D.R.
Networker
Hoping someone can help. I am confusion with the scope portion of this surgery. As of now the only thing I am sure of is 23430. Your help would be appreciated
Diagnostic arthroscopy was performed in the standard fashion. An anterior portal in the rotator interval was placed using an outside in spinal needle technique.
Findings: 4 mm Hill-Sachs lesion on the posterior humeral head
Type III SLAP tear with biceps tendinitis
Anterior-inferior bony Bankart fracture with 30% involvement of glenoid diameter
Intact rotator cuff tendons
After completion of the diagnostic arthroscopy attention was paid to the long head of the biceps. Utilizing an arthroscopic scissors as well as an ArthroCare wand, the biceps tendon was separated from the superior labrum. The biceps tendon immediately retracted into the bicipital groove. The labrum was debrided with a sucker shaver and the arthrocare wand.
Anterior superior portal was replaced with a 7 mm cannula. An 8 mm cannula was placed in the anterior-inferior portal position. A Gemini cannula was used to replace the posterior portal. 5:00 percutaneous portal was placed.
Attention was then paid to the Hill-Sachs lesion, utilizing the posterior portal microfracture of the Hill-Sachs lesion was performed after curetting of scar tissue.
Attention was then paid to the anterior-inferior labrum, sucker shaver, curette was used to remove clot. After cleaning the fracture fragment to devitalized pieces were identified on the distal and proximal aspect with a large 1 cm x 1 cm fragment centrally. Times two 3.0 by suture tacks were placed via the 5:00 portal to reduce the fragment. 45 degree right suture passer was used to pass a passing stitch through the glenoid fragment on the distal aspect. The distal bio suture tack was then passed through the fragment and tied down. While tying down, the anchor broke free from the glenoid face. This was secondary to traumatic nature of the injury and softer cancellus bone in the body of the glenoid. The softer cancellus bone in the exposed glenoid face made the case significantly more difficult as it made adequate anchor placement difficult. Traditionally Bankart repairs with bone involvement takes approximately 2 hours to complete. The difficult suture passage and soft bone resulting in failure of anchors added an additional hour to the length of the case. The anchor and suture was removed and a new drill hole was made just inferior to the existing. A fiber link was passed in the same place followed by a push lock. This slightly displaced the fracture fragment medial to the glenoid face. Subsequent 4:00 by a suture tack proximal to the initial was then secured with a 45 degree suture passer and held in place. This reduced the fracture fragment. A third bio suture tack was placed at the 5 o'clock position inferior to the fragment and a small anterior-inferior capsular shift was incorporated into the labrum. Examination of the reduced fragment demonstrated that placing a fourth by a suture tack proximal at the 3 o'clock position would result in partial closure of the rotator cuff interval. It was decided that no 3:00 anchor would be used. Final images in the shoulder were taken demonstrating a central humeral head over the glenoid bare area.
Open subpectoral biceps tenodesis was performed. The patient's arm was placed in an externally rotated position on a padded mayo stand. The pectoralis major tendon was identified as well as the axillary fold. An incision 1 cm lateral to the axillary fold extending 2 cm distal of the pectoralis major tendon was made with an indelible marker. The skin incision was performed with a 15 blade followed by dissection with electrocautery down to the fascia overlying the long head of the biceps. An interval between the long head of the biceps and short head of the biceps was identified and digitally dissected down to the fascia directly overlying the long head biceps tendon. The sheath was opened with Metzenbaum scissors and the long head of the biceps tendon was delivered with a right angle clamp. Marking the musculotendinous junction, a FiberWire loop on Keith needle was used to whipstitch 1.5 cm distal to the musculotendinous junction. The remaining tendon was excised. Utilizing a Chandler retractor to protect the medial structures, and a Homan retractor to expose the humerus, and an Army-Navy to expose the bicipital groove and retract the pectoralis major tendon superior, the drill guidewire for the Arthrex bio tenodesis screw and button guide was drilled through the anterior and posterior cortex of the humerus. This was followed by an 8 mm acorn reamer through the anterior cortex. Drill guide and reamer were removed from the shoulder. The strands of the biceps tendon were tied through the biceps button using a "marionette" suture technique. The biceps button was placed through the posterior cortex and flipped. The biceps tendon was brought into the tunnel using the marionette suture techniquie. An arthroscopic knot pusher was used to tie off the strands intramedullary. A single strand was passed through the arthrex screw driver and a 7x10mm PEEK screw was inserted into the anterior cortex. The remaining two sutures were tied over the top of the screw and cut. The wound was thoroughly irrigated and the wound was closed with 2-0 Vicryl deep dermal and skin staples.
All portals were closed with 3-0 monocryl, and dressed with skin glue and steristrips, folded 4 x 4, Tegaderm. Patient was placed in a shoulder sling without abduction pillow, patient was awoken from anesthesia without complication and transferred to the PACU where he recovered without incident and was discharged home.
