Cats3
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I am struggling with this note. I have 23466 and 23450, but I am not sure if it's correct or not. Thoughts??
PREOPERATIVE DIAGNOSIS:
Right shoulder instability with large Hill-Sachs lesion, anterior.
POSTOPERATIVE DIAGNOSIS:
Right shoulder instability with large Hill-Sachs lesion, anterior.
PROCEDURES:
Arthroscopic evaluation to the right shoulder with debridement. Open repair of large anterior Hill-Sachs lesion of the humeral head and capsular shift.
ANESTHESIA:
General anesthesia via ET tube with a scalene block assist.
HISTORY:
who has got a history of seizure disorder and drug use, presents with complaint of right shoulder pain and instability. He had a posterior dislocation that was out for quite some time causing an extremely large anterior Hill-Sachs lesion, which is about a third or more of the humeral head incised, when looking at imaging with a CT scan, MRI, and x-rays, and after reviewing with the patient and the family in detail, we felt that this would be best served with an anterior bone block into the humeral head utilizing a fresh osteochondral graft, and then proceeding with a capsular shift or whatever else needed to be done at the time. So we obtained a graft. The patient was scheduled.
PROCEDURE IN DETAIL:
We did do a urine drug screen prior to the surgery, and once that was cleared, he was given a scalene block and then brought back to the operating room, placed supine on the table, given general anesthesia via ET tube. Once asleep, an exam of the shoulder reveals full range of motion. He had anterior translation as well as some mild posterior translation in neutral position, but when I externally rotated, he tightened up, indicating mainly an anterior lesion. It was not really a posterior lesion or inferior, so we next positioned him up into a beach chair position. The left upper extremity was placed in a well-padded arm holding device. Bilateral pneumatic pressure stockings on the lower extremities. The right shoulder and axillary region were prepped and draped in sterile fashion with ChloraPrep solution. A standard posterior arthroscopic portal was established after which an anterior portal was made, and the exam starting in the glenohumeral joint, revealed minimal problems to the anterior labrum or other cartilage to the glenoid region. He had already had a prior Latarjet procedure, which still looked to be in good condition, and the cartilage was still intact in that area. There was a little bit a degenerative kind of fraying in the inferior portion, which I just debrided. Also, up at the superior portion, near the biceps, there was some fraying, but it was otherwise stable. The biceps was normal. His rotator cuff was completely intact and stable throughout, from the anterior subscap appearance to the supraspinatus and infraspinatus and teres. The posterior really did not have any other significant problems to it, and the articular surface anteriorly again showed that lesion to the anterior Hill-Sachs region. He also had a small mild posterior Hill-Sachs lesion, but with the Latarjet procedure, should not be a problem for the patient. We next proceeded to remove the arthroscopic equipment. I placed a suture in the posterior portal site and then the anterior. We extended with the old incision, dissected down through the skin and subcutaneous tissue. Bleeding controlled by electrocautery. I dissected over to the deltopectoral interval, identified the cephalic vein, and this was retracted laterally with the deltoid. I had to go down through some scar tissue to get down through this interval, but once I did, I could get down to the conjoined tendon, and then I freed that up, and I could take that medial as well as get up underneath the deltoid, and then I was able to place a LINK retractor in here. Once this was all freed up, I got down to the area of the subscapularis tendon. I made an incision down through that, and we subsequently released the subscapularis tendon from the capsule underneath, and then I tagged that subscap with 3 SutureTapes, so that we could repair that later, and then I took the subscapularis all the way off the capsule, all the way to the area of the glenoid. I released it inferiorly as well as superiorly up by the rotator interval, and then proceeded to do a arthrotomy through the capsule, leaving some capsular tissue, both laterally and medially, so that I could do a capsular shift at the end. Once that was done, I was staring right at the Hill-Sachs lesion. I was able to carefully dissect off some of the tissue from that capsule laterally so that I could get to that far anterior edge, and then I had it freed up to the other side. So next I measured the lesion. It was about 4 to 4-1/2 cm superior to inferior and anterior to posterior was a little over 2 cm. So I took that, and marked it onto the humeral head on the back table, and then utilizing the saw, I cut a wedge out of the humeral head to match that, and then I subsequently brought that to the table, and subsequently went back and forth, back and forth, just continuing to contour and mold it, so that it would fit into that defect anatomically. With that, I was using both the saw as well as a rasp. Once I got that done, I then used the power rasp on the patient's humerus, both the wedge side anteriorly as well as laterally. Once that was all cleaned up, so I had fresh bone now that would hold this, I put the wedge into position, and I placed 2 K-wires in it, so that I could use the 4.0 cannulated screws. Once the K-wires were in, we drilled those and I countersunk them, and then we proceeded to place the screws in with a 32 and 34 screw utilizing good purchase for both, and the wedge was now in a very good position, anatomic, covered the entire defect without any other problems noted. We irrigated out with copious amounts of irrigation solution, after which, we removed any of the retractors we had. We subsequently brought the capsule back, and reattached it, but I also did a capsular shift, and then once that was done with an ORTHOCORD suture, I closed up the superior portion at the rotator interval. Next, I brought the subscapularis tendon back, brought it to reattach that to the tendinous cuff laterally with the SutureTapes that we had placed before, and then we subsequently irrigated out once again. The stability was tested. He was noted to be stable in both 0 or neutral, as well as the external rotation. His external rotation was a little limited, but that was okay and acceptable with his prior history. We subsequently removed all the LINK retractors, closed the deltopectoral interval with 0, 2-0 in the subcutaneous tissue, and a STRATAFIX in the skin with a sterile dressing applied. He was placed into a sling and a Polar Care, and taken to the recovery room, stable.
