certificate of attendance -...

Certificate of Attendance

Advanced Clinic: Shoulder Surgery CPT Coding

July 8, 2004

_____________________________________NAME

Lolita M. Jones, RHIA, CCSPresenter

The American Health Information Management Association (AHIMA) has approved this program fortwo (2) continuing education clock hours in the External Forces content area.

Retain this certificate as evidence of participation.

Advanced Clinic Skin Grafts

All CPT Codes 2002 American Medical Association* Lolita M. Jones Consulting Services 1

Advanced Clinic:

Skin Graft

Presenter:

Lolita M. Jones, RHIA, CCS

Lolita M. Jones Consulting Services

1921 Taylor Avenue

Fort Washington, MD 20744

(V) 301-292-8027

(FAX) 301-292-8244

Coding Training: www.hcprofessor.com

E-mail: [email protected]

Distributed by HCPro, Inc.

Advanced Clinic: Skin Graft

Presenter:Lolita M. Jones, RHIA, CCS

Lolita M. Jones Consulting Services1921 Taylor Avenue

Fort Washington, MD 20744(V) 301-292-8027

(FAX) 301-292-8244Coding Training: www.hcprofessor.com


Distributed by HCPro, Inc.

Advanced Clinic: Shoulder Surgery

Author:Lolita M. Jones, RHIA, CCS

Lolita M. Jones Consulting Services1921 Taylor Avenue

Fort Washington, MD 20744(V) 301-292-8027

(FAX) 301-292-8244Coding Training: www.hcprofessor.com


Advanced Clinic Shoulder Surgery

All CPT Codes 2003 American Medical Association 2

Table of Contents

Disclaimer 3

About Lolita M. Jones Consulting Services 4

Objective 9

I. Shoulder Surgery 10

A. Arthroscopic Heat Application 10

B. Arthroscopic Shoulder Decompression of Subacromial

Space with Partial Acromioplasty 10

C. Injection for Shoulder Arthrography 11

D. Arthroscopic Rotator Cuff Repair 11

E. Partial Acromionectomy 11

Coding Resource: Shoulder Surgery-Arthroscopy vs. Open 12

F. Postoperative Pain Management 13

II. Case Studies 15

III. Answer Key 56



DisclaimerAdvanced Clinic: Shoulder Surgery is designed to provide accurate and authoritative

information in regard to the subject covered. Every reasonable effort has been made to

ensure the accuracy of the information within these pages. However, the ultimate

responsibility lies with the user.

Lolita M. Jones Consulting Services and staff make no representation, guarantee or

warranty, express or implied, that this compilation is error-free or that the use of this

publication will prevent differences of opinion or disputes with Medicare or other third-

party payers, and will bear no responsibility or liability for the results or consequences of

its use.

Physician’s Current Procedural Terminology, Fourth Edition (CPT-4) is a copyrighted

coding system owned and maintained by the American Medical Association.

Please contact Lolita M. Jones, RHIA, CCS at:

(V) 301-292-8027

(Fax) 301-292-8244

Coding Training: www.hcprofessor.com


©2004 Lolita M. Jones Consulting Services

All five-digit number Physician’s Current Procedural Terminology, Fourth Edition

(CPT) codes, service description, instructions and/or guidelines are 2003 American

Medical Association. All rights reserved.

All rights reserved. The author grants permission for photocopying for limited personal

use or internal use of the original purchaser. This consent does not extend to other kinds

of copying, such as for general distribution, for advertising or promotional purposes, for

creating new collective works, or for resale.

• SHOULDER



About Lolita M. Jones Consulting Services

HOSPITAL TRAINING PROGRAMSCoding Training: www.EzMedEd.com

(V) 301-292-8027

(FAX) 301-292-8244


BIOGRAPHY:

Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospital

outpatient and ambulatory surgery center coding, billing, reimbursement, and operations.

Ms. Jones recently launched her web-based coding program at www.EZMedEd.com.

She has over 15 years of experience in publishing, training, and auditing for the hospital

outpatient and freestanding ambulatory surgery center (ASC) markets. Ms. Jones has

earned both the Registered Health Information Administrator and Certified Coding

Specialist credentials from the American Health Information Management Association

(AHIMA) in Chicago, IL. Ms. Jones resides in Fort Washington, Maryland, and she has

developed six (6) specialty manuals for freestanding ambulatory surgery centers (ASCs)

as well as comprehensive manuals for the following ambulatory payment classification

(APC) training programs:

Basic CPT Outpatient Coding Clinic: This 6.5 hour program is designed for

(Future/Beginning/Current) Coding Specialists, Coding Managers, Reimbursement

Specialists, Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospital

staff responsible for outpatient coding including emergency room, ancillary department

and hospital-based clinic staff. The contents include general guidelines, steps for coding,

and official CPT guidelines for surgical procedures that are commonly performed in the

hospital outpatient setting. Exercises based on actual ambulatory surgery operative

reports will be used to strengthen the attendees’ understanding of the guidelines

presented.

APC Institute: Impact on Emergency Services: This 3 hour program is designed for

Emergency Department: Directors, Managers, Supervisors, and Nurses; Registration

Staff, Health Information Managers, Coding Specialists, and Cast Room Technicians.

The contents include APC Grouping Logic, Mapping Logic for ED Medical Visits,

APCs for Emergency Department Services, Modifiers –25 and –27, Emergency

Screening without Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound

Closure, and Documentation Guidelines.



APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program is

designed for Compliance Department Staff (Corporate Officers, Directors, Managers,

Analysts, Auditors); Health Information Management Staff (Directors, Coding

Managers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators,

Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors,

Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsible

for facility component outpatient coding in: Registration, Hospital-Based Clinics,

Ancillary Departments, and the Emergency Department. The contents include: Brief

Overview of APCs; CPT Surgery Coding Compliance; and APC Compliance Issues: site-

of-service billing, reason for visits, discontinued surgery, medical visits, “limited follow-

up services,” colorectal cancer screening, observation stay without recovery, critical

care, interventional radiology, modifiers, unlisted procedure codes, units of service, UB-

92 claims data, and higher level APC groups.

APC Institute: Clinical Documentation Strategies: This 6.5 hour program is designed

for nursing, utilization management, case management, and other health care

professionals responsible for health records documentation. The contents include

ambulatory payment classification (APC)-related clinical documentation requirements

and management tips for the following sites of service: Emergency Room, Observation

Beds/Unit, Ambulatory Surgery, Hospital-Based Outpatient Departments/Clinics, Pain

Management Clinic, Series/Recurring Services, Partial Hospitalization Program, Cast

Room, Ancillary Testing Areas, and Utilization Management.

APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designed

for all technical, clinical and managerial staff responsible for facility component

outpatient coding that will directly impact ambulatory payment classification (APC)

payments. The contents include: Ambulatory Surgery Reimbursement under APCs, APC

Data Reporting Requirements, Medicare Hospital Outpatient Edits, Outpatient Billing

Procedures and Guidelines, Ambulatory Claims Rejection Monitors, Peer Review

Ambulatory Surgery Review, Coding System Reviews, How to Use ICD-9-CM, How to

Use CPT, and CPT Coding Guidelines By Body System (Integumentary,

Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic,

Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital,

Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).



Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed for

coding, reimbursement, compliance, billing, database management, ancillary, and clinic

staff responsible for modifier programming, reporting, billing, and auditing. The

contents include: Modifier Reporting Requirements, Official Medicare Guidelines,

Recommended Hospital Front-End Modifier Edits, Electronic/On-Line UB-92 Reporting

of Modifiers, Coding and Billing Aborted/Discontinued Procedures, ICD-9-CM vs.

Medicare Coding Guidelines, Unsuccessful vs. Aborted/Discontinued Procedures,

Documentation of Reduced/Discontinued Procedures, Testing Potential Coders, Software

Encoder Modifier Edits, Interventional Radiology Procedures, Information System

Upgrades, Data Quality Review, Radiology Modifier Reporting Issues, Ancillary

Department Modifier Reporting for Hospitals, and Exercises/Case Studies.

APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program is

designed for hospital executives, directors, chargemaster coordinators,

coding/reimbursement staff, and information system/database managers who will

implement ambulatory payment classifications (APCs). The contents include: General

Overview of APCs, APC Data Reporting Requirements, APC Policy Issues, Developing

a Plan of Action, Conducting Hospital-Wide APC Education, and Assessing Current

Outpatient Operations for: Overall Hospital, Management Information Systems, Business

Office/Patient Accounts, Health Information Management, Ancillary

Departments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-Owned

Satellite Facilities, Hospital-Based Physician Coding and Billing, and Utilization

Management.

APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designed

for Chief Financial Officers, Vice Presidents of Finance, Controllers, Chargemaster

Coordinators, Database Managers, Software Vendor Product Managers, Coding

Managers, Reimbursement Specialists, Director of Patient Accounts/Business Office,

Outpatient Billing Supervisor/Coordinator, Outpatient Billing Specialists. The contents

include: Durable Medical Equipment and Prosthetics, Pre-operative Registration,

Outpatient Service “Red Flags,” Chargemaster/Charge Entry, Claims Preparation, Claims

Payment, Tracking and Reviewing Medicare Billing Guidelines.



Lolita M. Jones Consulting Services

FREESTANDING

AMBUALTORY SURGERY CENTER

TRAINING PROGRAMS

ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed for

Freestanding ambulatory surgery center (ASC) Managers (Business, Nurse,

Reimbursement), Directors, Administrators, Coding Supervisors, Coding Specialists, and

Billers. The contents include: Current Freestanding ASC Structure, Proposed

Freestanding ASC Structure, Medicare Coding Requirements, Medicare Billing

Requirements, Coding Ambulatory Surgery, How To Use CPT When Coding

Ambulatory Surgery, and CPT Coding Guidelines By Body System (Integumentary,

Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic,

Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital,

Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).

ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour program is designed for

all technical, clinical and managerial staff responsible for facility component freestanding

ASC coding and billing. The contents include: exercises based on actual outpatient

operative reports; and CPT coding guidelines for topics such as: tissue expander, pedicle

flap, pressure ulcer, skin grafts, nail avulsion and excision, scar revision, burn treatment,

lesion excisions, wound repair, adjacent tissue transfer/rearrangement, breast surgery,

free flaps with microvascular anastomosis.

ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for all

technical, clinical and managerial staff responsible for facility component freestanding


operative reports; and CPT coding guidelines for topics such as: cataracts. intraocular

lens, keratoplasty, trabeculectomy, strabismus surgery, punctum plugs, tarsorrhaphy,

trichiasis correction, retinal detachment repair, vitrectomy.



ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for all



operative reports; and CPT coding guidelines for topics such as: hernia repair, nasogastric

intubation, percutaneous gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage,

dental procedures, covered and noncovered colorectal cancer screening, gastrointestinal

endoscopy, esophageal dilation.

ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for all



operative reports; and CPT coding guidelines for topics such as: ganglion cyst, joint

injections, decompression fasciotomy, treatment of fractures/dislocations, skeletal

anatomy of the hand and foot, surgical knee arthroscopy, bunionectomy, toe-to-hand

transfer with microvascular anastomosis.

ASC Clinic: Urology Procedures - This 6.5 hour program is designed for all technical,

clinical and managerial staff responsible for facility component freestanding ASC coding

and billing. The contents include: exercises based on actual outpatient operative reports;

and CPT coding guidelines for topics such as: retrograde pyelogram, ureter vs. urethra,

urethral dilation, ureteral stent, urethral stent, Burch Procedure,

vesicourethropexy/urethropexy, urodynamics, chemotherapy.



OBJECTIVE: This program will first provide a detailed review of the shoulder surgery

CPT coding guidelines to assist the participants in their understanding of the numerous

techniques that are performed. “Real life” operative report case studies will also be

presented for many of the shoulder surgery techniques that are discussed.



I. Shoulder Surgery

A. Arthroscopic Shoulder Heat Application

Assign unlisted arthroscopy CPT code 29999 to report the use of heat to shrink the

capsule in the shoulder performed through an arthroscope. (Source: CPT Assistant

newsletter, August 1998, page 11.)

B. Arthroscopic Shoulder Decompression of Subacromial

Space with Partial Acromioplasty

The arthroscopic procedure involves exposing the subacromial space, bursectomy,

debridement, detaching the coracoacromial ligament and removing the undersurface of

the acromion. When subacromial decompression is performed, a flat undersurface of the

acromion and acromioclavicular joint is produced, which enlarges the supraspinatus

outlet and prevents impingement.

Coding Tip: The partial acromioplasty, arch decompression, excision of bursal tissue and

release of the coracoacromial ligament would not be reported separately, as these are

considered to be inclusive components of code 29826. [Source: May 2001 CPT Assistant

newsletter, AMA]



C. Injection for Shoulder Arthrography

To report an MRI of the shoulder with intra-articular contrast (MR arthrography of the

shoulder), it is appropriate to report 23350 for the shoulder joint injection. Report 76003

if fluoroscopic guidance was used to guide needle placement into the joint, and 73222 for

the MRI shoulder with contrast.

Coding Tip: There is a correct coding initiative (CCI) edit in place as a comprehensive

code pair edit for 23350 and 76003, since fluoroscopic-guided imaging is considered

included in the radiographic arthrography code (73040). Therefore, modifier –59,

Distinct procedure, should be appended to 76003 to designate the fluoroscopic guidance

as a distinct and separate procedure when radiographic arthrography is not performed.

(July 2001 CPT Assistant newsletter, AMA).

D. Arthroscopic Rotator Cuff Repair

Rotator cuff injuries are strains or tears of one or more rotator muscles or tendons, the

most common site being the supraspinatous muscle. Acute tears result from trauma, such

as falls on an outstretched hand or injuries from football throwing, baseball or softball

pitching. Racquetball serving or manipulation of a frozen shoulder. Chronic tears

originate from over-use or constant stress. Assign CPT code 23410 or 23412 for repairs

involving one or two tendons or major muscles of the rotator cuff. Assign CPT code

23420 for a repair of a complete shoulder (rotator) cuff avulsion, referring to the repair of

all three major muscles/tendons of the shoulder cuff. Source: February 2002 CPT

Assistant newsletter, AMA.

Clinical Tip: The major muscles of the rotator cuff: supraspinatus, infraspinatus and

teres minor.

. Partial Acromionectomy

23410 [Repair of musculotendinous cuff (e.g. rotator cuff); acute] includes the work

involved in performing a partial acromionectomy (23130). Therefore, it would not be

appropriate to report 23130 separately. (Source: August 2001 CPT Assistant, AMA).



Coding Resource:



F. Postoperative Pain Management

Source – 2001 Complimentary Issue CPT Assistant newsletter, AMA:

• CPT reporting of peripheral nerve/plexus nerve catheter placement is based on the :

* exclusion of other anesthesia service(s);

* performance of concomitant operative service(s) by same physician; and

* target nerve involved.

• If the catheter is placed primarily for anesthesia administration during an operative

session, then the appropriate anesthesia services code(s) should be reported.

• If placement is performed for the purpose of post-operative pain management by the

same physician at the time of another operative service (e.g., total shoulder

reconstruction), then the appropriate 64400-64450 series code should be reported

with the modifier –51 appended (if modifier –51 is acceptable by the third-party

payer).

• The appropriate nerve block code (64400-64450) should also be reported when the

catheter is placed by a physician, other than the physician performing anesthesia or

surgical services. For example, for placement of a lumbar plexus catheter, code

64449 should be reported. Similarly, a sciatic nerve catheter insertion would be

reported with the appropriate code.

• Currently, there is no specific CPT code for “daily” management of the peripheral or

plexus nerve catheter. It is not appropriate to report anesthesia code 01996 as this is

specific to epidural catheters (NOTE: anesthesia CPT codes are frequently non-

reportable by hospitals to most third-party payers).



October 2001 CPT Assistant newsletter, AMA:

• When general anesthesia is administered and pain management injections are

performed to provide postoperative analgesia, they are separate and distinct services

and are reported in addition to the anesthesia code. Whether the block procedure

(insertion of catheter, injection of narcotic or local anesthetic agent) occurs

preoperatively, postoperatively, or during the procedure is immaterial.

