oceania
New
I would like someone else's opinion on this procedure and diagnosis codes. I've included the OP note.
PREOPERATIVE DIAGNOSES:
1. Left shoulder rotator cuff tear.
2. Left shoulder labral tearing and proximal biceps tendon tearing.
3. Left shoulder impingement.
4. Left shoulder cyst of the spinoglenoid notch.
POSTOPERATIVE DIAGNOSES:
1. Left shoulder rotator cuff tear.
2. Left shoulder labral tearing and proximal biceps tendon tearing.
3. Left shoulder impingement.
4. Left shoulder cyst of the spinoglenoid notch.
OPERATIONS:
1. Left shoulder arthroscopic rotator cuff repair.
2. Left shoulder arthroscopic decompression of the cyst in the spinoglenoid
notch.
3. Left shoulder arthroscopic subacromial decompression and acromioplasty.
4. Left shoulder arthroscopic debridement of extensive labral tearing.
5. Left shoulder mini open subpectoral biceps tenodesis performed as a
separate procedure.
ANESTHESIA: Regional, supplemented with general.
BLOOD LOSS: Minimal.
BLOOD REPLACEMENT: None.
INTRAVENOUS FLUIDS: Please see the anesthesia record.
WOUND: Clean.
COMPLICATIONS: None.
DRAINS AND PACKING: None.
IMPLANTS: Please see the hospital record for exact implant specifications,
but, briefly, 2 separate 3.5 mm titanium Arthrex corkscrew anchors were used
as a medial row construct of the rotator cuff repair and these were backed up
laterally to a 4.75 mm PEEK Arthrex SwiveLock anchor to complete a
transosseous equivalent double row construct. An Arthrex biceps button system
was used for the biceps tenodesis.
INDICATIONS FOR SURGERY: Please see my accompanying history/consultation
dictations for details, but I explained the anatomy and pathophysiology
involved with the above diagnosis, and recommended surgical intervention as a
treatment option. I explained the technical aspect of the procedure and the
post-operative rehabilitation program. I explained risks and benefits as well
as alternatives to surgery, with risks including infection, neurovascular
injury, neuropraxia, the possibility of future surgery, limb length
inequality, malrotation, nonunion, malunion, post-traumatic pain, arthritis,
weakness, and stiffness, and medical and cardiac complications of anesthesia,
and DVT. I explained clearly that the surgery would be unlikely to completely
eliminate all pain. All these concepts were reviewed and all questions were
answered. Informed consent was obtained, and I marked the operative site in
the preoperative holding area.
DESCRIPTION OF PROCEDURE: At this point, as viewing the labral tearing from
the lateral portal, an extensive debridement was used with the arthroscopic
shaver and radiofrequency device of substantial tearing in the superior and
posterior aspect of the labrum. Frayed tissue was debrided down to a stable
base and no remnant tearing was seen.
Regional anesthesia was achieved by the anesthesia team in the preoperative
holding area and the patient was transported from there to the operating room.
The patient was gently
transferred to the hospital operating room table, where supplemental general
anesthesia was achieved by the anesthesia team. The patient was then placed
in a well-padded beach chair position, where all bony prominences were well
padded. Preoperative antibiotics were administered to the patient prior to any
operative incision and the shoulder was prepped and draped in standard sterile
fashion for shoulder arthroscopy. A timeout was called and confirmed.
At this point, bony landmarks were palpated and marked and a standard
posterior portal to the shoulder was developed with an 11-blade scalpel.
Diagnostic arthroscopy ensued.
Survey of the glenohumeral joint showed no significant undue damage to the
cartilaginous surfaces and a standard anterior working portal was developed
through the rotator cuff interval using a spinal needle for localization.
Further survey of the shoulder showed only age-appropriate degenerative
changes at the subscapularis, but significant tearing of the proximal biceps
tendon and the SLAP region of the labrum. Furthermore, a full-thickness tear
was seen of the supraspinatus tendon.
