trose45116
Expert
29827
29826
29999
am I missing anything else. this is for the doctor charge.
would you code anything else? This is the doctors charge.
29827
29826
29999
PREOPERATIVE DIAGNOSES: 1. Right shoulder full-thickness rotator cuff tear, supraspinatus infraspinatus.
2. Right shoulder high-grade subscapularis tear.
POSTOPERATIVE DIAGNOSES: 1. Right shoulder full-thickness rotator cuff tear, supraspinatus infraspinatus, plus retraction.
2. Right shoulder high-grade subscapularis tear.
3. Right shoulder proximal biceps rupture.
PROCEDURES PERFORMED: 1. Right shoulder arthroscopy.
2. Right shoulder arthroscopic rotator cuff repair, subscapularis.
3. Right shoulder arthroscopic rotator cuff repair, supraspinatus/infraspinatus.
4. Right shoulder rotator cuff graft jacket augmentation with acellular human dermis.
5. Right shoulder subacromial decompression.
6. Right shoulder subcoracoid decompression.
7. Right shoulder extensive debridement, adhesions, subacromial space, with labral stump debridement.
ASSISTANT: Robert Hutchison, P.A.-C.
ANESTHESIA: GET with interscalene block.
COMPLICATIONS: None noted.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS: The patient comes in with chief complaint of right shoulder pain. She did have a full thickness rotator cuff tear about the supraspinatus and infraspinatus. She also had a high-grade subscapularis tear. I spent significant amount of time counseling the patient. She was very interested in operative intervention. Given her young age, I felt that it would be very reasonable to attempt a repair. She was beginning to get some fatty atrophy of the musculature. I did explain this to her. I explained the possibility that she may simply have a partial repair and/or debridement. She understood this.
I also explained augmenting the repair with a graft jacket. She was interested in graft jacket if this was required. Risks and benefits of surgery were described in detail including but not limited to infection, bleeding, damage to vessels or nerves, continued pain, and possible repeat surgery. All questions were answered.
OPERATIVE PROCEDURE: The patient was taken to the operating room, after appropriate side was marked and consent obtained. The patient was transferred to OR table, and anesthesia was successfully induced. She was placed in the supine position. Head and neck were stabilized throughout. Right upper extremity was prepped and draped in the usual sterile fashion. Timeout was performed. Antibiotics were given prior to skin incision. Standard posterior portal was initially created. I went into the shoulder. Glenoid and humeral articular surfaces were well maintained. Evaluation of the labrum showed there was no evidence of significant labral tearing anteriorly or posteriorly. She had rupture of proximal biceps. She had a stump of biceps in the joint and this was debrided. Evaluation of the supra and infraspinatus showed full-thickness tearing. The tissue was actually quite mobile. We felt that we could perform an adequate repair. Evaluation of the subscapularis showed high-grade tearing. We felt that this required repair as well. Evaluation of the axillary pouch showed no evidence of loose bodies. We initially began with the subscapularis. We gently decorticated the lesser tuberosity. We did clean out the interval tissue with an ArthroCare device. She had a fairly prominent coracoid, and she had some stripping about the subscapularis. Therefore, we removed 5 mm of the coracoid as we did a subcoracoid plasty. We then put 55 anchor in the lesser tuberosity. We had previously mobilized the subscapularis, releasing bursal adhesions as well as articular-sided adhesions. We placed two horizontal mattress sutures using a penetrator. We were pleased with this. We tied this down. Then for the leading edge, we placed one FiberTape and a mattress suture was placed and this was subsequently placed into the bone to the very superior aspect of the lesser tuberosity with a 4.75 BioComposite SwiveLock. We were very pleased with this reduction. We then turned our attention toward the rotator cuff. Her tissue was essentially retracted to the glenoid. We did an anterior interval release. We also did a superior capsular release to gain as much length as we could. She did not require the posterior slide. We were able to reduce her anatomically. Her tissue quality was reasonable. Given the overall situation being a massive rotator cuff tear, I did want to do the graft jacket augmentation. We then placed three sutures medially, one anterior, one in the middle and one posteriorly. We gently decorticated the greater tuberosity. We placed two 55 Corkscrew anchors and we leveled with FiberTape as well as FiberWire. We had two traction sutures and the cuff was pulled over. We then placed a construct of FiberTape-FiberWire FiberWire-FiberTape and then we repeated this construct going from anterior to posterior. We then tied down the two FiberTapes. We were very pleased with the reduction. We then used K-wire and stimulated the greater tuberosity via the crimson duvet effect. We then took a FiberWire FiberTape from each anchor, which gave us four limbs, and we placed 4.75 SwiveLock anchor laterally. We then used the remaining four sutures and placed another anchor 4.75 BioComposite posteriorly. This gave us a double row. Again, we were very pleased with the reduction. We then went back intraarticularly and we were pleased with this. We then took measurements for the graft jacket. The graft jacket was subsequently at approximately 35 from anterior to posterior and 25 mm from medial lateral. The graft jacket was subsequently cut.