• If, on the other hand, the block procedure is used primarily for the anesthesia itself,

the service should be reported using the anesthesia code alone. In a combined

epidural/general anesthetic, the block cannot be reported separately.

Examples:

[NOTE: Many third-party payers do not accept CPT anesthesia codes from hospitals.]

• A femoral nerve block placed to provide post-operative analgesia for an anterior

cruciate ligament repair or a total knee replacement would be reported separately

from the surgical anesthesia.

• A patient undergoing a thoracotomy might receive an epidural injection of a local

anesthetic and/or narcotic (62318) for postoperative pain control in addition to the

general anesthetic, which is administered through an endotracheal tube (00540). In

this case, the epidural is not the surgical anesthetic and it would be reported

separately, as an independent procedure.

• Shoulder surgery could be performed under an interscalene brachial plexus block that

would also provide postoperative analgesia. This would be reported using the

anesthetic code (e.g., 01620). If the block were intended primarily to alleviate

postsurgical pain, and a general anesthetic was administered for the shoulder

procedure, the block would be separately reportable.

• A brachial plexus block might also provide both the anesthesia and the postoperative

pain control for an open reduction of a wrist fracture. Only the anesthesia code would

be reported.



II. Case Studies



Case Study # 1. Please assign the CPT code(s)-modifiers for

this case: _____________________________________________________________.

OPERATIVE REPORT

ASSISTANT: None.

PREOPERATIVE DIAGNOSIS: Adhesive capsulitis, large rotator cuff tear on the

right shoulder.

POSTOPERATIVE DIAGNOSIS: Adhesive capsulitis, large rotator cuff tear on the

right shoulder.

OPERATION: Manipulation under anesthesia of the right shoulder and injection of

steroids into the right glenohumeral joint.

INDICATIONS:

This is a 74-year-old female who has had persistent pain, loss of mobility in the shoulder.

She has 9 degrees at forward flexion and abduction both passively and actively. Internal

rotation is also limited to the level of L5 and she has 30 degrees of external rotation. She

has a known rotator cuff tear but she also has significant adhesive capsulitis. I will try to

immobilize the shoulder first and if we need good mobility and strength and no other

treatments really necessary for the rotator cuff tear; however, she has persistent pain and

she regains mobility then eliminating to fix the rotator cuff.

PROCEDURE/FINDINGS

The patient was placed in the supine position on the operating table. After adequate

general anesthesia was given, we gently manipulated obtaining full mobility back to

the shoulder and then placed 20 cc of 0.25% Marcaine with epinephrine and 2 cc of

Solu-Medrol. She was discharged to the recovery room in satisfactory condition. She

would start in a physiotherapy program and the CPM machine.




this case: _____________________________________________________________.

PREOPERATIVE DIAGNOSIS: Right acromioclavicular arthritis.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION PERFORMED: Excision, right distal clavicle.

ANESTHESIA: General.

PROCEDURE: The patient was taken to the operating room and identified. General

endotracheal anesthesia was induced. The patient received prophylactic Ancef and was

placed in the beachchair position. The right shoulder was prepped and draped in the

usual sterile manner. The skin was incised over the AC joint. Bleeders were coagulated

with the Bovie. The joint was subperiosteally exposed. The micro-saw was used to

remove 1 cm of the distal clavicle. The end of the clavicle was arthritis. The wound

was irrigated. Hemostasis was reassessed. The wound was closed with 2-0 Vicryl and

staples. After closure, the area was injected with 0.5% Marcaine without epinephrine.

The patient was taken to the recovery room in stable condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: 1. Right rotator cuff rupture.

2. Right acromioclavicular joint disease.

POSTOPERATIVE DIAGNOSIS: 1. Right rotator cuff rupture.

2. Right acromioclavicular joint disease.

OPERATION PERFORMED:

1. Right rotator cuff reconstruction using curve TAC instrumentation.

2. Open Mumford procedure.

ANESTHESIA:

General.

INDICATIONS: The patient is a 69-year-old white male who has a right rotator cuff

tear. He has failed nonoperative treatment. He also has been noted to have right AC

joint disease, has weakness, pain and discomfort in the shoulder. He is brought today for

definitive treatment. He is aware of possible risks and benefits.

PROCEDURE: The patient underwent general anesthesia without event. He was

sterilely prepped and draped in the usual fashion. He was placed in a semirecumbent

barber chair position.

An incision was made over the anterolateral aspect of the shoulder extending over

the AC joint. The subcutaneous was identified and incised. Dissection was carried

down to the level of the superior AC ligament. Subperiosteal dissection was performed.

Distal clavicle was identified. There was noted to be a large spur and severe degenerative

changes over the clavicle. Distal clavicle was then excised first using a saw and then a

rasp to smooth out the area. The wound was copiously irrigated out.

Attention was then placed to the lateral acromion. A subperiosteal dissection was

performed off the lateral acromion and deltoid split was performed. Bursa was

excised. There was noted to be a very complex rotator cuff tear. Complete avulsion

of supraspinatus, infraspinatus and teres minor off the greater tuberosity. Biceps

tendon was noted to be intact. There was noted to be a second tear which was separate

and a longitudinal tear between the interval between the supraspinatus and the

infraspinatus as well. This was a hypertrophic type tear. There was calcification in the

edges of the tendon in that area. The calcific deposits were then excised and the

longitudinal tear was repaired in a side-to-side fashion between the supraspinatus

and infraspinatus.



Case Study # 3 - continued

After completion of this, there was a longitudinal tear in the infraspinatus as well

which was appreciated. There were some calcium deposits in that as well and these

were excised as well. Using a #2 Ethibond suture, retention sutures were then placed

over the cuff and it was delivered laterally. A Cobb elevator was then used to free up

the adhesions and bring the cuff laterally, both deep and superficial to the cuff. A

rongeur was taken and a trough was made laterally. The wound was copiously

irrigated out. Hemostasis was obtained with electrocautery. Using a curved TAC

instrumentation after adequate mobilization of the cuff was completed, the cuff was

delivered in the three drill holes which had been placed laterally with a #2 Ethibond

suture utilized. The cuff was then oversewn after having been tied with the arm at the

side with good coaptation into the trough itself. The cuff was then oversewn using the

Ethibond as well as 0 Vicryl. After completion of this, the wound was copiously

irrigated out. The joint was copiously irrigated as well. Prior to closure of the joint, an

anterior-inferior acromioplasty was done at that point as well. A rasp was utilized prior

to closure of the cuff to smooth out the inferior aspect of the acromion. Hemostasis

was obtained using electrocautery. The superior AC ligament was then closed using 0

vicryl figure-of-eight. The deltoid split was repaired using 0 Vicryl figure-of-eight

suture. Subcutaneous was closed using 3-0 Vicryl and skin was closed using staples. A

sterile compressive dressing was placed. The patient tolerated the procedure well and left

the operating room in stable condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:

Complete rotator cuff tear of right shoulder.

POSTOPERATIVE DIAGNOSIS:

Complete rotator cuff tear of right shoulder.


Repair of complete rotator cuff tear right shoulder with acromioplasty.

ANESTHESIA:

General.

PROCEDURE: The patient was placed supine on the Operating Room table at which

time he was put to sleep under general anesthesia. Following this, a bump was then

placed beneath the left scapular area. The shoulder was then prepped with Betadine

Solution for a full five minute prep and draped in a sterile fashion. A saber type incision

was made over the superior aspect of the shoulder and carried down through skin and

subcutaneous tissue to the underlying tip of the acromion. The attachments of the deltoid

muscle were released and subacromial space identified. Here there is noted to be

evidence of a complete avulsion of the rotator cuff with approximately 1 cm of

retraction. This measured approximately 1.5 cm in width. In order to better visualize as

well as to decompress an oblique osteotomy cut was made across the tip of the acromion.

This was smoothed with a rasp. Next, the tear was mobilized and the bed prepared.

Two bone anchors were used to reattach the rotator cuff. Once done there was good

stability at the repair site. The area was then thoroughly irrigated with antibiotic solution

following which two drill holes were placed in the remaining tip of the acromion. #1

PDS sutures were then placed through these and the deltoid muscle was reattached.

