Wiki left shoulder open distal tibial allograft for chronic instability and cartilage loss

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mistysmith119803@gmail.com

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Help please! Patient has Hills Sachs Lesion and large glenoid bone defect. Doc also did an arthroscopic remplissage and I am assuming that is bundled to the open procedure. Patient had failed labral repairs in the past but did not have a Latarjet procedure previously. Please let me know your thoughts in regards to CPT code.

Thanks!
 
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You may want to post the redacted op note. A Hills Sachs lesion is a bone defect. Was there a separate bone defect other than the Hills Sachs lesion? If the bone allograft was used to fill the Hills Sachs lesion before the Remplissage procedure it would be bundled.
 
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Description of Procedure:
Patient was identified in the preoperative holding area and his left shoulder was marked. He was transported to the operating was placed supine on the operating table and general anesthesia was induced. Examination under anesthesia showed gross instability of the shoulder with his shoulder sitting dislocated at rest and actively having to reduce the shoulder. Due to this he did have restricted range of motion in external rotation prior to dislocation of the shoulder. He had near full forward elevation and internal rotation. Patient was then positioned in the beachchair position. Left arm was then prepped and draped in the usual sterile fashion. Preoperative timeout was performed indicating correct patient correct side correct procedure and that preoperative antibiotics have been given. I next started with the arthroscopic portion of procedure. 60 cc of normal saline was injected into the shoulder followed by creation of a standard posterior portal. The scope was placed into the shoulder and diagnostic exam was performed. There is noted to be significant wear at the central aspect of the glenoid both superiorly and inferiorly. There is noted to be significant glenoid bone loss. On the humeral head there is noted to be a large Hill-Sachs deformity with loss of cartilage of the posterior aspect of the humeral head. The labrum posteriorly and extending superiorly was noted to be intact there was some degenerative fraying of the superior labrum which was debrided using an arthroscopic shaver. The biceps tendon was noted to be firmly attached to the superior labrum. This was pulled into the joint and not noted to have any significant tearing or erythema along its course. The rotator cuff was noted to be intact throughout. Posteriorly there is noted to be a posterior HAGHL injury. An anterior superior portal was created and the scope was placed into this. Next through the posterior portal the Hill-Sachs lesion was debrided using a curette and shaver to healthy-appearing bone. Next to 3.0 mm swivel lock anchors were placed inferiorly and then superiorly in the Hill-Sachs defect. The scope was moved to the subacromial space where bursectomy and subacromial decompression were performed. Care was taken to not injure the previously passed sutures. These were next identified and the appropriate trajectory for passing the sutures through the infraspinatus was obtained using a spinal needle. A cannula was then placed in this trajectory. The scope was then placed back into the glenohumeral joint and using a BirdBeak suture passer the inferior sutures were passed through the capsule and musculotendinous tissue and in a similar fashion the superior anchors were withdrawn from the more superior puncture through the capsular tissue. Of note given the posterior HAGHL I did attempt to incorporate the torn portion of the capsule into the tissue to try to attempt some sort of repair of this tissue. Next the locking mechanisms of the 2 suture tack anchors were used to pass the ultimate working suture through each anchor and these were loosely tightened. These were set aside for later after the glenoid portion of the procedure to have final fixation. Next I turned my attention to the open portion of the procedure. Utilizing a anterior approach to the shoulder an incision was made. This is carried down to the subcutaneous tissues. The previously scarred in deltopectoral interval was then identified. Retractors were placed exposing the coracoid and conjoined tendon. The conjoined tendon was then elevated and retracted medially exposing the anterior shoulder and the subscapularis. Next a subscapularis split was performed at the midportion of the subscapularis. This was freed of the capsule deep. An L-shaped capsulotomy was then performed exposing the anterior glenoid neck. Retractors were placed to get exposure. Next a combination of rongour and high-speed bur were used to debride the glenoid neck to prepare for bony graft. The graft measuring tools were then utilized to estimate the appropriate size of the graft. Next the distal tibial allograft was opened and prepared utilizing the information from the graft size. Once the graft been harvested it was irrigated copiously for 10 minutes using a Pulsavac. Next PRP which had previously been obtained from a peripheral blood draw was injected onto the graft and allowed to soak for approximately 10 minutes. Once this was complete the graft was brought onto the field and positioned on the anterior glenoid neck. 2 K wires were placed through the graft into the glenoid to secured into place. These were then overdrilled. 2 screws were then placed across the graft securing it into place. Of note during this process I made sure to leave the graft flush to the glenoid surface. Screw fixation did achieve excellent purchase. I did place 2 FiberWire sutures around the washers and these were then used to repair the inferior aspect of the capsular split. Prior to doing this I did place the scope into the shoulder through the opening and tightened down the remplissage sutures under direct visualization which did show compression of the soft tissues into the humeral head defect. Next an additional FiberWire was used to close the remainder of the capsule. A 0 Vicryl was used to close the subscapularis muscle split. The anterior soft tissues were then closed using 2-0 Vicryl followed by a running 3-0 Monocryl and prineo for the skin. The scope was placed back into the subacromial space to identify the sutures ensure that the sutures were compressed down which they were. The sutures were then cut. Scope was removed and the shoulder and the portals were closed using 3-0 Monocryl. The shoulder was then washed and dressed the patient was placed in a postoperative shoulder brace. The patient was then awoken and taken to the recovery room.
 
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