We then pulled the medial limb of sutures, one from each medial row, and these were subsequently passed through the graft jacket. We then pulled and the graft jacket was introduced on top of the rotator cuff. We felt the coverage was excellent. We subsequently tied this down. We had previously placed two lateral sutures, and these were secured laterally to the greater tuberosity, a 4.75 BioComposite anchor SwiveLock anteriorly and an 8 x 19 anchor posteriorly. We had to use a bigger anchor posteriorly as the bone quality was somewhat suspect. We then placed one midline stitch anteriorly and one posteriorly. We were very pleased with the graft jacket augment. We then debrided the CA ligament. This was not taken down. She had a subacromial spur with 10 mm of anterolateral acromion. She had a small spur at the distal clavicle and this was gently coplaned. We did not perform a distal clavicle excision. All debris was removed from the shoulder. The portals were closed with 3-0 nylon in a whipstitch fashion. Xeroform, 4 x 4?s, ABDs, Ace wrap, and a sling were applied. The patient was taken to the recovery room in stable condition. There were no apparent complications.
ADDENDUM: She had evidence of a subacromial spur with about 10 mm of anterolateral acromion. This was resected with a bur.
29826
29999
am I missing anything else. this is for the doctor charge.
would you code anything else? This is the doctors charge.
29827
29826
29999
PREOPERATIVE DIAGNOSES: 1. Right shoulder full-thickness rotator cuff tear, supraspinatus infraspinatus.
2. Right shoulder high-grade subscapularis tear.
POSTOPERATIVE DIAGNOSES: 1. Right shoulder full-thickness rotator cuff tear, supraspinatus infraspinatus, plus retraction.
2. Right shoulder high-grade subscapularis tear.
3. Right shoulder proximal biceps rupture.
PROCEDURES PERFORMED: 1. Right shoulder arthroscopy.
2. Right shoulder arthroscopic rotator cuff repair, subscapularis.
3. Right shoulder arthroscopic rotator cuff repair, supraspinatus/infraspinatus.
4. Right shoulder rotator cuff graft jacket augmentation with acellular human dermis.
5. Right shoulder subacromial decompression.
6. Right shoulder subcoracoid decompression.
7. Right shoulder extensive debridement, adhesions, subacromial space, with labral stump debridement.
ASSISTANT: Robert Hutchison, P.A.-C.
ANESTHESIA: GET with interscalene block.
COMPLICATIONS: None noted.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS: The patient comes in with chief complaint of right shoulder pain. She did have a full thickness rotator cuff tear about the supraspinatus and infraspinatus. She also had a high-grade subscapularis tear. I spent significant amount of time counseling the patient. She was very interested in operative intervention. Given her young age, I felt that it would be very reasonable to attempt a repair. She was beginning to get some fatty atrophy of the musculature. I did explain this to her. I explained the possibility that she may simply have a partial repair and/or debridement. She understood this.
I also explained augmenting the repair with a graft jacket. She was interested in graft jacket if this was required. Risks and benefits of surgery were described in detail including but not limited to infection, bleeding, damage to vessels or nerves, continued pain, and possible repeat surgery. All questions were answered.