This was oversewn with another #1 PDS suture. Subcutaneous tissues were closed with

#3-0 Vicryl. Skin was closed with #5-0 Vicryl subcuticular suture. The wound was then

dressed in a sterile fashion and a sling and swathe applied. The patient was then returned

to the Recovery Room in satisfactory condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Adhesive capsulitis, left shoulder.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE PERFORMED: Left shoulder arthroscopy with manipulation,

lysis of adhesions and pain capsular release.

INDICATIONS: The patient is a 58 year old with recalcitrant adhesive capsulitis. He

failed nonoperative management. He failed initial manipulation. He elected to proceed

with the above procedure and risks and benefits were discussed with him and I answered

all his questions, consents were signed and placed on the chart.

OPERATIVE TECHNIQUE: The patient was taken to the Operating Room, was

placed in the supine position and given general anesthesia per Anesthesia protocol. He

was given 1 gram of IV Kefzol and brought up in the beach chair position. Pressure

points were well padded. The arm was then manipulated and brought to a near forward

flexion. External rotation was to about 45 degrees. There was extensive release with

the manipulation. The posterior portal was established. After prepping and draping in

the usual sterile fashion, the posterior portal was established, the anterior portal was

established. A 4.5 shaver was used to debride the synovitis. Underwater

electrocautery was used for capsular release anteriorly. Once the capsular release was

complete all down to 6 o’clock from the manipulation, the remainder that needed to be

released was superiorly from 3 to 1 o’clock.

This was completed and the 4.5 shaver was used to debride the remainder capsular

tissue for this release. Once this was complete, the portals were switched and the scope

was placed in the anterior portal and a working portal was then used posteriorly.

Posterior capsular release was performed. The arm was, then again, manipulated

and the release was completed from about 5 o’clock up to a 1 o’clock position

posteriorly. The arm was then manipulated and external rotation was achieved to

about 65 degrees. Once this was complete, the joint was lavaged. The scope was

removed. A pain pump was introduced in the subacromial space. The wounds were

closed with 4-0 nylon. Sterile dressing was applied. The patient was awakened and

taken to the Recovery Room in stable condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

ASSISTANT: None.

PREOPERATIVE DIAGNOSIS: Chronic rotator cuff impingement syndrome and

acromioclavicular arthrosis, right shoulder.

POSTOPERATIVE DIAGNOSIS: Chronic rotator cuff impingement syndrome and

acromioclavicular arthrosis, right shoulder.

OPERATION: Arthroscopy right shoulder with arthroscopic subacromial

decompression and open Mumford distal claviculectomy.


INDICATIONS: The patient is a 47-year-old security guard with long history of

progressive right shoulder pain, primarily at the acromioclavicular joint. He has

responded well but only temporarily to the previous acromioclavicular and subacromial

cortisone injections. Because of chronic symptoms, which have failed conservative

management, the patient was taken to the operating room at this time to undergo

arthroscopic subacromial decompression and Mumford distal claviculectomy.

PROCEDURE/FINDINGS: After induction of awaken nasal intubation and general

anesthesia, the patient was placed in the upright sitting position in the beachchair

attachment to the operating room table. The right upper extremity was prepped and

draped free in the usual fashion. Bony landmarks were outlined with a marking pen and

a standard posterior portal was made after instilling the glenohumeral joint and

subacromial space with 0.25% Marcaine with epinephrine. The glenohumeral joint was

inspected. The glenohumeral surfaces demonstrate some minimal grade 1

chrondromalacia. There was some minimal fraying of the undersurface of the rotator cuff

but no tear. Biceps and subcapularis tendons were normal. The anterior labrum was

normal. The arthroscope was removed from the glenohumeral joint and reinserted into

the subacromial space through the posterior portal and a second portal was made laterally

along the edge of the acromion. Using a combination of a full radius shave, Arthrocare

Cautery wand and a acromionizer bur, a subacromial decompression was performed

removing soft tissue from the undersurface of the acromion, removing several millimeters

of bone and detachment of the coracoacromial ligament from the anterior edge of the

acromion. Because of the patient’s large size of over 300 pounds, and somewhat difficult

visualization, it was elected to perform an open Mumford distal claviculectomy.




Arthroscopic instruments were removed and incision was made overlying the Case

acromioclavicular joint and carried down to subperiosteally expose the distal clavicle.

Approximately 1.5 cm of distal clavicle was excised with a sagittal saw and the end of

the bone was rasped smooth. Periosteal and fascial tissues were closed with multiple #1

Vicryl interrupted sutures and the wound was then irrigated and infiltrated with 0.25%

Marcaine with epinephrine for postoperative pain relief. Portals and wounds were closed

in routine fashion.

An indwelling, Marcaine pump catheter was placed at the distal claviculectomy site

for postoperative pain relief. Sterile dressings and a sling were applied after reversal of

anesthesia.

The patient was transported to the recovery room in stable condition. There were no

apparent intraoperative complications.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Possible rotator cuff tendonitis, acromioclavicular

arthritis, and frozen shoulder, right shoulder.

POSTOPERATIVE DIAGNOSIS: Frozen shoulder, subacromial bursitis-

impingement, and acromioclavicular arthritis, right shoulder.

OPERATIVE PROCEDURE: Arthroscopic subacromial decompression with open

distal clavicle resection and manipulation under anesthesia, right shoulder.

ANESHESIA: General and block.

INDICATION FOR PROCEDURE: The patient is a 51-year-old male with reclacitrant

shoulder pain and a frozen shoulder. He had failed rehabilitative and injection treatments

and requested operative intervention.

FINDINGS AT OPERATION: Preoperative motion was 90 degrees of flexion and 30

degrees of external and internal rotation. There was significant subacromial bursitis with

very thickened coracoacromial ligament and a subacromial spur. The intra-articular

structures were normal.

DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite and

general anesthesia was smoothly induced. The shoulder was examined and the above

noted limitation of motion was found. An interscalene block was placed for postop

pain control and the patient was placed in the beach chair position. The right shoulder

was manipulated with palpable and audible crepitace into 150 degrees of elevation,

external rotation was to 80 with the opposite shoulder being 90, and internal rotation

was equivalent at 70. Adduction and abduction were equivalent. The shoulder was

prepped and draped in a sterile fashion. Through anterolateral, direct lateral, and

posterolateral portals, the shoulder was examined and treated arthroscopically. The

glenohumeral joint was entered. The glenoid, humeral head, biceps tendon, and labrum

were intact. The rotator cuff was intact. The arthroscopic instruments were placed in

the subacromial space. The bursa was resected. The coracoacromial ligament was

released from the acromion with the cautery. Utilizing a bur and a shaver, the acromion

was flattened. The anterior portion was excised and the rotator cuff was found to have

a significant partial-thickness bursal side tear, but no full-thickness tear and the

arthroscopic instruments were removed. A small incision was made over the distal

clavicle. The deltotrapezial raphe was taken down in a subperiosteal fashion off of the

distal clavicle and the distal 2.5 cm of clavicle was excised with a saw. Bone wax was

placed over the cut end. The deltotrapezial raphe was closed with #1 Nurolon.




A small closed suction drain was placed and the wound was closed with 2-0 Vicryl and a

Monocryl for the skin. Steri-Strips were applied. The acomioplasty was checked

manually before closure. A sterile compressive dressing was applied. The patient was

awakened and taken to the recovery room in good condition. There were no

complications. Blood loss was minimal. Postoperative plans are to rehabilitate the

patient’s shoulder.




this case: _____________________________________________________________.

OPERATIVE REPORT


1. Left shoulder rotator cuff tear with subacromial impingement.


1. Left shoulder rotator cuff tendonitis/synovitis.

OPERATION:

Left shoulder arthroscopy, glenohumeral debridement, limited.

Subacromial decompression.


FINDINGS: The patient had an MRI which reportedly demonstrated a rotator cuff tear.

There was no tear noted either on the bursal surface or on the articular surface. There

was evidence of an impingement-type lesion on the greater tuberosity; however, the

rotator cuff insertion appeared to be intact. The rotator cuff was inspected both on the

articular and bursal surfaces. There was significant hyperemia throughout the rotator

cuff, and there was some questionable synovitis throughout the joint. A tissue sample

was sent for a pathologic evaluation, as the patient did have psoriasis. The patient

previously did undergo rheumatologic workup, which was reportedly negative. The

patient had a subacromial spur.