PREOPERATIVE DIAGNOSIS:
Right shoulder instability with large Hill-Sachs lesion, anterior.
POSTOPERATIVE DIAGNOSIS:
Right shoulder instability with large Hill-Sachs lesion, anterior.
PROCEDURES:
Arthroscopic evaluation to the right shoulder with debridement. Open repair of large anterior Hill-Sachs lesion of the humeral head and capsular shift.
ANESTHESIA:
General anesthesia via ET tube with a scalene block assist.
HISTORY:
who has got a history of seizure disorder and drug use, presents with complaint of right shoulder pain and instability. He had a posterior dislocation that was out for quite some time causing an extremely large anterior Hill-Sachs lesion, which is about a third or more of the humeral head incised, when looking at imaging with a CT scan, MRI, and x-rays, and after reviewing with the patient and the family in detail, we felt that this would be best served with an anterior bone block into the humeral head utilizing a fresh osteochondral graft, and then proceeding with a capsular shift or whatever else needed to be done at the time. So we obtained a graft. The patient was scheduled.
PROCEDURE IN DETAIL:
We did do a urine drug screen prior to the surgery, and once that was cleared, he was given a scalene block and then brought back to the operating room, placed supine on the table, given general anesthesia via ET tube. Once asleep, an exam of the shoulder reveals full range of motion. He had anterior translation as well as some mild posterior translation in neutral position, but when I externally rotated, he tightened up, indicating mainly an anterior lesion. It was not really a posterior lesion or inferior, so we next positioned him up into a beach chair position. The left upper extremity was placed in a well-padded arm holding device. Bilateral pneumatic pressure stockings on the lower extremities. The right shoulder and axillary region were prepped and draped in sterile fashion with ChloraPrep solution. A standard posterior arthroscopic portal was established after which an anterior portal was made, and the exam starting in the glenohumeral joint, revealed minimal problems to the anterior labrum or other cartilage to the glenoid region. He had already had a prior Latarjet procedure, which still looked to be in good condition, and the cartilage was still intact in that area. There was a little bit a degenerative kind of fraying in the inferior portion, which I just debrided. Also, up at the superior portion, near the biceps, there was some fraying, but it was otherwise stable. The biceps was normal. His rotator cuff was completely intact and stable throughout, from the anterior subscap appearance to the supraspinatus and infraspinatus and teres. The posterior really did not have any other significant problems to it, and the articular surface anteriorly again showed that lesion to the anterior Hill-Sachs region. He also had a small mild posterior Hill-Sachs lesion, but with the Latarjet procedure, should not be a problem for the patient. We next proceeded to remove the arthroscopic equipment. I placed a suture in the posterior portal site and then the anterior. We extended with the old incision, dissected down through the skin and subcutaneous tissue. Bleeding controlled by electrocautery. I dissected over to the deltopectoral interval, identified the cephalic vein, and this was retracted laterally with the deltoid. I had to go down through some scar tissue to get down through this interval, but once I did, I could get down to the conjoined tendon, and then I freed that up, and I could take that medial as well as get up underneath the deltoid, and then I was able to place a LINK retractor in here. Once this was all freed up, I got down to the area of the subscapularis tendon. I made an incision down through that, and we subsequently released the subscapularis tendon from the capsule underneath, and then I tagged that subscap with 3 SutureTapes, so that we could repair that later, and then I took the subscapularis all the way off the capsule, all the way to the area of the glenoid. I released it inferiorly as well as superiorly up by the rotator interval, and then proceeded to do a arthrotomy through the capsule, leaving some capsular tissue, both laterally and medially, so that I could do a capsular shift at the end. Once that was done, I was staring right at the Hill-Sachs lesion. I was able to carefully dissect off some of the tissue from that capsule laterally so that I could get to that far anterior edge, and then I had it freed up to the other side. So next I measured the lesion. It was about 4 to 4-1/2 cm superior to inferior and anterior to posterior was a little over 2 cm. So I took that, and marked it onto the humeral head on the back table, and then utilizing the saw, I cut a wedge out of the humeral head to match that, and then I subsequently brought that to the table, and subsequently went back and forth, back and forth, just continuing to contour and mold it, so that it would fit into that defect anatomically. With that, I was using both the saw as well as a rasp. Once I got that done, I then used the power rasp on the patient's humerus, both the wedge side anteriorly as well as laterally. Once that was all cleaned up, so I had fresh bone now that would hold this, I put the wedge into position, and I placed 2 K-wires in it, so that I could use the 4.0 cannulated screws. Once the K-wires were in, we drilled those and I countersunk them, and then we proceeded to place the screws in with a 32 and 34 screw utilizing good purchase for both, and the wedge was now in a very good position, anatomic, covered the entire defect without any other problems noted. We irrigated out with copious amounts of irrigation solution, after which, we removed any of the retractors we had. We subsequently brought the capsule back, and reattached it, but I also did a capsular shift, and then once that was done with an ORTHOCORD suture, I closed up the superior portion at the rotator interval. Next, I brought the subscapularis tendon back, brought it to reattach that to the tendinous cuff laterally with the SutureTapes that we had placed before, and then we subsequently irrigated out once again. The stability was tested. He was noted to be stable in both 0 or neutral, as well as the external rotation. His external rotation was a little limited, but that was okay and acceptable with his prior history. We subsequently removed all the LINK retractors, closed the deltopectoral interval with 0, 2-0 in the subcutaneous tissue, and a STRATAFIX in the skin with a sterile dressing applied. He was placed into a sling and a Polar Care, and taken to the recovery room, stable.