Diagnostic arthroscopy was performed in the standard fashion. An anterior portal in the rotator interval was placed using an outside in spinal needle technique.
Findings: 4 mm Hill-Sachs lesion on the posterior humeral head
Type III SLAP tear with biceps tendinitis
Anterior-inferior bony Bankart fracture with 30% involvement of glenoid diameter
Intact rotator cuff tendons
After completion of the diagnostic arthroscopy attention was paid to the long head of the biceps. Utilizing an arthroscopic scissors as well as an ArthroCare wand, the biceps tendon was separated from the superior labrum. The biceps tendon immediately retracted into the bicipital groove. The labrum was debrided with a sucker shaver and the arthrocare wand.
Anterior superior portal was replaced with a 7 mm cannula. An 8 mm cannula was placed in the anterior-inferior portal position. A Gemini cannula was used to replace the posterior portal. 5:00 percutaneous portal was placed.
Attention was then paid to the Hill-Sachs lesion, utilizing the posterior portal microfracture of the Hill-Sachs lesion was performed after curetting of scar tissue.
Attention was then paid to the anterior-inferior labrum, sucker shaver, curette was used to remove clot. After cleaning the fracture fragment to devitalized pieces were identified on the distal and proximal aspect with a large 1 cm x 1 cm fragment centrally. Times two 3.0 by suture tacks were placed via the 5:00 portal to reduce the fragment. 45 degree right suture passer was used to pass a passing stitch through the glenoid fragment on the distal aspect. The distal bio suture tack was then passed through the fragment and tied down. While tying down, the anchor broke free from the glenoid face. This was secondary to traumatic nature of the injury and softer cancellus bone in the body of the glenoid. The softer cancellus bone in the exposed glenoid face made the case significantly more difficult as it made adequate anchor placement difficult. Traditionally Bankart repairs with bone involvement takes approximately 2 hours to complete. The difficult suture passage and soft bone resulting in failure of anchors added an additional hour to the length of the case. The anchor and suture was removed and a new drill hole was made just inferior to the existing. A fiber link was passed in the same place followed by a push lock. This slightly displaced the fracture fragment medial to the glenoid face. Subsequent 4:00 by a suture tack proximal to the initial was then secured with a 45 degree suture passer and held in place. This reduced the fracture fragment. A third bio suture tack was placed at the 5 o'clock position inferior to the fragment and a small anterior-inferior capsular shift was incorporated into the labrum. Examination of the reduced fragment demonstrated that placing a fourth by a suture tack proximal at the 3 o'clock position would result in partial closure of the rotator cuff interval. It was decided that no 3:00 anchor would be used. Final images in the shoulder were taken demonstrating a central humeral head over the glenoid bare area.
Open subpectoral biceps tenodesis was performed. The patient's arm was placed in an externally rotated position on a padded mayo stand. The pectoralis major tendon was identified as well as the axillary fold. An incision 1 cm lateral to the axillary fold extending 2 cm distal of the pectoralis major tendon was made with an indelible marker. The skin incision was performed with a 15 blade followed by dissection with electrocautery down to the fascia overlying the long head of the biceps. An interval between the long head of the biceps and short head of the biceps was identified and digitally dissected down to the fascia directly overlying the long head biceps tendon. The sheath was opened with Metzenbaum scissors and the long head of the biceps tendon was delivered with a right angle clamp. Marking the musculotendinous junction, a FiberWire loop on Keith needle was used to whipstitch 1.5 cm distal to the musculotendinous junction. The remaining tendon was excised. Utilizing a Chandler retractor to protect the medial structures, and a Homan retractor to expose the humerus, and an Army-Navy to expose the bicipital groove and retract the pectoralis major tendon superior, the drill guidewire for the Arthrex bio tenodesis screw and button guide was drilled through the anterior and posterior cortex of the humerus. This was followed by an 8 mm acorn reamer through the anterior cortex. Drill guide and reamer were removed from the shoulder. The strands of the biceps tendon were tied through the biceps button using a "marionette" suture technique. The biceps button was placed through the posterior cortex and flipped. The biceps tendon was brought into the tunnel using the marionette suture techniquie. An arthroscopic knot pusher was used to tie off the strands intramedullary. A single strand was passed through the arthrex screw driver and a 7x10mm PEEK screw was inserted into the anterior cortex. The remaining two sutures were tied over the top of the screw and cut. The wound was thoroughly irrigated and the wound was closed with 2-0 Vicryl deep dermal and skin staples.
All portals were closed with 3-0 monocryl, and dressed with skin glue and steristrips, folded 4 x 4, Tegaderm. Patient was placed in a shoulder sling without abduction pillow, patient was awoken from anesthesia without complication and transferred to the PACU where he recovered without incident and was discharged home.