PROCEDURE: The patient was brought to the operating room and placed on a table in

a supine position. General anesthesia was induced. The left shoulder was prepped and

draped in the usual sterile fashion. A posterior portal was created, through which the

osteoscope was introduced. The above-noted findings were appreciated. An anterior

portal was then created with a Wissinger rod. Through this anterior portal the shaver was

introduced, and limited glenohumeral debridement was performed. Next, attention

was directed to the subacromial space, and a standard lateral portal was created through

which the cautery device and arthroscopic shaver were used to perform a

bursectomy.

Upon completion of the bursectomy, the borders of the acromion were defined. A burr

was used to perform an acromioplasty. The arthroscope was then introduced into the

lateral portal, and the burr was placed posteriorly. The burr was used to plane the

acromion. The AC joint was then visualized by using cautery and shaver to remove the

inferior capsule. There was a spur on the undersurface of the distal clavicle, and this

was coplaned. The rotator cuff was then inspected, and was found to be intact along its

bursal surface.




Wounds were irrigated copiously. Instruments were removed. 3.0 nylon sutures were

used to close the skin. A sterile dressing was applied. The patient was brought to the

recovery room in stable condition, having tolerated the procedure well.




PATHOLOGY REPORT

Age/Sex: 55/M

Received: 04/24/02-1322

Spec Type: SURGICAL P

PREOPERATIVE DIAGNOSIS: LEFT SHOULDER IMPINGEMENT


DATE: 04/24/02

PROCEDURE: LEFT-ARTHROSCOPY SHOULDER W/DECOMP

ACROMIOPLASTY; OPEN ROT REPAIR

TISSUE REMOVED

A. SYNOVIAL BIOPSY (LT SHOULDER)

GROSS DESCRIPTION

RECEIVED LABELED SYNOVIAL BIOPSY. THE SPECIMEN CONSISTS

OF A NODULE OF TAN GRAYISH TISSUE MEASURING 0.3 CM IN

GREATEST DIMENSIONS. ALL BLOCKED.

PATH PROCEDURES

PROCEDURES: PATH DSM, A1 BLK

FINAL DIAGNOSIS

SYNOVIUM, LEFT SHOULDER, BIOPSY: DENSE FIBROUS TISSUE

SHOWING SCANT CHRONIC INFLAMMATION. SYNOVIAL MEMBRANE

IS NOT UNEQUIVOCALLY IDENTIFIED.




this case: _____________________________________________________________.

OPERATIVE REPORT

ASSISTANT: None.


1. Rule out partial tear, rotator cuff, right shoulder.

2. Chronic impingement syndrome.

POSSTOPERATIVE DIAGNOSIS:

1. Partial tear, rotator cuff, supraspinatus tendon, 20 x 20 mm (30 to 40% torn),

right shoulder.

2. Chronic impingement syndrome with large subacromial spur and marked fraying

of the coracoacromial ligament.

OPERATION:

1. Arthroscopic subacromial decompression (arthroscopic acromioplasty) with

coracoacromial ligament release using electrocautery.

2. Extensive arthroscopic debridement of undersurface, partial tear, rotator cuff and

supraspinatus tendon (20 x 20 mm, approximately 30% torn), right shoulder.

ANESTHESIA:

INDICATIONS: The patient is a 55-year-old male who has been followed since April

2002 for severe adhesive capsulitis of the right shoulder. The adhesive capsulitis has

significantly improved with conservative treatment including injection, medications and

physical therapy.

X-rays obtained on October 5, 2002 revealed a normal glenohumeral joint with a type II

acromion. Despite a good passive range of motion, the patient continued to have

debilitating night pain, pain with over-activity and weakness of the rotator cuff.

An MRI was performed on December 19, 2001 and revealed rotator cuff tendinitis.

The patient has persisted with debilitating pain. The patient and his family understand

the serious nature of the proposed operative procedure. They understand the inherent

risks involved.




PROCEDURE: The patient was taken to the operating room and placed on the

operating table in the supine position. Following the induction of general anesthesia, the

patient was rotated to the left lateral decubitus position with the right side up. The right

shoulder was then prepped and draped in the usual sterile fashion.

Standard portals were used for the arthroscopic examination of the right shoulder.

Examination of the glenohumeral joint revealed normal articular surfaces. The anterior

and posterior glenoid and labra were intact; the middle and inferior glenohumeral

ligaments were intact. There was mild fraying of the biceps tendon.

The underside of the rotator cuff revealed a large underside partial tear measuring 20

x 20 mm, estimated to be 30 to 40% torn. This area was extensively debrided using the

full-radius resector. The arthroscope was then placed anteriorly and posteriorly for

further evaluation of the rotator cuff and for more extensive debridement.

The arthroscope was then placed into the subacromial space using the standard anterior,

posterior and lateral portals. Examination of the superior side of the rotator cuff revealed

marked fraying of the supraspinatus tendon. There was no complete tear identified.

The underside of the acromion revealed a large subacromial spur with marked fraying of

the coracoacromial ligament. This was transected with the use of electrocautery. The

underside of the acromion was then debrided using the Dyonics acromioplasty blade

and the Dyonics clavicularis blade; in this manner, 5 to 8 mm of bone were resected.

The arthroscope was then placed laterally and the shaver was inserted posteriorly to

further flatten the anterior hook of the acromion. The acromioclavicular joint was

visualized arthroscopically. Soft tissue was resected with the use of electrocautery.

Due to the absence of preoperative acromioclavicular joint pain, a distal clavicle

excision was not carried out. The superior side of the rotator cuff was extensively

debrided and the partial tear was estimated to be approximately 30 to 40%, involving

only the supraspinatus tendon.

The wounds were copiously irrigated throughout the procedure. Then 0.25% Marcaine

with epinephrine was instilled into the arthroscopic portals and 20 cc were placed into the

joint. A dry bulky compressive dressing was applied.

The patient tolerated the procedure well and was transferred to the recovery room in a

good condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Right rotator cuff tear.


1. Right partial thickness rotator cuff tear.

2. Subacromial impingement.

3. Acromioclavicular joint arthritis.

OPERATION:

1. Right shoulder arthroscopy.

2. Subacromial decompression.

3. Arthroscopic Mumford (distal clavicle) resection.

4. Limited glenohumeral debridement.


OPERATIVE FINDINGS: The patient had an MRI which was reported as showing a full

thickness rotator cuff tear. She had evidence of undersurface fraying. However, there

was no evidence of a full thickness tear. A Prolene suture was placed at the articular

surface at the articular margin of the rotator cuff tendon where it appeared to have a

partial thickness tear. When this bursal surface was probed there was no evidence of a

full thickness tear. The spur was removed as was the distal clavicle.

PROCEDURE: The patient was brought to the operating room, placed on the operating

room table in the supine position. Right shoulder was prepped and draped in the usual

sterile fashion. Right shoulder was then entered through a standard posterior portal. The

above noted arthroscopic findings were appreciated. A Wissinger rod was used to create

an anterior portal for the inside-out technique. There was some fraying of the biceps

tendon at its anchor. However, there was no instability. The biceps anchor origin was

debrided. There was evidence of an undersurface fraying of the rotator cuff. This

was debrided as well in a limited fashion. Next a Prolene suture was passed through a

spinal needle in this area where the tendon appeared attenuated. It was grasped through

the anterior portal and left out at the skin as a tag suture and marking suture for later

inspection from the bursal surface. Instruments were then removed from the

glenohumeral joint. The arthroscope was placed into the subacromial space. A standard

lateral portal was created. Through this lateral portal a cautery device was used as was a

shaver to perform a bursectomy. We defined the borders of the acromion. A bone spur

was found on the undersurface of the acromion. This was resected using the

acromioblaster. Next the distal clavicle was exposed. The distal clavicle was then

resected as well.




The arthroscope was placed into the lateral portal. Acromioblaster was used to plane the

acromion. The distal clavicle was also resected through this posterior portal. Next

attention was directed directly to the anterior AC joint, and the camera was placed into

the AC joint, and the completion of the distal clavicle resection was performed by

creating a posterior portal just behind the AC joint, the port of Neviaser. The

portal was then placed. Distal clavicle was resected.

