arickord23
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Operative Procedure:
1. Right shoulder arthroscopy with anterior labral repair
2. Rotator Cuff Tear
3. Subacromial Decompression
4. Biceps Tenotomy
Description of procedure:
A posterior portal was made with an 11-blade, followed by the insertion of a blunt obturator and arthroscope. Lateral, anterolateral and anterior portals were established under direct vision with the spinal needle and 11-blade. The glenohumeral articulation was visualized. These was noted to be some grade 3 and grade 4 changes on the humeral head. The glenoid cartilage surface was intact. However, an anterior rim glenoid fracture was clearly evident with posterior displacement of the anterior labrum. The anterior - inferior labrum was intact. At this point, I cleared away the fibrous tissue associated with early healing of the anterior labrum due to the displaced nature of the labrum. A double-armed 3.0 Bio...Corkscrew anchor was placed at the anterior margin. Sutures were passed around the labrum and the labrum was secured into the defect. The initial anchor placed had pulled out, as the bone had been compromised by the fracture. The second anchor was placed in a more distal position. Good bony purchase was achieved. The sutures were passed around the labrum, and the labrum was fully secured into the glenoid defect.
The bicep tendon was fully evaluated. It was noted to show significant fraying, greater than 50%, and a bicep tenotomy was performed. The subscapularis tendon was intact, with no frayong or degenerative changed, and there was a large suprapinatus rotator cuff tear.
THe arthroscope was placed into a subacromial position. Extensive bursectomy was performed. There was a prominent subacromial spur and an appoximately 1 cm bony resection was performed from the anterior aspect of the acromion. The rotator cuff footprint was cleared of all soft tissues, until a bleeding bone was created. A single 5.5 mm Bio....Corkscrew was placed at the articular margin. The sutures were passed in a horizontal mattress configuration. The biceps tendon was incorporated into the anterior aspect of the rotator cuff repair. When the sutures were tied, the rotator cuff was fully mobilized into the footprint and they were secured on the lateral aspect with a modified cross-bridge configuration with two 3.5 mm push lock anchors. The arm could be fully internally and externally rotated and placed at the patients side without excessive tension on the repair or gapping of the rotator cuff repair.
The surgeon gives me codes: 29827, 29806 & 23405
Can someone please take a look at this op report and give me some advice??
Thank you!!!
Andrea
1. Right shoulder arthroscopy with anterior labral repair
2. Rotator Cuff Tear
3. Subacromial Decompression
4. Biceps Tenotomy
Description of procedure:
A posterior portal was made with an 11-blade, followed by the insertion of a blunt obturator and arthroscope. Lateral, anterolateral and anterior portals were established under direct vision with the spinal needle and 11-blade. The glenohumeral articulation was visualized. These was noted to be some grade 3 and grade 4 changes on the humeral head. The glenoid cartilage surface was intact. However, an anterior rim glenoid fracture was clearly evident with posterior displacement of the anterior labrum. The anterior - inferior labrum was intact. At this point, I cleared away the fibrous tissue associated with early healing of the anterior labrum due to the displaced nature of the labrum. A double-armed 3.0 Bio...Corkscrew anchor was placed at the anterior margin. Sutures were passed around the labrum and the labrum was secured into the defect. The initial anchor placed had pulled out, as the bone had been compromised by the fracture. The second anchor was placed in a more distal position. Good bony purchase was achieved. The sutures were passed around the labrum, and the labrum was fully secured into the glenoid defect.
The bicep tendon was fully evaluated. It was noted to show significant fraying, greater than 50%, and a bicep tenotomy was performed. The subscapularis tendon was intact, with no frayong or degenerative changed, and there was a large suprapinatus rotator cuff tear.
THe arthroscope was placed into a subacromial position. Extensive bursectomy was performed. There was a prominent subacromial spur and an appoximately 1 cm bony resection was performed from the anterior aspect of the acromion. The rotator cuff footprint was cleared of all soft tissues, until a bleeding bone was created. A single 5.5 mm Bio....Corkscrew was placed at the articular margin. The sutures were passed in a horizontal mattress configuration. The biceps tendon was incorporated into the anterior aspect of the rotator cuff repair. When the sutures were tied, the rotator cuff was fully mobilized into the footprint and they were secured on the lateral aspect with a modified cross-bridge configuration with two 3.5 mm push lock anchors. The arm could be fully internally and externally rotated and placed at the patients side without excessive tension on the repair or gapping of the rotator cuff repair.
The surgeon gives me codes: 29827, 29806 & 23405
Can someone please take a look at this op report and give me some advice??
Thank you!!!
Andrea