Would CPT 23420 be more appropriate for the following case over 23412? I am leaning towards 23420 due to the CPT assistant article from Feb. 2002 stating Code 23420 describes a repair of a complete shoulder (rotator) cuff avulsion, referring to the repair of all three major muscles/tendons of the shoulder cuff and the physician lists the procedure performed as Right shoulder open revision rotator cuff repair (massive tear of the supraspinatus, infraspinatus, and upper border of the subscapularis).
INDICATIONS FOR SURGERY: The patient is a 59-year-old male whom I have operated on twice in the past back in 2021 and then again last year for a rotator cuff tearing of the right shoulder. With his most recent surgery, he has had increasing pain and dysfunction in the shoulder. Repeat MRI demonstrated a massive re-tearing of the tendon with retraction back to the glenohumeral joint. We discussed different treatment options including revision repair, patch augmentation, and potential reverse shoulder arthroplasty. He wished to proceed with revision repair of rather than proceeding with any sort of shoulder reconstruction option. The risks, benefits, and alternatives of the surgery were discussed and the patient agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified and marked in the preoperative area. His H&P and consent form were signed and updated. He had a regional block placed by the Anesthesia service without complication. He was taken to operating room where he was intubated and seated. He was placed in the beach-chair position. His right upper extremity was prepped and draped in normal sterile fashion. Preoperative antibiotics and tranexamic acid were given.
After a surgical time-out was performed, we started with a standard open approach to the right shoulder. We dissected down through the skin and subcutaneous tissues with knife and the Bovie electrocautery. The cephalic vein was identified and retracted medially. We made our way down to the clavipectoral fascia. I incised this lateral to the conjoint tendon. There was some typical joint fluid once we opened up this fascia layer. We looked first at the anterior portion of the rotator cuff. He had a pretty large defect in the rotator interval, but it seemed like the quality of the anterior supraspinatus tendon tissue was pretty good. It was just retracted back superiorly and posteriorly as well as a little bit medially. It seemed to pull down nicely down to the cuff insertion. Also, the upper half or so of the subscapularis tendon was attached all the way out the insertion, but the underside of the footprint was not attached as well. We debrided the overlying bursal tissue. I elected to do a SpeedBridge construct here, placing 2 medial row anchors, 1 mostly passing suture through the supraspinatus tissue and then the other one more anteriorly and passing those sutures through the subscapularis tissue. We then tied these down to lateral row anchors to provide nice compression of the footprint. We then used some additional #2 sutures from the lateral row anchors to pass in a side-to-side fashion to help close down the rotator cuff tissue interval and gave us a nice anterior repair. From here, we examined a part of the posterior rotator cuff as I was releasing some of the adhesions from the rotator cuff to the underside of the acromion and could feel posteriorly, it was very thin and even some areas where there was full-thickness defect. This was actually in the area where we previously repaired his previous repair, the 4-anchor repair was noted. The sutures were all intact, but there was no cuff tissue attached to it. I grabbed the cuff tissue with an Allis clamp and actually could bring it out over the insertion after we had done some soft tissue releases around it. I elected to do a revision repair here. We debrided the footprint with curette and tried to get good bleeding tissue. We then used a SpeedBridge construct, passing the twin-tailed FiberTape sutures and then the individual FiberWire sutures through the torn cuff tissue. We then tied this down to 2 lateral row anchors again making a SpeedBridge construct. This provided great compression of this tissue down on the bone. From here finally we moved to placement of out patch where initially I thought that our anterior tissue was going to be the most need of a patch, it was actually the posterior tissue, which was weaker and more deficient. I placed the large Regeneten patch here. Since it was still an open case, we deployed the patch. It actually had difficulty with the deployment mechanism on inserter, but we were able to take the patch off without any damage to it. We then laid it over the tendon repair. We used 8 of the soft tissue tacks and tied that down to the medial soft tissue and then used 2 bony anchors to tie into the lateral row. We put the shoulder through range of motion. This all seemed to be very secure and stable. From here, we moved to closure. We thoroughly irrigated with saline solution. We closed the deltopectorale interval with finger-of-eight #0 Vicryl suture, the subcuticular layer with 2-0 Vicryl suture, and the skin with staples. Sterile dressings were applied. The patient was awakened from anesthesia and taken to the recovery area in stable condition
INDICATIONS FOR SURGERY: The patient is a 59-year-old male whom I have operated on twice in the past back in 2021 and then again last year for a rotator cuff tearing of the right shoulder. With his most recent surgery, he has had increasing pain and dysfunction in the shoulder. Repeat MRI demonstrated a massive re-tearing of the tendon with retraction back to the glenohumeral joint. We discussed different treatment options including revision repair, patch augmentation, and potential reverse shoulder arthroplasty. He wished to proceed with revision repair of rather than proceeding with any sort of shoulder reconstruction option. The risks, benefits, and alternatives of the surgery were discussed and the patient agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was identified and marked in the preoperative area. His H&P and consent form were signed and updated. He had a regional block placed by the Anesthesia service without complication. He was taken to operating room where he was intubated and seated. He was placed in the beach-chair position. His right upper extremity was prepped and draped in normal sterile fashion. Preoperative antibiotics and tranexamic acid were given.