The superior capsule was left intact. Wounds were then irrigated. Instruments were

removed. 3-0 nylon was used to close the skin. Sterile dressing was applied. The patient

was placed in a shoulder immobilizer and brought to the recovery room in stable

condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

OPERATION: Arthroscopic acromioplasty and arthroscopic rotator cuff repair, right

shoulder.

ANESTHESIA: Scalene block.

PREOPERATIVE DIAGNOSIS: Full thickness rotator cuff tear, supraspinatus insertion

site with impingement syndrome of the right shoulder.

POSTOPERATIVE DIAGNOSIS: Full thickness rotator cuff tear, supraspinatus

insertion site with impingement syndrome of the right shoulder.

OPERATIVE PROCEDURE: The patient was brought to the operative suite, scalene

block right shoulder followed by intravenous sedation anesthesia performed. The right

shoulder was examined and demonstrated full passive loss of shoulder motion. The

patient was then placed in the supine beach chair position and the right shoulder was

prepped and draped in the usual sterile fashion. A 30-degree arthroscope was

introduced through the posterior portal, intra-articular structures were visualized

demonstrating significant synovitis at the rotator interval and superior aspect of the

cuff. This area was initially cauterized and then debrided with the full radius resector.

Hemostasis was achieved. The long head of the biceps also had synovitis at its intra-

articular portion under the cuff tear. There was no fraying or fibrillation of the biceps.

The area of hyperemia was also cauterized. The superior glenoid labrum was intact.

There was some degree of fraying and fibrillation in this area but no evidence for a type 2

slap lesion. Anterior-inferior capsule labrum, posterior-inferior capsule labrum were

normal. Humeral head and articular surfaces of the glenoid and humeral head were

normal. There was full thickness tear of the supraspinatus insertion site over

approximately a 3 cm area from the rotator interval to the posterior-superior corner of the

greater tuberosity. The tear was retracted to approximately the mid humeral head. The

biceps tendon anchor and bicipital groove were normal, subscapularis was normal and

posterior cuff was normal. The arthroscope was then placed in the subacromial

space, there was marked bursal thickening and hypertrophy. A partial bursectomy was

carried out, there were some minor changes on the undersurface of the acromion. Soft

tissue was removed from the acromion with the cautery device and shaver. A minimal

acromioplasty was required, plus 3 to 4 mm of bone anteriorly and tapering this

posteriorly. The acromioclavicular joint was visualized but not resected. The soft tissue

was removed from the greater tuberosity, a bone trough was made over the greater

tuberosity from the bicipital groove to the posterior most extent of the cuff. This was

approximately a 2 to 2.5 cm bone trough.




The cuff was mobilized by release of the intra-articular portion of the capsule, release of

the coracohumeral ligament at the base of the coracoid. This was done with a cautery

device.

The cuff was then mobilized and pulled to the bone trough, two 5 mm Arthrex

anchors were placed in the lateral most aspect of the bone trough, and the sutures

were tied with three simple sutures and one mattress suture. An excellent anatomic

repair was achieved with the cuff being opposed to the tuberosity with firm fixation.

The arthroscopic equipment was removed from the shoulder, the portal sites were closed

with #3-0 Prolene and Steri-Strips. Sterile dressings were applied. The patient was

reversed from anesthetic and brought to the recovery room in stable and satisfactory

condition.

COMPLICATIONS: None.




this case: _____________________________________________________________.

OPERATIVE REPORT


1. Acromioclavicular joint arthritis right shoulder.

2. Possible superior labrum anterior and posterior lesion or labrum tear right shoulder.


1. Osteoarthritis right acromioclavicular joint.

2. Anterior superior labrum anterior and posterior lesion right shoulder.

TITLE OF THE OPERATION:

1. Arthroscopic superior labrum anterior and posterior lesion repair with one 3.0 mm

Fast-Tac suture anchor.

2. Arthroscopic distal clavicle excision right shoulder.


PREOPERATIVE NOTE: The patient is a 57-year-old gentleman with a long history of

right shoulder pain. Preoperative evaluation indicated pain emanating from an arthritic

AC joint, and we suspected a SLAP lesion as well. We did not suspect the rotator cuff or

impingement. Therefore, the above procedure was recommended.

DETAILS OF THE PROCEDURE:

Under general anesthetic, the patient was placed supine in the semi-sitting position with

the head on a Mayfield headrest. The right shoulder was scrubbed, prepped and draped in

the usual manner. The posterior viewing scrubbed, prepped and draped in the usual

manner. The posterior viewing portals were established through the glenohumeral

joint. The articular cartilage in the glenoid and humeral sides was normal. The posterior

labrum and direct superior labrum was normal. However, the anterior superior labrum

was detached. There was a SLAP lesion under the biceps anchored anteriorly coming

down to the approximately 1 o’clock. We probed this through an anterior portal in the

rotator interval and found this to be true. The biceps tendon anchor was normal except

for the anterior portion of the anterior superior labrum. The biceps tendon exited the joint

normally. The rotator cuff was normal.




We prepared the anterior superior glenoid neck with a shaver and a bur after using

the periosteal elevator to mobilize the soft tissue. Next, we placed a single 3.0 Bio Fast-

Tac suture anchor at approximately 12:30 on the anterior superior glenoid rim. We

used standard arthroscopic knot tying techniques to tie down the anterior superior

labrum with the anterior portion of the biceps anchor. Fortunately, the majority of

the biceps anchor was intact. We had established this using a peel-back sign

intraoperatively. Once the labrum was repaired, we probed it and found it to be stable.

Next, the subacromial space was entered. A lateral working portal was established.

We excised enough of the subacromial bursa to visualize the anterior acromion. We

denuded the anterior acromion across to the AC joint removing the inferior AC joint

ligaments. The distal clavicle was clearly identified. We removed the osteophyte on

the medial end of the anterior acromion, which was in part partial of the AC joint

osteophyte. We then did approximately an 8 mm distal clavicle excision through the

same anterior portal that we used for the labrum repair by redirecting it directly into the

AC joint. We removed all the clavicle up to, but not including the superior AC joint

ligaments.

Next, the arthroscopic instruments were removed. The portals were closed with 4-0

nylon. A sterile dressing was applied followed by a Don Joy shoulder immobilizer.

Sponge and instrument counts are correct. The patient tolerated the procedure well and

was transferred to the recovery room in satisfactory condition.

POSTOPERATIVE PLAN: The patient will be discharged home today and I will see

him in the office in a few days time for follow-up.




this case: _____________________________________________________________.

OPERATIVE RECORD

PREOPERATIVE DIAGNOSIS: Left shoulder acromioclavicular joint arthroscopy

with possible rotator cuff tear.

POSTOPERATIVE DIAGNOSIS: Superior labrum anterior and posterior (SLAP)

lesion, left shoulder with acromioclavicular joint arthritis and impingement.

OPERATION: 1. Arthroscopy of left shoulder with repair of superior labrum

anterior and posterior (SLAP) lesion.

2. Arthroscopic Mumford procedure and subacromial decompression.


INDICATIONS: This is a 64-year-old male who has been followed for some time with

shoulder pain of the left side. He has failed conservative treatment and presents for

definitive treatment.

MRI and symptoms are consistent with AC joint arthrosis as well as possible rotator cuff

tear.

PROCEDURE: The patient was taken to the operating room and placed in the supine

position. After general anesthesia was obtained, he was placed in the beach-chair

position with all bony prominences carefully padded. The left shoulder was prepped and

draped in the usual sterile fashion.

First, a posterior portal was made, and a diagnostic arthroscopy was performed.

Immediately noted was a significant SLAP lesion on the anterior aspect of the

labrum. The rotator cuff was inspected and was noted to be completely intact. There

was some mild synovitis around the SLAP lesion as well.

Next, an anterior portal was made. The labrum was probed. Most of the labrum was well

attached to the anterior lip of the glenoid.

Next, ArthroCare wand was used to repair the SLAP lesion as well as debride it.

With this completed then, the synovectomy was completed as well. The biceps tendon

was intact as were all other ligament and structures.




