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Thread: SHOULDER EXPERTS I know this is long, GOOD NOTE THOUGH

  1. #1

    Default SHOULDER EXPERTS I know this is long, GOOD NOTE THOUGH

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    . The scope sheath with the blunt tip trocar was passed in through this portal site, aiming anteriorly toward the coracoid process until I could feel the tip of the blunt tip trocar pop through the posterior shoulder joint capsule. I then removed the trocar and placed the scope and the sheath, confirming that I was intraarticular. Immediately evident was subluxation of the long head biceps tendon anteriorly. I then established the anterior portal using a spinal needle. The skin was pierced superior and medial to the coracoid process in order to decrease the chance of damage to neurovascular structures in the area. I watched the tip of the needle enter the glenohumeral joint superior to the subluxated long head biceps tendon, and also superior to the subscapularis tendon stump. I chose the position to get the best angle on placing my anchor for subscapularis repair. Once I was satisfied with the position, I incised the skin here, and then placed the clear instrument cannula through this portal site, entering the glenohumeral joint anteriorly. Diagnostic arthroscopy then commenced.

    The long head biceps tendon demonstrated longitudinal split tearing, in addition to the subluxation of the tendon anterior and inferior to the humeral head. I used arthroscopic scissors to cut the long head biceps tendon at its insertion into the superior labrum, with the plan being to tenodese the long head biceps tendon in the bicipital groove at the time of the supraspinatus tendon repair. I then used the 4 mm resector shaver to débride the superior third of the torn glenoid labrum. I also inspected the supraspinatus and subscapularis tendons, which both were found to be torn, with significant retraction. I placed the scope through the anterior portal to complete the evaluation of the posterior structures. No infraspinatus or teres minor tendon tearing was found to be present, nor was there any significant posterior labral tearing, aside from the posterior superior tearing that was already treated with debridement. With the scope in this anterior portal site, I completed the inspection of the subscapularis tendon anteriorly. Complete tearing with retraction was evident.

    I then placed the 70 degree scope through the posterior portal so that I could look around the anterior aspect of the lesser tuberosity more easily, and then I decorticated the bone of the lesser tuberosity at the subscapularis footprint using the shaver, and then I passed two #2 fiber wire fiber loops through the torn subscapularis tendon stump, and I then threaded these two fiber loops through the eyelet of a BioSwivel lock anchor. I then inserted the anchor into the central portion of the decorticated lesser tuberosity, which pulled the subscapularis stump back to anatomic position. Excess suture was cut, and then attention was directed to the subacromial space.

    Keeping the scope in the posterior portal, I pulled it out of the glenohumeral joint and then placed it above the humeral head in the subacromial space. The lateral portal was then established, first using the spinal needle. When I was satisfied with the position, I incised the skin here using the #11 blade scalpel, and then I performed subacromial bursectomy using the 4 mm resector shaver, and then the shaver was placed through the anterior portal and the soft tissues around the undersurface of the acromioclavicular joint were exposed as well. I also used the 90 degree angle ArthroWand thermoablation device to coagulate small bleeders as they were encountered.

    I then performed subacromial decompression, placing a bur through the lateral portal, and I planed the undersurface of the anterior half of the acromion from a lateral to medial direction. Once it was planed flat, I placed the bur through the anterior portal and I changed the 30 degree scope for a 70 degree scope, and I placed it in the lateral portal, and I removed the distal 1 cm of the arthritic hypertrophic distal clavicle bone, taking care to remove the bone all the way up to the dorsal capsular tissue. I placed the 70 degree scope through the anterior portal, confirming that I was entering the acromioclavicular joint to directly visualize it with the 70 degree scope, confirming that I removed adequate bone of the distal clavicle. Once this was confirmed, I placed the 30 degree scope once again through the posterior portal and inspected the supraspinatus tendon tear through this extraarticular vantage point. The tear was found to be quite large and retracted.

    I then removed the arthroscopic equipment from the shoulder and used the #15 blade scalpel to make a longitudinal skin incision starting at the anterolateral aspect of the acromion, continuing anterior inferiorly in line with the fibers of the deltoid. The subcutaneous fat was divided in line with the skin incision to expose the underlying deltoid fascia, which was also incised in line with the skin incision, and the fibers of the deltoid were split in line with their fibers bluntly and a small Covelle retractor was placed in the depths of the wound to facilitate exposure. My assistant then externally rotated the patient's shoulder to bring the bicipital groove into the wound. The long head biceps tendon stump was identified, and the tendon had a significant amount of tearing throughout the substance of the tendon as far distally as I could pull into the wound, and I therefore elected to simply tenotomize the long head tendon because there was such extensive tearing throughout the tendon I was afraid that tenodesis would still result in pain. I then used a #2 fiber wire suture to act as a grasping suture, placing it along the torn supraspinatus tendon in an interlock fashion. I then used the Freer to free the retracted scarred supraspinatus tendon from the surrounding soft tissues, and then once I was able to mobilize it satisfactorily, I decorticated the bone of the superior aspect of the greater tuberosity, and then I reapproximated the torn rotator cuff tissue back down to the decorticated bone using Arthrex BioSwivel lock suture bridge technique, using #2 fiber tape suture.

    The two medial anchors were first placed, just lateral to the articular cartilage of the humeral head. I used the scorpion suture passer to pass the #2 fiber tape through the torn rotator cuff tissue approximately a cm medial to the free torn edge. Since each anchor had another #2 fiber wire suture projecting from the dorsal aspect of each anchor, I also passed these sutures, one through the most anterior aspect of the torn tissue, and one through the more posterior aspect of the torn tissue. I then tied these #2 fiber wire sutures to their respective mates to re-enforce the repair. I then placed the lateral row of BioSwivel lock anchors approximately 2 to 3 cm lateral to the medial row. I then took one of the posterior fiber tape sutures and one of the anterior fiber tape sutures, as well as the anterior two #2 fiber wire sutures and passed them through the eyelet of the anterior BioSwivel lock, and I place the other sutures through the eyelet of the posterior BioSwivel lock, so that when I inserted these anchors into the bone, it pulled the sutures firmly down over the lateral aspect of the torn rotator cuff tissue, resulting in a double row type repair

    23412 lt
    29826 59 Lt
    29824 lt
    29822 59 lt

    What do you think?????
    Last edited by ASC CODER; 02-15-2011 at 02:13 PM.

  2. #2


    I think the codes that you have are appropriately; however, I would change the order since 29824 has a higher RVU than 29826. I would do it the following way:

    23412 LT
    29824 51 LT
    29826 59 LT
    29822 59 LT

  3. #3


    Thanks for your input. I should of said that I am in an ASC and I sequenced them that way per our managed care contract. But just wanted to make sure from the ortho experts that I was not missing anything... boy this was a good one.

    Thanks again.

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