The patient was seen in the preoperative unit and the left shoulder was marked appropriately. He was taken back to the operating suite and placed in the supine position where a time-out was performed indicating the proper patient, proper procedure and proper shoulder. The orthopedic staff, nursing staff and anesthesia staff were in agreement. A regional block was performed in the preoperative unit. General anesthesia was administered. Preoperative IV antibiotics were given. All bony prominences were well padded.
The patient was then placed in a beach-chair position with the head rest. We then prepped and draped the patient's left shoulder in a usual sterile fashion placing the left arm in the Spider arm holder. I then insufflated the joint with 20 cc of sterile saline. I established my posterolateral portal with an 11-blade, placing my scope in the shoulder. I noted immediate synovitis in the shoulder. His tissue appeared inflamed. The undersurface of the rotator cuff appeared inflamed as did the biceps tendon and as the insertion of the superior labrum appeared inflamed. There was degenerative fraying of the anterior labrum and superior labrum as well. There was also cartilaginous thinning of his glenoid and humeral head.
I examined the subscapularis tendon, which appeared to be intact without any inflammation or tearing. His biceps tendon appeared to be inflamed with degenerative tearing at its insertion in the superior labrum. There was also degenerative tearing of his anterior labrum. His posterior labrum was fine and intact. There were no loose bodies in his axillary pouch. There was thinning of the glenoid and the humeral head without any large osteochondral defects. The undersurface did appear inflamed and did not demonstrate any full thickness tearing.
I then established my anterior portal with the help of a spinal needle. I placed a cannula just above the subscapularis tendon. I pulled the biceps tendon in a plain view and again it had degenerative fraying on it. I thus made a decision to perform a proximal biceps tenotomy at its insertion. I brought in my electrocautery and cut the biceps tendon at its insertion on the superior labrum. I then brought in my shaver. I debrided degenerative fraying of the superior labrum as well as the anterior labrum.
I then brought in my cautery and I cauterized some synovitic change on the superior labrum as well as on the undersurface of the rotator cuff. I probed the rotator cuff and examined it through full external and internal rotation of the shoulder. There did not appear to be any tearing. With my shaver, I was able to debride all of degenerative tearing on the labrum as well as some partial degenerative tearing of the undersurface of rotator cuff.
Once I was happy with my debridement, I then placed my scope in the subacromial space. I established my lateral subacromial portal with the help of a spinal needle and induced my shaver. He had large amounts of inflammatory tissue overlying the rotator cuff, which I debrided thoroughly with the shaver. I cauterized any bleeders with my electrocautery. He had a type II acromion with large spurring. I released the soft tissue attachments on the acromion and then with a burr, I then performed acromioplasty to flatten the acromion to prevent impingement.
I then switched my scope and placed my scope in the lateral portal and my burr in the posterior portal. I then completed the acromioplasty and ensured a flat surface to prevent impingement. I cauterized any bleeders. I placed my shaver back into the subacromial space and debrided all synovitic and inflamed tissue overlying the rotator cuff. Again, I examined the rotator cuff through full external and internal rotation. I did not appreciate any full thickness rotator cuff tears.
Once I was done with my biceps tenotomy, debridement and subacromial decompression, I turned my attention to the distal clavicle excision. I made a 2 cm saber-type incision over the distal clavicle. I dissected down to the fascia, which I split longitudinally to expose the superior ligaments of the AC joint. I then split these ligaments with my Bovie to expose the acromioclavicular joint. He had extensive arthrosis with synovitis within the joint. I then placed Hohmann around the distal clavicle and performed a distal clavicle excision with the help of a thin oscillating saw taking off the distal 7 mm of the clavicle. I then used a rasp to smoothen out the edges. I removed all synovitis within the AC joint. I ensured that there were good smooth edges.
leaning toward 29823 since 29826 is bundled into 23120. Suggestions please
The patient was then placed in a beach-chair position with the head rest. We then prepped and draped the patient's left shoulder in a usual sterile fashion placing the left arm in the Spider arm holder. I then insufflated the joint with 20 cc of sterile saline. I established my posterolateral portal with an 11-blade, placing my scope in the shoulder. I noted immediate synovitis in the shoulder. His tissue appeared inflamed. The undersurface of the rotator cuff appeared inflamed as did the biceps tendon and as the insertion of the superior labrum appeared inflamed. There was degenerative fraying of the anterior labrum and superior labrum as well. There was also cartilaginous thinning of his glenoid and humeral head.
I examined the subscapularis tendon, which appeared to be intact without any inflammation or tearing. His biceps tendon appeared to be inflamed with degenerative tearing at its insertion in the superior labrum. There was also degenerative tearing of his anterior labrum. His posterior labrum was fine and intact. There were no loose bodies in his axillary pouch. There was thinning of the glenoid and the humeral head without any large osteochondral defects. The undersurface did appear inflamed and did not demonstrate any full thickness tearing.
I then established my anterior portal with the help of a spinal needle. I placed a cannula just above the subscapularis tendon. I pulled the biceps tendon in a plain view and again it had degenerative fraying on it. I thus made a decision to perform a proximal biceps tenotomy at its insertion. I brought in my electrocautery and cut the biceps tendon at its insertion on the superior labrum. I then brought in my shaver. I debrided degenerative fraying of the superior labrum as well as the anterior labrum.
I then brought in my cautery and I cauterized some synovitic change on the superior labrum as well as on the undersurface of the rotator cuff. I probed the rotator cuff and examined it through full external and internal rotation of the shoulder. There did not appear to be any tearing. With my shaver, I was able to debride all of degenerative tearing on the labrum as well as some partial degenerative tearing of the undersurface of rotator cuff.
Once I was happy with my debridement, I then placed my scope in the subacromial space. I established my lateral subacromial portal with the help of a spinal needle and induced my shaver. He had large amounts of inflammatory tissue overlying the rotator cuff, which I debrided thoroughly with the shaver. I cauterized any bleeders with my electrocautery. He had a type II acromion with large spurring. I released the soft tissue attachments on the acromion and then with a burr, I then performed acromioplasty to flatten the acromion to prevent impingement.
I then switched my scope and placed my scope in the lateral portal and my burr in the posterior portal. I then completed the acromioplasty and ensured a flat surface to prevent impingement. I cauterized any bleeders. I placed my shaver back into the subacromial space and debrided all synovitic and inflamed tissue overlying the rotator cuff. Again, I examined the rotator cuff through full external and internal rotation. I did not appreciate any full thickness rotator cuff tears.
Once I was done with my biceps tenotomy, debridement and subacromial decompression, I turned my attention to the distal clavicle excision. I made a 2 cm saber-type incision over the distal clavicle. I dissected down to the fascia, which I split longitudinally to expose the superior ligaments of the AC joint. I then split these ligaments with my Bovie to expose the acromioclavicular joint. He had extensive arthrosis with synovitis within the joint. I then placed Hohmann around the distal clavicle and performed a distal clavicle excision with the help of a thin oscillating saw taking off the distal 7 mm of the clavicle. I then used a rasp to smoothen out the edges. I removed all synovitis within the AC joint. I ensured that there were good smooth edges.
leaning toward 29823 since 29826 is bundled into 23120. Suggestions please