The above-mentioned pathology was debrided using a combination of an
arthroscopic scissor, arthroscopic shaver, and radiofrequency device. Given
the patient's age, the tearing in the labrum and biceps tendon necessitated a
biceps tenodesis and the biceps tendon was cut from its attachment on the
supraglenoid tubercle and this remnant was debrided down to a stable base.
A lateral working portal was also developed as the degenerative torn
supraspinatus was debrided as well and arthroscopic bur was used to prepare
the greater tuberosity as a footprint for rotator cuff repair.
Attention then turned to the subacromial space, where standard subacromial
bursectomy was performed. Furthermore, the undersurface of the acromion was
found to have significant wear with signs of external impingement and thus a
formal acromioplasty using an arthroscopic bur in a cutting block technique
was performed. Following this portion of the procedure, the shoulder was
taken through a full range of motion and no external impingement was seen.
At this point, a correlated surgical treatment based on preoperative findings
and particularly with the advanced imaging in that an MRI preoperatively
demonstrating the posterior-superior paralabral cyst extending to the
spinoglenoid notch. I, using a mosquito clamp and arthroscopic probe from the
posterior portal, dissected the above-mentioned area and with the help of the
arthroscopic shaver and using a pituitary for gentle dissection, the cyst was
approached with the arthroscope and successfully decompressed. Gelatinous
fluid was yielded and rinsed via arthroscopic lavage, thus completing the
decompression of the cyst. Again, appropriate decompression was performed as
much as possible through the arthroscope and no indication for open surgery in
this area was seen.
Attention returned to the rotator cuff and the above-mentioned medial row
anchors were implanted in standard technique. A DePuy Mitek suture passer
device was used to pass horizontal mattress stitches in the appropriate aspect
of the rotator cuff and these were tied down using standard arthroscopic
knots. The limbs were locked laterally to the above-mentioned lateral anchor
and this completed an anatomic repair in double row fashion. The ends of the
sutures were cut and a robust anatomic repair was clearly visualized and the
shoulder was taken through full range of motion without incident.
The shoulder was rinsed via arthroscopic lavage and attention turned to the
mini open subpectoral biceps tenodesis.
A mini open incision was made in an anterior axillary fold totally normal with
approximately 4 cm. Meticulous hemostasis was maintained with Bovie
electrocautery and dissection ensued to the subpectoral interval and Hohmann
retractors were placed in that interfold with care to avoid even traction
injuries to the neurovascular structures including the musculocutaneous nerve
in particular. The long head of the biceps tendon was easily identified and
removed from the wound. Using the standard Arthrex biceps button technique,
the appropriate tension and length of the biceps was identified and a #2
FiberLoop stitch was used to create a locking suture construct in the biceps
tendon near the musculotendinous junction. The end of the tendon was removed
and again confirmed to be significantly degenerative and torn. The limbs of
the FiberWire were passed through the button in proper fashion and the
appropriate location, the biceps groove was once again identified due to
appropriate tension of the tenodesis.
Using the Arthrex spade drill, a bicortical path was drilled and the anterior
cortex was reamed with a size 6 reamer. Meticulous irrigation was used to
debride the reamed bone for fear of heterotopic ossification and this was
confirmed. The button was passed out the posterior cortex and flipped and the
sutures were pulled docking the tendon into the tenodesis site. Excellent
dockage of the tendon was clearly visualized and a secure construct was
obvious. One of the limbs of the FiberWire was passed through the tendon and
this was used as post to lock a knot, which was tied with the help of an
arthroscopic knot pusher. The end of the sutures were cut and the elbow was
taken through a full range of motion and a robust secure tenodesis was
visualized with appropriate tension.
All wounds were thoroughly irrigated with normal saline and the subdermal
layers were closed with a 3-0 Vicryl suture. The skin was closed with a
combination of 3-0 Monocryl suture and Dermabond and a standard sterile
dressing was applied. The patient was placed in a shoulder immobilizer and
anesthesia was discontinued. The patient was gently taken down from the beach
chair position and transferred to a hospital stretcher and transported to the
recovery room, where the patient arrived in a hemodynamically stable condition
having tolerated the procedure well.
