Desperate Denise
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This is a beauty - I would greatly appreciate all the help I can get!!!!
I checked the CCI edits and came up with 29827, 29826-51, 29825-51, 29999 biceps tenotomy (should there be a modifier)
THANK YOU SO MUCH!!!!!
POSTOPERATIVE DIAGNOSIS:
1. Left shoulder adhesive capsulitis.
2. Rotator cuff tear.
3. Type 1 labral tear.
4. Biceps tear.
OPERATION PERFORMED:
1. Left shoulder arthroscopy.
2. Arthroscopic rotator cuff repair.
3. Capsular release.
4. Subacromial decompression.
5. Debridement of type 1 labral tear.
6. Excision of os acromiale.
7. Biceps tenotomy.
INDICATIONS FOR PROCEDURE: Patient is a 60-year-old female with
complaints of left shoulder pain who has failed conservative measures.
She has had difficulty with loss of motion and pain with motion. The
risks and benefits of surgery were discussed with the patient including
bleeding, infection, nerve or artery damage, failure to improve her pain,
need for further surgery, and she wished to proceed.
DESCRIPTION OF PROCEDURE: Patient was brought to the operating room and
placed supine on the operating table. After induction of general
anesthetic and interscalene block, she was placed in the beach chair
position. All bony prominences were padded. Her left shoulder was
prepped and draped in the standard surgical fashion. A posterior portal
was created. Examination of the joint showed normal glenohumeral
articular surfaces. The subscapularis tendon was intact. There was a
thick adhesive capsulitis that was seen, which was taken down with a
capsular release with a TurboVac wand. The biceps had significant fraying
and was smoothed. After smoothing of the biceps, it was noted to have an
80% tear in its mid substance. A tenotomy was carried out. Attention was
directed to the rotator cuff, where the supraspinatus insertion was
intact. The infraspinatus insertion was intact. The teres minor was
intact.
Attention was directed to the subacromial space, where a subacromial
decompression was carried out after a bursectomy. There was a large, 90%,
bursal surface tear of the rotator cuff, which was completed with the
TurboVac wand. There was a spur on the greater tuberosity, which was
smoothed with an acromionizer. An os acromiale was seen medially and
anteriorly which was removed with an acromionizer. A portal was created
anteriorly, and two 5.5 PEEK anchors were placed into the greater
tuberosity. Two sutures were passed in a horizontal fashion through the
tendon and tied down. Two 4.5 PushLock anchors were then placed
laterally, bringing the tendon back to the greater tuberosity nicely,
covering the tuberosity completely. Intra-articularly, a type 1 labral
tear was seen superiorly which was debrided with a 4.5-mm full radius
shaver. :
I checked the CCI edits and came up with 29827, 29826-51, 29825-51, 29999 biceps tenotomy (should there be a modifier)
THANK YOU SO MUCH!!!!!
POSTOPERATIVE DIAGNOSIS:
1. Left shoulder adhesive capsulitis.
2. Rotator cuff tear.
3. Type 1 labral tear.
4. Biceps tear.
OPERATION PERFORMED:
1. Left shoulder arthroscopy.
2. Arthroscopic rotator cuff repair.
3. Capsular release.
4. Subacromial decompression.
5. Debridement of type 1 labral tear.
6. Excision of os acromiale.
7. Biceps tenotomy.
INDICATIONS FOR PROCEDURE: Patient is a 60-year-old female with
complaints of left shoulder pain who has failed conservative measures.
She has had difficulty with loss of motion and pain with motion. The
risks and benefits of surgery were discussed with the patient including
bleeding, infection, nerve or artery damage, failure to improve her pain,
need for further surgery, and she wished to proceed.
DESCRIPTION OF PROCEDURE: Patient was brought to the operating room and
placed supine on the operating table. After induction of general
anesthetic and interscalene block, she was placed in the beach chair
position. All bony prominences were padded. Her left shoulder was
prepped and draped in the standard surgical fashion. A posterior portal
was created. Examination of the joint showed normal glenohumeral
articular surfaces. The subscapularis tendon was intact. There was a
thick adhesive capsulitis that was seen, which was taken down with a
capsular release with a TurboVac wand. The biceps had significant fraying
and was smoothed. After smoothing of the biceps, it was noted to have an
80% tear in its mid substance. A tenotomy was carried out. Attention was
directed to the rotator cuff, where the supraspinatus insertion was
intact. The infraspinatus insertion was intact. The teres minor was
intact.
Attention was directed to the subacromial space, where a subacromial
decompression was carried out after a bursectomy. There was a large, 90%,
bursal surface tear of the rotator cuff, which was completed with the
TurboVac wand. There was a spur on the greater tuberosity, which was
smoothed with an acromionizer. An os acromiale was seen medially and
anteriorly which was removed with an acromionizer. A portal was created
anteriorly, and two 5.5 PEEK anchors were placed into the greater
tuberosity. Two sutures were passed in a horizontal fashion through the
tendon and tied down. Two 4.5 PushLock anchors were then placed
laterally, bringing the tendon back to the greater tuberosity nicely,
covering the tuberosity completely. Intra-articularly, a type 1 labral
tear was seen superiorly which was debrided with a 4.5-mm full radius
shaver. :