I do not code Ortho very ofter and this one is stumping me. Thank you for your help!
PREOPERATIVE DIAGNOSES: Left frozen shoulder, impingement syndrome, partial rotatorcuff tear.
POSTOPERATIVE DIAGNOSES: Left frozen shoulder, impingement syndrome, partialrotator cuff tear; biceps pathology; plus glenohumeral arthritis.
PROCEDURES: Diagnostic and operative arthroscopy of the left shoulder, arthroscopiccapsule release and lysis of adhesions, arthroscopic joint debridement and rotatorcuff tendon debridement, arthroscopic biceps tenotomy, arthroscopic subacromialdecompression including acromioplasty.
DRAINS: One PainBuster.
PROCEDURE: After regional anesthesia been induced, the patient was placed on thetable in a beach-chair position. The left upper extremity and shoulder was preppedand draped in a sterile fashion. Examination under anesthesia, showed the patientlacked about 20% of her terminal motion arc in all directions. Standard anterior-posterior lateral portals were established. Diagnostic and operative arthroscopythen ensued. Intra-articular pathology found diffuse cartilage loss. I wouldestimate she has lost 50% of the articular cartilage throughout her joint. Therewas nothing really that needed to be debrided, though. Biceps tendon was extremelytenosynovitic and degenerative in appearance and a tenotomy was performed with thecautery. Superior labrum was debrided. Rotator cuff tendon had a 20% undersurfacetear that required debridement. This was done with a shaver. We then redirectedthe instruments in the subacromial space. A thorough arthroscopic subacromialdecompression including acromioplasty was performed with a shaver, bur and suctionablator. The patient had a moderate-sized acromial spur. Very dense and thickperihumeral adhesions present. At this point, I removed the arthroscopicinstruments from the joint and put a PainBuster in the subacromial space and Iclosed the portals with 3-0 nylon, I applied a sterile bulky dressing. There wereno operative complications.
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