PREOPERATIVE DIAGNOSES:
1. Left shoulder rotator cuff tear.
2. Left shoulder labral tearing and proximal biceps tendon tearing.
3. Left shoulder impingement.
4. Left shoulder cyst of the spinoglenoid notch.
POSTOPERATIVE DIAGNOSES:
1. Left shoulder rotator cuff tear.
2. Left shoulder labral tearing and proximal biceps tendon tearing.
3. Left shoulder impingement.
4. Left shoulder cyst of the spinoglenoid notch.
OPERATIONS:
1. Left shoulder arthroscopic rotator cuff repair.
2. Left shoulder arthroscopic decompression of the cyst in the spinoglenoid
notch.
3. Left shoulder arthroscopic subacromial decompression and acromioplasty.
4. Left shoulder arthroscopic debridement of extensive labral tearing.
5. Left shoulder mini open subpectoral biceps tenodesis performed as a
separate procedure.
ANESTHESIA: Regional, supplemented with general.
BLOOD LOSS: Minimal.
BLOOD REPLACEMENT: None.
INTRAVENOUS FLUIDS: Please see the anesthesia record.
WOUND: Clean.
COMPLICATIONS: None.
DRAINS AND PACKING: None.
IMPLANTS: Please see the hospital record for exact implant specifications,
but, briefly, 2 separate 3.5 mm titanium Arthrex corkscrew anchors were used
as a medial row construct of the rotator cuff repair and these were backed up
laterally to a 4.75 mm PEEK Arthrex SwiveLock anchor to complete a
transosseous equivalent double row construct. An Arthrex biceps button system
was used for the biceps tenodesis.
INDICATIONS FOR SURGERY: Please see my accompanying history/consultation
dictations for details, but I explained the anatomy and pathophysiology
involved with the above diagnosis, and recommended surgical intervention as a
treatment option. I explained the technical aspect of the procedure and the
post-operative rehabilitation program. I explained risks and benefits as well
as alternatives to surgery, with risks including infection, neurovascular
injury, neuropraxia, the possibility of future surgery, limb length
inequality, malrotation, nonunion, malunion, post-traumatic pain, arthritis,
weakness, and stiffness, and medical and cardiac complications of anesthesia,
and DVT. I explained clearly that the surgery would be unlikely to completely
eliminate all pain. All these concepts were reviewed and all questions were
answered. Informed consent was obtained, and I marked the operative site in
the preoperative holding area.
DESCRIPTION OF PROCEDURE: At this point, as viewing the labral tearing from
the lateral portal, an extensive debridement was used with the arthroscopic
shaver and radiofrequency device of substantial tearing in the superior and
posterior aspect of the labrum. Frayed tissue was debrided down to a stable
base and no remnant tearing was seen.
Regional anesthesia was achieved by the anesthesia team in the preoperative
holding area and the patient was transported from there to the operating room.
The patient was gently
transferred to the hospital operating room table, where supplemental general
anesthesia was achieved by the anesthesia team. The patient was then placed
in a well-padded beach chair position, where all bony prominences were well
padded. Preoperative antibiotics were administered to the patient prior to any
operative incision and the shoulder was prepped and draped in standard sterile
fashion for shoulder arthroscopy. A timeout was called and confirmed.
At this point, bony landmarks were palpated and marked and a standard
posterior portal to the shoulder was developed with an 11-blade scalpel.
Diagnostic arthroscopy ensued.
Survey of the glenohumeral joint showed no significant undue damage to the
cartilaginous surfaces and a standard anterior working portal was developed
through the rotator cuff interval using a spinal needle for localization.
Further survey of the shoulder showed only age-appropriate degenerative
changes at the subscapularis, but significant tearing of the proximal biceps
tendon and the SLAP region of the labrum. Furthermore, a full-thickness tear
was seen of the supraspinatus tendon.