OPERATIVE PROCEDURE: The patient was taken to the operating room, after appropriate side was marked and consent obtained. The patient was transferred to OR table, and anesthesia was successfully induced. She was placed in the supine position. Head and neck were stabilized throughout. Right upper extremity was prepped and draped in the usual sterile fashion. Timeout was performed. Antibiotics were given prior to skin incision. Standard posterior portal was initially created. I went into the shoulder. Glenoid and humeral articular surfaces were well maintained. Evaluation of the labrum showed there was no evidence of significant labral tearing anteriorly or posteriorly. She had rupture of proximal biceps. She had a stump of biceps in the joint and this was debrided. Evaluation of the supra and infraspinatus showed full-thickness tearing. The tissue was actually quite mobile. We felt that we could perform an adequate repair. Evaluation of the subscapularis showed high-grade tearing. We felt that this required repair as well. Evaluation of the axillary pouch showed no evidence of loose bodies. We initially began with the subscapularis. We gently decorticated the lesser tuberosity. We did clean out the interval tissue with an ArthroCare device. She had a fairly prominent coracoid, and she had some stripping about the subscapularis. Therefore, we removed 5 mm of the coracoid as we did a subcoracoid plasty. We then put 55 anchor in the lesser tuberosity. We had previously mobilized the subscapularis, releasing bursal adhesions as well as articular-sided adhesions. We placed two horizontal mattress sutures using a penetrator. We were pleased with this. We tied this down. Then for the leading edge, we placed one FiberTape and a mattress suture was placed and this was subsequently placed into the bone to the very superior aspect of the lesser tuberosity with a 4.75 BioComposite SwiveLock. We were very pleased with this reduction. We then turned our attention toward the rotator cuff. Her tissue was essentially retracted to the glenoid. We did an anterior interval release. We also did a superior capsular release to gain as much length as we could. She did not require the posterior slide. We were able to reduce her anatomically. Her tissue quality was reasonable. Given the overall situation being a massive rotator cuff tear, I did want to do the graft jacket augmentation. We then placed three sutures medially, one anterior, one in the middle and one posteriorly. We gently decorticated the greater tuberosity. We placed two 55 Corkscrew anchors and we leveled with FiberTape as well as FiberWire. We had two traction sutures and the cuff was pulled over. We then placed a construct of FiberTape-FiberWire FiberWire-FiberTape and then we repeated this construct going from anterior to posterior. We then tied down the two FiberTapes. We were very pleased with the reduction. We then used K-wire and stimulated the greater tuberosity via the crimson duvet effect. We then took a FiberWire FiberTape from each anchor, which gave us four limbs, and we placed 4.75 SwiveLock anchor laterally. We then used the remaining four sutures and placed another anchor 4.75 BioComposite posteriorly. This gave us a double row. Again, we were very pleased with the reduction. We then went back intraarticularly and we were pleased with this. We then took measurements for the graft jacket. The graft jacket was subsequently at approximately 35 from anterior to posterior and 25 mm from medial lateral. The graft jacket was subsequently cut.
We then pulled the medial limb of sutures, one from each medial row, and these were subsequently passed through the graft jacket. We then pulled and the graft jacket was introduced on top of the rotator cuff. We felt the coverage was excellent. We subsequently tied this down. We had previously placed two lateral sutures, and these were secured laterally to the greater tuberosity, a 4.75 BioComposite anchor SwiveLock anteriorly and an 8 x 19 anchor posteriorly. We had to use a bigger anchor posteriorly as the bone quality was somewhat suspect. We then placed one midline stitch anteriorly and one posteriorly. We were very pleased with the graft jacket augment. We then debrided the CA ligament. This was not taken down. She had a subacromial spur with 10 mm of anterolateral acromion. She had a small spur at the distal clavicle and this was gently coplaned. We did not perform a distal clavicle excision. All debris was removed from the shoulder. The portals were closed with 3-0 nylon in a whipstitch fashion. Xeroform, 4 x 4?s, ABDs, Ace wrap, and a sling were applied. The patient was taken to the recovery room in stable condition. There were no apparent complications.
ADDENDUM: She had evidence of a subacromial spur with about 10 mm of anterolateral acromion. This was resected with a bur.