Hey everyone, I have a sx that I seem to be having some trouble with...the physician is stating he is doing open repair of coracoid process fracture, biceps tendon transfer, greater tuberosity tuberoplasty, rotator cuff debridement, and a Botox injection in the bicep muscle...we were thinking 23585 for the coracoid process fracture and 23440 for the tendon transfer but are having trouble with every thing else. Here is the op note:

Right shoulder rotator cuff tear, right shoulder coracoid/scapula fracture,
right shoulder biceps instability with dislocation.


Right shoulder open coracoid process fracture repair, rotator cuff debridement, greater tuberosity tuberoplasty, biceps tendon transfer to pectoralis major tendon, and Botox injection to biceps brachialis and biceps muscle bellies.

One Acutrak standard screw, 22.5 mm in length, Botox injection 80 units.

The patient is a gentleman with a history of right-sided shoulder
pain, consistent with the aforementioned diagnoses.

After obtaining appropriate consent and identification of the right upper
extremity in the preoperative holding area by the surgeon. He was transferred to the operating room and placed supine on the operating table for induction of general endotracheal anesthesia. He was then placed into a beach chair position and all bony prominences were well padded. A time out was performed by the operating team confirming side, site, and dose of antibiotic. We identified the deltopectoral interval and insufflated the skin incision line with 10 mL of 0.5% Marcaine with epinephrine. We incised the skin and carried out deeper dissection with diathermy and blunt instrumentation and we identified the deltopectoral interval and retracted the cephalic vein laterally from the deltoid muscle protecting it throughout the case. We immediately encountered significant adhesions and scarring. We were able to locate the proximal stump of the coracoid process and then isolate the distal coracoid process fracture with traction sutures. The piece had attached pectoralis minor tendon as well as the conjoined tendon and some remnants of supraspinatus. The CA ligament was not identified or visualized. We cleared adhesions from around the deltoid and could not find a CA ligament to speak of and we were able to then forward flex and isolate the humeral head. We identified essentially complete rupture of the supraspinatus and infraspinatus but the subscapularis appeared to be intact and we were able to visualize down the lesser tuberosity and it appeared to be intact. The long head of the biceps tendon, however, was unstable moving it out of the groove and hyperemic. We transferred it to the pectoralis major tendon and secured it with a nonabsorbable suture and then rescued the intraarticular portion. Utilizing humeral head depressor retractors we were able to work superiorly at the supraspinatus and infraspinatus fossa and found only degenerative scarified muscle bellies. There was no appropriate tendon to mobilize and, in fact, what we had noted on the humeral head was what appeared to be chronic degenerative tissue as well as acute tearing involving the majority of the supraspinatus and infraspinatus which, in essence, whatever supra and infra were left at the time of his injury he sustained a myotendinous rupture leaving essentially no appropriate tissue for reconstruction. Furthermore there was not appropriate tissue even to perform a graft jacket-type grafting procedure. Instead we debrided the remaining soft tissue and performed a gentle tuberoplasty.

We did note areas on the superior articular surface of the humerus where he had already had cuff tear changes, indicating that he was articulating with
acromion, likely for some time.

We then directed our attention back to the conjoined tendon and coracoid process fracture fragment and continued to mobilize tissue. We debrided tissue from the proximal and distal fracture extents and felt we were able to mobilize the coracoid back to its native insertion. We placed four #2 Orthocords transosseously at both proximal and distal fracture sites. We performed a direct reduction and secured it with a single K-wire and then secured our suture fixation. The coracoid process appeared to be stable. We then placed an Acutrak screw over our guide pin that we had placed and confirmed excellent stability.

All sites were copiously irrigated. We took the arm through a range of motion
gently confirming appropriate alignment, stability and range of motion. We then directed our attention to layered closure.

The deltopectoral interval was reapproximated with 2-0 Vicryl in a running
locked fashion, the deep skin with 3-0 Monocryl, and skin with intracuticular
4-0 Monocryl. Skin was cleansed and wounds were dressed with Benzoin and
Steri-Strips, Xeroform, 4 x 4s and a compression dressing. We then injected the biceps and brachialis with a total of 80 units of Botox and placed him into an abduction pillow intraoperatively under my direction. He was then extubated and transferred to the recovery room in stable condition.

Any help would be great!