Next, attention was paid to the subacromial space. In the subacromial space, a

subacromial bursectomy was performed with the ArthroCare wand. AC joint

arthrosis was noted. This was debrided also with the ArthroCare system. The distal

clavicle was excised with a large bur. Also, the opposing acromion was smoothed

down with the bur as well completing our subacromial decompression.

The area was copiously irrigated. The wounds were gently approximated with 4-0

undyed Vicryl. The whole area was infiltrated with 0.5% Marcaine with epinephrine

and 0.75% Marcaine plain for postoperative anesthesia. Bulky dressing was placed

and held with tape. ABD was placed under the armpit, and the arm was placed in a

regular sling.

Estimated blood loss was minimal. The IV fluid replaced: Less than 3000 cc of

crystalloid. Drains and packs: None. Complications: None.

The patient tolerated the procedure well and was taken to the recovery room in a good

postoperative condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Bilateral shoulder impingement syndrome and rotator

cuff tears with a SLAP lesion of right shoulder.

POSTOPERATIVE DIAGNOSIS: Bilateral shoulder impingement syndrome and

rotator cuff tears with a SLAP lesion of right shoulder.

OPERATIVE PROCEDURE: Arthroscopic subacromial decompression and distal

clavicle planing, both shoulders, with debridement of SLAP lesion of right shoulder

followed by mini-open repair of rotator cuff tears of both shoulders.

INDICATIONS: Mr. Scott is a 55-year-old man, who has persistent and worsening

bilateral shoulder pain, right shoulder worse than left. Because of the persistent problems

with his shoulders, he is indicated for arthroscopic inspection of the rotator cuff repair.

The patient desired to do both shoulders at same time.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room,

where a suitable general anesthetic was induced. He was initially positioned on his side,

left shoulder up so that we could work on his left arm. His left arm was placed in the

shoulder holder and the shoulder was prepped and draped in the usual sterile fashion.

The arthroscope was instilled through a posterior portal and a shoulder inspection

carried out revealing normal-appearing glenohumeral joint and biceps tendon with a

rough irregular under surface of the rotator cuff consistent with the rotator cuff tear. The

instruments were then placed in the subacromial space and a thorough subacromial

decompression was carried out. Rotatory bur, Mitek debrider and the synovial

dissector were used to debride the subacromial space. The clavicle was coplaned.

Following this thorough decompression and observation of the rotator cuff tear, a mini-

open incision was made laterally and carried down through the deltoid. The deltoid was

split at the midline raphe and the anterior of the shoulder was inspected. Two sutures of

#2 Panacryl were placed through the edge of the cuff and the SCOI fashion holding the

edge of the cuff securely. One Bio-Absorbable Arthrex suture anchor was placed at

the articular margin and two sutures were placed through the rotator cuff more

proximally. Two sutures through the edge of the cuff were tied through bone holes

using the Concept instrumentation. The four sutures were then tied, allowing for a two-

layer repair of the rotator cuff. The repair was quite secure. Once the sutures had been

tied, the deltoid was re-approximated with 0 Panacryl and subcutaneous tissues with 2-0

Monocryl and the skin with running subcuticular Prolene. Steri-Strips and sterile

dressings were placed. The patient turned with the left shoulder down, right shoulder

up, and the same procedure performed on the right. The only difference being that the




superior border of the labrum and the biceps tendon had a rough, irregular area

consistent with a nondisplaced SLAP lesion. This was debrided with a synovial

dissector. The rotator cuff was repaired in the same fashion with the same suture

techniques.

The repair was quite secure. A little more of the deltoid was detached at the acromion on

the right, than the left. One #2 Panacryl suture was placed through the acromion and

through the deltoid to secure the deltoid back to the acromion. Following the procedure,

the patient was placed in two slings. He was turned, awakened, and taken to recovery in

satisfactory condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: 1. Right shoulder multidirectional instability.

2. Right rotator cuff impingement.

3. Right acromioclavicular joint arthrosis.

POSTOPERATIVE DIAGNOSIS: 1. Right shoulder multidirectional instability.

2. Right rotator cuff impingement.

3. Right acromioclavicular joint arthrosis.

OPERATION: 1. Right shoulder arthroscopy.

2. Arthroscopic subacromial decompression.

3. Arthroscopic distal clavicle resection.

4. Arthroscopic thermal capsulorrhaphy of the shoulder.


ESTIMATED BLOOD LOSS: Minimal.

CONDITION: To the PACU stable.

DESCRIPTION OF PROCEDURE: The patient was brought to the main operating room suite

where she was placed supine on the operating room table and underwent administration of a

general anesthetic. After which the right upper extremity and shoulder were prepped and draped

under sterile conditions. Marcaine 0.25% with epinephrine was used to infiltrate the proposed

incision sites and the anterolateral superimposed sites. The shoulder was distended with 40 cc of

saline through the posterior shoulder portal and the posterior shoulder portal was made. The

arthroscope was placed into the glenohumeral articulation where there was noted to be a

redundant axillary pouch involving the inferior glenohumeral ligament. All ligaments were

intact. The biceps were normal. The humeral head was found to have normal articular cartilage,

as was the same on the glenoid. An anterior portal was made and a thermal capsulorrhaphy

was performed with the use of the CapSure ArthroCare wand, so as to reduce and eliminate the

patient’s complaints of neurologic issues radiating into the hand, particularly given that the EMG

was negative. The arthroscope was then placed into the subacromial space, where

subacromial decompression was performed with the use of the ArthroCare wand, the 4.0

shaver, and the 5.0 burr. Thereafter the distal clavicle resection was performed, removing

approximately 9 to 10 mm of the distal clavicle.

The incisions were irrigated and thereafter closed with 3-0 Prolene sutures. The shoulder was

thereafter injected with 20 cc of 0.5% Marcaine and 5 mg of Duramorph. It was dressed with

Xeroform, 4 by 4 gauze pads, fluff, ABD, basic tape, and a basic sling. The patient was taken to

the PACU in stable condition.




SURGICAL PATHOLOGY REPORT

DOB: 8/9/1958 (Age: 45)

SEX: F

Specimen(s) Received

A. right distal clavicle

Final Diagnosis

Right Distal Clavicle, showing mild nonspecific reactive changes of the

osteochondrous tissue.

The bone marrow shows normocellular marrow for age with all three hematopoietic

cell lines with progressive maturation.

Clinical History

(Not Provided)

Gross Description

The specimen is labeled “right distal clavicle”.

The specimen is submitted in formalin and consists of a roughly dome-shaped portion of

bone measuring 2.0 x 1.5 x 1.0 cm. The dome portion of the bone shows attached fibrous

brown tan tissue. The opposite surface is a cut-surface showing trabeculated spongy

bone. The specimen is serially sectioned and submitted in its entirety after

decalcification.

Two sections/one cassette

Entire specimen submitted.




this case: _____________________________________________________________.

OPERATIVE NOTE

ANESTHESIA: General, with interscalene block augmentation, right shoulder.

PREOPERATIVE DIAGNOSIS: Torn rotator cuff.

POSTOPERATIVE DIAGNOSIS: 1. Massive tear rotator cuff.

2. AC joint arthritis.

3. Dislocated biceps tendon anteriorly.

OPERATIVE PROCEDURES:

1. Open repair of massive and chronic rotator cuff tear, with acromioplasty and

CA ligament resection.

2. Open Mumford procedure (AC joint resection).

3. Biceps tenodesis.

PROCEDURE: Under a good general anesthetic, augmented by interscalene block, the

patient’s right shoulder is examined. The patient has no abnormalities on inspection.

The patient is put through a massive range of motion. With the arm abducted to 90

degrees, he can externally rotate to about 70, internal rotation is about 50 and forward

elevation is to about 160-170. There is no evidence of instability.

At this point, the patient is placed in the beach chair position and the sandbag placed

underneath the operative scapula. The right shoulder and neck are prepped and draped in

the usual fashion for right shoulder surgery. A modified anterolateral approach is made

to the shoulder. A 2-inch incision starts under the palpable AC joint and extends

distally and laterally for a couple of inches. The incision is taken through skin and

subcutaneous tissues, down to the deltoid. The deltoid is split along the raphe, separating

the anterior and middle deltoid fibers. The deltoid is subperiosteally dissected from the

anterolateral border of the acromion. The CA ligament is identified and resected. The

humeral head is depressed with a Cloverleaf retractor and an anterior inferior

acromioplasty is performed.