After a surgical time-out was performed, we started with a standard open approach to the right shoulder. We dissected down through the skin and subcutaneous tissues with knife and the Bovie electrocautery. The cephalic vein was identified and retracted medially. We made our way down to the clavipectoral fascia. I incised this lateral to the conjoint tendon. There was some typical joint fluid once we opened up this fascia layer. We looked first at the anterior portion of the rotator cuff. He had a pretty large defect in the rotator interval, but it seemed like the quality of the anterior supraspinatus tendon tissue was pretty good. It was just retracted back superiorly and posteriorly as well as a little bit medially. It seemed to pull down nicely down to the cuff insertion. Also, the upper half or so of the subscapularis tendon was attached all the way out the insertion, but the underside of the footprint was not attached as well. We debrided the overlying bursal tissue. I elected to do a SpeedBridge construct here, placing 2 medial row anchors, 1 mostly passing suture through the supraspinatus tissue and then the other one more anteriorly and passing those sutures through the subscapularis tissue. We then tied these down to lateral row anchors to provide nice compression of the footprint. We then used some additional #2 sutures from the lateral row anchors to pass in a side-to-side fashion to help close down the rotator cuff tissue interval and gave us a nice anterior repair. From here, we examined a part of the posterior rotator cuff as I was releasing some of the adhesions from the rotator cuff to the underside of the acromion and could feel posteriorly, it was very thin and even some areas where there was full-thickness defect. This was actually in the area where we previously repaired his previous repair, the 4-anchor repair was noted. The sutures were all intact, but there was no cuff tissue attached to it. I grabbed the cuff tissue with an Allis clamp and actually could bring it out over the insertion after we had done some soft tissue releases around it. I elected to do a revision repair here. We debrided the footprint with curette and tried to get good bleeding tissue. We then used a SpeedBridge construct, passing the twin-tailed FiberTape sutures and then the individual FiberWire sutures through the torn cuff tissue. We then tied this down to 2 lateral row anchors again making a SpeedBridge construct. This provided great compression of this tissue down on the bone. From here finally we moved to placement of out patch where initially I thought that our anterior tissue was going to be the most need of a patch, it was actually the posterior tissue, which was weaker and more deficient. I placed the large Regeneten patch here. Since it was still an open case, we deployed the patch. It actually had difficulty with the deployment mechanism on inserter, but we were able to take the patch off without any damage to it. We then laid it over the tendon repair. We used 8 of the soft tissue tacks and tied that down to the medial soft tissue and then used 2 bony anchors to tie into the lateral row. We put the shoulder through range of motion. This all seemed to be very secure and stable. From here, we moved to closure. We thoroughly irrigated with saline solution. We closed the deltopectorale interval with finger-of-eight #0 Vicryl suture, the subcuticular layer with 2-0 Vicryl suture, and the skin with staples. Sterile dressings were applied. The patient was awakened from anesthesia and taken to the recovery area in stable condition