The above-mentioned pathology was debrided using a combination of an
arthroscopic scissor, arthroscopic shaver, and radiofrequency device. Given
the patient's age, the tearing in the labrum and biceps tendon necessitated a
biceps tenodesis and the biceps tendon was cut from its attachment on the
supraglenoid tubercle and this remnant was debrided down to a stable base.
A lateral working portal was also developed as the degenerative torn
supraspinatus was debrided as well and arthroscopic bur was used to prepare
the greater tuberosity as a footprint for rotator cuff repair.
Attention then turned to the subacromial space, where standard subacromial
bursectomy was performed. Furthermore, the undersurface of the acromion was
found to have significant wear with signs of external impingement and thus a
formal acromioplasty using an arthroscopic bur in a cutting block technique
was performed. Following this portion of the procedure, the shoulder was
taken through a full range of motion and no external impingement was seen.
At this point, a correlated surgical treatment based on preoperative findings
and particularly with the advanced imaging in that an MRI preoperatively
demonstrating the posterior-superior paralabral cyst extending to the
spinoglenoid notch. I, using a mosquito clamp and arthroscopic probe from the
posterior portal, dissected the above-mentioned area and with the help of the
arthroscopic shaver and using a pituitary for gentle dissection, the cyst was
approached with the arthroscope and successfully decompressed. Gelatinous
fluid was yielded and rinsed via arthroscopic lavage, thus completing the
decompression of the cyst. Again, appropriate decompression was performed as
much as possible through the arthroscope and no indication for open surgery in
this area was seen.
Attention returned to the rotator cuff and the above-mentioned medial row
anchors were implanted in standard technique. A DePuy Mitek suture passer
device was used to pass horizontal mattress stitches in the appropriate aspect
of the rotator cuff and these were tied down using standard arthroscopic
knots. The limbs were locked laterally to the above-mentioned lateral anchor
and this completed an anatomic repair in double row fashion. The ends of the
sutures were cut and a robust anatomic repair was clearly visualized and the
shoulder was taken through full range of motion without incident.
The shoulder was rinsed via arthroscopic lavage and attention turned to the
mini open subpectoral biceps tenodesis.
A mini open incision was made in an anterior axillary fold totally normal with
approximately 4 cm. Meticulous hemostasis was maintained with Bovie
electrocautery and dissection ensued to the subpectoral interval and Hohmann
retractors were placed in that interfold with care to avoid even traction
injuries to the neurovascular structures including the musculocutaneous nerve
in particular. The long head of the biceps tendon was easily identified and
removed from the wound. Using the standard Arthrex biceps button technique,
the appropriate tension and length of the biceps was identified and a #2
FiberLoop stitch was used to create a locking suture construct in the biceps
tendon near the musculotendinous junction. The end of the tendon was removed
and again confirmed to be significantly degenerative and torn. The limbs of
the FiberWire were passed through the button in proper fashion and the
appropriate location, the biceps groove was once again identified due to
appropriate tension of the tenodesis.
Using the Arthrex spade drill, a bicortical path was drilled and the anterior
cortex was reamed with a size 6 reamer. Meticulous irrigation was used to
debride the reamed bone for fear of heterotopic ossification and this was
confirmed. The button was passed out the posterior cortex and flipped and the
sutures were pulled docking the tendon into the tenodesis site. Excellent
dockage of the tendon was clearly visualized and a secure construct was
obvious. One of the limbs of the FiberWire was passed through the tendon and
this was used as post to lock a knot, which was tied with the help of an
arthroscopic knot pusher. The end of the sutures were cut and the elbow was
taken through a full range of motion and a robust secure tenodesis was
visualized with appropriate tension.
All wounds were thoroughly irrigated with normal saline and the subdermal
layers were closed with a 3-0 Vicryl suture. The skin was closed with a
combination of 3-0 Monocryl suture and Dermabond and a standard sterile
dressing was applied. The patient was placed in a shoulder immobilizer and
anesthesia was discontinued. The patient was gently taken down from the beach
chair position and transferred to a hospital stretcher and transported to the
recovery room, where the patient arrived in a hemodynamically stable condition
having tolerated the procedure well.