was torn and retracted. The interval tissue was still connecting it and the supraspinatus, and there was actually also a flap of tissue from the biceps tendon sheath that was keeping it from becoming more retracted. The anterolateral portal was established under arthroscopic vision, and the shoulder was inspected. The glenohumeral joint was actually in excellent condition. The labrum had some mild fraying. The supraspinatus, infraspinatus, and subscapularis were all as above. The teres minor was still attached and the inferior pouch was intact.
An accessory anterolateral portal was established, and to get the biceps out of the way so that we could do the repair of the subscapularis, it was looped and released and the suture pulled out through this anterolateral portal. This anterolateral portal was also used to create the bleeding bed on the lesser tuberosity. Once that bed was created, FiberTape was passed in a reverse mattress fashion to make a good bridge over about 2 cm of the leading edge of the subscapularis with the bite of the suture approximately 1.5 cm separated. This gave good purchase of the subscapularis. The accessory tissue that was still attached from the sheath of the biceps tendon was then released, and this gave full mobility of this flap. Using a swivel lock with a self-tapping tip, the FiberTape was pulled down into the bleeding bed and the repair was excellent. The shoulder was put through a full arc of external and internal rotation in neutral, and there were no signs of gapping. Probing showed it to be quite stable and pulled well into the bleeding bed. Attention was then turned to the supraspinatus bleeding bed, which was debrided. This was done both through the anterior and the anterolateral portal. The shoulder was then drained, instruments removed, and then the subacromial space was entered.
There was a fair amount of bursa present, and this was debrided. Then the very significantly thickened periosteum on the undersurface of the acromion was removed with the ablation device up until the edge of the acromion and the insertion of the coracoacromial ligament. As suggested on x-ray, it was part of the coracoacromial ligament that was calcified, but fortunately it was far enough medially that I felt that that part did not have to be debrided. However, the lateral acromion and the anterior acromion were quite pronounced and very hooked and they were debrided and taken back to a type 1 shape. A total of about 8 mm were removed anteriorly and about 4 mm removed laterally. This gave good access.
The rotator cuff was then further inspected. There was no way that we could get the anterior half of the supraspinatus into its original footprint with arthroscopic techniques. This being the case, although I was not sure I would be able to get there with open techniques either, I felt a mini open approach was necessary. The subacromial space was drained after placing two traction sutures in the rotator cuff. Then attention was turned to the mini open approach.
The incision was parallel to and just lateral and anterior to the anterolateral acromion. Once through the skin and dermal tissue, the subdermal fat was elevated off the deltoid fascia, and then the deltoid fascia was opened in line with its fibers to allow placement of retractors. This brought us right onto the defect. The bleeding bed preparation had been quite good. Attempts to mobilize the anterior half of the supraspinatus were found to be unsuccessful. We were able to get the posterior half and all of the infraspinatus back into its original bleeding bed. This being the case, to gain coverage and to help with support of the frayed rotator cuff, the small dermal graft was brought in and prepared in the usual fashion. It was marked appropriately so that the appropriate side would be against the soft tissue. Then three 5.5 bioabsorbable suture anchors with suture tape were placed along the medial border of the bleeding bed. Each of these three suture tapes were then passed through the overlying supraspinatus and infraspinatus, receptively. With pulling them into position, the infraspinatus and the posterior half of the supraspinatus came into the original beds in good contact. The anterior part of the supraspinatus did not. The anterior-most suture anchor also had its #2 FiberWire used to suture the biceps down into the bleeding bed. This gave good mattress style closure and reduced it beautifully into the groove. Then the dermal graft was brought in with the appropriate side down, and the three suture tapes were passed through the dermal graft in such a way that it gave another flap on top of the rotator cuff repair. It was pushed all the way down to the leading edge of the rotator cuff to make sure there was no laxity. Then two arms from each of the two FiberTapes were passed through each of three self-tapping swivel locks. The middle suture was passed to the anterior- and posterior-most suture. The posterior suture was passed to the posterior-most swivel lock and then to the middle suture. The anterior suture tape was passed through the anterior swivel lock and then one onto the middle swivel lock. This gave excellent double row fixation and pulled the rotator cuff beautifully into the bed as well as the dermal graft into the bed and held it into position. The anterior-most swivel lock was actually a little bit anterior to the biceps, so this gave even additional closure of the biceps into the groove. The shoulder was then put through arc of motion of 60 degrees under observation, and there were no signs of undue tension or gapping or laxity within the repair of the infraspinatus and the posterior half of the supraspinatus, and the anterior half of the supraspinatus was covered well by this dermal graft. The wound was then irrigated and attention turned to closure.
WHAT DO I DO??? ANY IDEAS? Thanks so much!!!