This is the op note -
Pre-Op
Diagnosis Codes:
* Adhesive capsulitis of right shoulder [M75.01]
Post-Op Diagnosis: Same
Procedure(s):
RIGHT SHOULDER ARTHROSCOPY; CAPSULAR RELEASE WITH MANIPULATION-INTERSCALENE BLOCK
Surgeon(s):
Brian Chilelli, MD
Assistant:
Surgical Assistant: Leeanne Harper
Anesthesia: General
Estimated Blood Loss (mL): Minimal
Complications: None
Specimens:
* No specimens in log *
Implants:
* No implants in log *
Drains: * No LDAs found *
Findings: per dictation
Detailed Description of Procedure:
The patient was met in the preoperative holding area. Informed consent was obtained. Interscalene block was placed by anesthesia. She was taken back to the operative room and transferred to the table. General anesthesia was performed. He was placed in the beachchair position. All bony prominences were well-padded. Bilateral SCDs were placed. Upper extremity did demonstrate significant decreased passive motion. There was only about 80 degrees of forward flexion and abduction with about 20-30 degrees of external rotation. Upper extremity was prepped and draped using standard sterile technique. Formal timeout was performed in which the correct patient, surgical site, and procedure was reaffirmed. Preventive antibiotics were given within 30 minutes of skin incision.
Initial incision was made just inferior medial to the posterior lateral border of the acromion. Trocar was introduced into the glenohumeral joint. Arthroscope was introduced. Diagnostic arthroscopy was performed. Anterior portal was created via an outside in technique. The subscapularis was intact. Glenoid was intact without evidence of chondral abnormality. There was no abnormality of the humeral head chondral surface. There are some fraying of the anterior labrum but no discrete tear. There is significant adhesions in scarring within the rotator cuff interval. Overall the rotator cuff repair appear to be intact. There is significant erythema within the joint itself.
At that point we proceeded with capsular release. We used a radiofrequency wand to release the anterior interval tissue as well as the tissue anterior to the subscapularis down to the inferior capsule. Arthroscopic shaver was also utilized to debride interval tissue. Following this we did switch her camera to the anterior portal. We did perform a posterior capsular release using a radiofrequency wand. I'm leaning towards 29825, but would like another opinion.
At that point the arthroscope was taken to the subacromial space. A lateral working portal was created. There was significant bursal tissue and adhesions within the subacromial space. Therefore a thorough subacromial bursectomy was performed with lysis of adhesions within the subacromial space. The entire bursal surface of the rotator cuff was completely healed. Following our lysis of adhesions and bursectomy we did remove arthroscopic instruments and performed a gentle manipulation under anesthesia. Following this we were able to achieve about 130 to 140 degrees of forward flexion and abduction with approximately 40 to 50 degrees of external rotation.
Portal sites were closed using 3-0 nylon in interrupted fashion. Sterile dressings were applied in the form of Xeroform, 4 x 4's, ABD, and foam tape. She was placed into a standard sling. Then the procedure all counts were correct and I was present for entire case. Postoperatively the sling will be for comfort only. She was instructed to come out of it and start using range of motion immediately once the block wears off. He will start physical therapy tomorrow with aggressive range of motion exercises. Return to see me in office of the neck scheduled visit.