Still a newbie in Ortho... Would you just code 29823??
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSES:
Right shoulder strain, synovitis, and possible glenoid labral
tear.
POSTOPERATIVE DIAGNOSES:
Right shoulder strain with synovitis and old anterior inferior
glenoid label tear with scarring and deficient anterior
inferior glenoid and injury to the superior humeral head
articular surface.
PROCEDURES:
Arthroscopic examination with extensor debridement of the
shoulder joint, synovectomy and debridement of portion of the
labrum.
SURGEON:
.
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 27-year-old black male with history of occasional
pain of his right shoulder. He mostly has pain with athletic
activities. No pain with normal daily activities. Also pain
with overhead type throwing. He does not recall a specific
history of dislocation. He played sports and has *** but
does not recall episode where he had heavy shoulder reduced.
He has had persistent trouble despite conservative care, and
the options of continued conservative care versus arthroscopic
examination treatment were discussed with him at length. He
requests surgical treatment.
The MRI scan showed abnormality of the glenoid and abnormality
of the humeral head.
DESCRIPTION OF PROCEDURE:
After taking informed consent, the patient was brought to the
operating room table in supine position. After administration
of general LMA anesthesia, the right shoulder and arm was
sterilely prepped and draped in a routine manner. Time-out
was then performed. The patient was identified, appropriate
biopsy site had been marked and he received appropriate
antibiotics.
Next, the posterior arthroscopy portal was then made and the
joint was infiltrated with saline with epinephrine. Next, the
arthroscope was placed in the shoulder joint posteriorly and
examined of the joint was performed. The rotator cuff was
normal in appearance. The biceps tendon was intact. The
articular surface with normal appearance. The superior
glenoid labrum was intact. There was no SLAP lesion, but just
below the biceps tendon. The labrum was noted to be absent.
On further exploration, there was some tissue inferiorly and
it may have been scarring of the remnant of the labrum. That
was noted be quite chronic in appearance. There was
significant inflammation throughout the shoulder joint, both
anteriorly, posteriorly, superiorly and inferiorly. The
inferior labrum was intact. There appeared to be some ***
abnormality of the anterior inferior glenoid. The glenoid did
not have a normal pear shape. It almost appeared that he had
an old anterior inferior dislocation or subluxation with some
trauma to the superior humeral head and anterior inferior
glenoid. There was indentation on the superior aspect of the
head just medial to the attachment of the rotator cuff. Next,
with the aid of Wissinger rod, an anterior portal was made and
a cannula was placed anteriorly. Plain synovium was debrided.
The area of the labral tear was probed and it was not felt
that this could be repaired plus with this defect in the
glenoid and humeral head that it may not provide enough
stability just to repair back the labrum. This, however,
could not be repaired. The toe was thoroughly debrided and
anteriorly and posteriorly, superiorly and inferiorly.
Remainder of the exam was otherwise unremarkable. The
extremity was elected to see how he does with rehab to
strengthen the shoulder and see if that will help stabilize
it.
Interrupted Vicryl sutures used to approximate the
subcutaneous and subcuticular tissue. Steri-Strips used to
approximate the skin edges. He had received a block in the
holding room and a sterile dressing was applied and is placed
in a sling and transferred to recovery in stable condition.
At this time, I am going to see how he does with therapy
including strengthening. He may need something further down
such as bone grafting of the glenoid or opened capsular shift
or possible allograft labrum.
We would refer him to a shoulder specialist for this. We will
see him back in 10 days and start him on some therapy at that
time.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSES:
Right shoulder strain, synovitis, and possible glenoid labral
tear.
POSTOPERATIVE DIAGNOSES:
Right shoulder strain with synovitis and old anterior inferior
glenoid label tear with scarring and deficient anterior
inferior glenoid and injury to the superior humeral head
articular surface.
PROCEDURES:
Arthroscopic examination with extensor debridement of the
shoulder joint, synovectomy and debridement of portion of the
labrum.
SURGEON:
.
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 27-year-old black male with history of occasional
pain of his right shoulder. He mostly has pain with athletic
activities. No pain with normal daily activities. Also pain
with overhead type throwing. He does not recall a specific
history of dislocation. He played sports and has *** but
does not recall episode where he had heavy shoulder reduced.
He has had persistent trouble despite conservative care, and
the options of continued conservative care versus arthroscopic
examination treatment were discussed with him at length. He
requests surgical treatment.
The MRI scan showed abnormality of the glenoid and abnormality
of the humeral head.
DESCRIPTION OF PROCEDURE:
After taking informed consent, the patient was brought to the
operating room table in supine position. After administration
of general LMA anesthesia, the right shoulder and arm was
sterilely prepped and draped in a routine manner. Time-out
was then performed. The patient was identified, appropriate
biopsy site had been marked and he received appropriate
antibiotics.
Next, the posterior arthroscopy portal was then made and the
joint was infiltrated with saline with epinephrine. Next, the
arthroscope was placed in the shoulder joint posteriorly and
examined of the joint was performed. The rotator cuff was
normal in appearance. The biceps tendon was intact. The
articular surface with normal appearance. The superior
glenoid labrum was intact. There was no SLAP lesion, but just
below the biceps tendon. The labrum was noted to be absent.
On further exploration, there was some tissue inferiorly and
it may have been scarring of the remnant of the labrum. That
was noted be quite chronic in appearance. There was
significant inflammation throughout the shoulder joint, both
anteriorly, posteriorly, superiorly and inferiorly. The
inferior labrum was intact. There appeared to be some ***
abnormality of the anterior inferior glenoid. The glenoid did
not have a normal pear shape. It almost appeared that he had
an old anterior inferior dislocation or subluxation with some
trauma to the superior humeral head and anterior inferior
glenoid. There was indentation on the superior aspect of the
head just medial to the attachment of the rotator cuff. Next,
with the aid of Wissinger rod, an anterior portal was made and
a cannula was placed anteriorly. Plain synovium was debrided.
The area of the labral tear was probed and it was not felt
that this could be repaired plus with this defect in the
glenoid and humeral head that it may not provide enough
stability just to repair back the labrum. This, however,
could not be repaired. The toe was thoroughly debrided and
anteriorly and posteriorly, superiorly and inferiorly.
Remainder of the exam was otherwise unremarkable. The
extremity was elected to see how he does with rehab to
strengthen the shoulder and see if that will help stabilize
it.
Interrupted Vicryl sutures used to approximate the
subcutaneous and subcuticular tissue. Steri-Strips used to
approximate the skin edges. He had received a block in the
holding room and a sterile dressing was applied and is placed
in a sling and transferred to recovery in stable condition.
At this time, I am going to see how he does with therapy
including strengthening. He may need something further down
such as bone grafting of the glenoid or opened capsular shift
or possible allograft labrum.
We would refer him to a shoulder specialist for this. We will
see him back in 10 days and start him on some therapy at that
time.