The undersurface of the acromion is smoothed out with a rasp. We are very happy with

our decompression. The AC joint is identified. There is inferior spurring and arthritic

changes in the AC joint, so a Mumford is performed. An oblique osteotomy is

performed, removing the distal 1 cm of the clavicle, maintaining the superior AC

ligaments. Thorough irrigation of this area is performed. Again, the undersurface is




rasped to a smooth surface. We are very happy with our decompression of the

subacromial arch area.

Attention is now paid to the cuff. There is an obvious massive tear involving the

supraspinatus, infraspinatus and teres minor. There is also a rotator interval split.

The biceps tendon is dislocated anteriorly. The hypertrophic bursa is resected. The

biceps tendon is relocated into its bicipital groove and tenodesed with #1 Ethibond.

The free edges of the rotator cuff are identified and 0 Vicryl is used for stay sutures. The

cuff is mobilized. We are very happy with the mobilization. A trough is made into the

greater tuberosity. The cuff is then repaired tendon-to-bone into the trough with #1

Ethibond.

We are very happy with our repair. The rotator interval is then closed with #1 Ethibond

as well. There is no undue tension with the cuff at the neutral position. We are happy

with our repair. Thorough irrigation is performed. Hemostasis is achieved where

necessary and closure started. The deltoid is reattached to the anterior acromion with #1

Ethibond. The deltoid split is closed with #1 Ethibond. The subcutaneous tissues are

closed with 2-0 Vicryl and the skin with staples. The wounds are cleaned and dried. A

sterile compression dressing is applied. The patient is put into an abductor pillow. There

were no intraoperative complications. The patient tolerated the procedure well and went

to the recovery room in good condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: RECURRENT INSTABILITY AND BANKART

LESION LEFT SHOULDER.

POSTOPERATIVE DIAGNOSIS: SAME.

PROCEDURE PERFORMED: ARTHROSCPIC LEFT BANKART REPAIR AND

ELECTRICAL THERMAL SHRINKAGE OF THE CAPSULE.

ANESTHESIA: Intrascalene block.

INDICATION FOR SURGERY: This is a 52-year-old gentleman with recurrent

dislocation to his left shoulder; elected for operative intervention.

OPERATIVE PROCEDURE: The patient was properly identified, brought to the

Operating Room; had intrascalene block gently induced. The left upper extremity was

prepped and draped in the usual sterile fashion and placed in modified beach-chair

position, all bony prominences being padded and he was secured to the table. The left

upper extremity was prepped and draped in the usual sterile fashion. Posterior portal

was performed two fingerbreadths below the posterior scapula spine, two fingerbreadths

medially. Blunt for the camera sheath was introduced into the glenohumeral space and

the joint was inflated and the camera was applied. There was anterior tearing of the

labrum from the 12 o’clock to the 6 o’clock position with some chondromalacia, Grade

II, to the glenoid. There was a Hill-Sacks lesion noted. The subscapularis and the

surface of the rotator cuff biceps tendon was intact. At which point under 18 gauge

spinal needle guidance, anterior portal was performed and a disposable cannula was

placed through this. The area was shaved to abrade the anterior glenoid because

bleeding points could help the labrum heal in. A guide-wire was drilled for the

Surtak system, drilled over which. This was removed then and the Surtak system,

drilled over which. This was removed then an the Surtak anchor was then deployed.

This was done x three. A second anterior portal had to be deployed however it had to be

made to adequately deploy an appropriate anchor. Upon the three anchors being

deployed, probing showed excellent stability to the labrum. At which point the Tak-S

Oratec blade was then placed into the joint and used to electrical thermally shrink;

the collagen fibers decreased the volume in the joint. This was then removed as well as

the rest of the instrumentation. The joint was copiously irrigated with irrigant solution

and suctioned dry. The portals were closed with interrupted 4-0 nylon; 10 mg of

Duramorph was injected intra articularly. Sterile dressing with Xeroform, 4 x 4,

Combine and shoulder immobilizer was applied.




COMPLICATIONS: None.

DRAINS: None.

The patient returned to the recovery room in stable condition.




SURGICAL PATHOLOGY REPORT

DOB: 9/16/1938 (Age: 62)

SEX: M

Pathologic Diagnosis:

DEBRIDED TISSUE LT SHOULDER: Fragments of Synovium.

Nature of Specimen:

DEBRIDED TISSUE LT SHOULDER

Gross Description:

The specimen is received in formalin and consists of two cloth filters containing

approximately 4 cc in aggregate of pale gray and yellow tissue. Representative sections

are submitted. One cassette.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Left recurrent anterior shoulder instability.

POSTOPERATIVE DIAGNOSIS: Left recurrent anterior shoulder instability.

OPERATION: Left shoulder Bankart capsulorrhaphy, open.

INDICATIONS: The patient is a 24-year-old ruby player who presents with recurrent

anterior shoulder instability. The patient had a fairly new history of symptoms and

rehabilitation without complete resolution of his instability symptoms.

PROCEDURE/FINDINGS: The patient was brought to the main operating room and

placed supine on the operating room table. After satisfactory endotracheal intubation

general anesthetic, the patient was placed in the modified beach-chair position with the

left arm on an arm board. Her shoulder was examined under anesthesia, and it was able

to be dislocated anteriorly. The left shoulder was prepped and draped in a sterile fashion.

Subcutaneous tissue was infiltrated with 10 cc of 0.25% Marcaine with epinephrine.

Approximately an 8 cm incision was made from the coracoid process down the axillary

crease. This was carried down through soft tissue down to the deltopectoral fascia.

Medial and lateral flaps were elevated. The deltopectoral intervals were identified and

sharply and bluntly developed. The cephalic vein was retracted medially. The conjoined

tendon was then mobilized laterally and retracted medially. Soft tissues were then held

with an Innovasive self-retaining retractor. This gave us excellent visualization of the

subscapularis muscle. In the midsubstance of the subscapularis from medial to lateral,

the subscapularis was split with electrocautery down to the capsule. Superior and

inferior flaps of the subscapularis was immobilized and retracted with a Gelpi

retractor. A dural retractor was placed medially, and a medial to lateral capsulotomy was

made. A Fukuda retractor was placed holding the humeral head laterally with good

visualization of the glenoid rim. The patient had evidence of an old Bankart lesion and

had some abrasions and thinning of the anterior glenoid and appeared to have an

old Bankart lesion that at least tried to heal. He was mobilized from 6 o’clock to 9

o’clock, and two Mitek anchors were placed in the glenoid rim. These were then used

to anchor the capsule to the glenoid rim. The shoulder was then irrigated out. A #1

Mersilene and OS-1 needle were then used to do an imbrication stitch bringing the

inferior flap over the superior flap. These were tied in the shoulder in neutral position.

This reduced the capsular redundancy.




At this time the shoulder was irrigated again. The subscapularis muscle was

reapproximated with #1 Vicryl suture. Self-retaining retractors were taken out. The

wounds were observed for hemostasis. Hemostasis was obtained. The subcutaneous

tissue was reapproximated with 3-0 Vicryl suture, and the skin closed in a running

subcuticular 3-0 Prolene. Wound edges were infiltrated with an additional 20 cc of

0.25% Marcaine with epinephrine. Steri-Strips were used to reinforce this skin closure.

The wounds were dressed with Xeroform, plain dressing sponges, ABD pad, and foam

tape. The patient was placed in a shoulder immobilizer, extubated and brought to the

recovery room in stable condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Recurrent anterior shoulder dislocation left.

POSTOPERATIVE DIAGNOSIS: Recurrent anterior shoulder dislocation left.

OPERATION: Open capsular shift reconstruction left shoulder.

ANESTHESIA: General anesthesia.

ESTIMATED BLOOD LOSS: Less than 100 cc.

DRAINS: None.

INDICATIONS FOR SURGERY: This is a 24-year-old gentleman who is status post

open Bankart reconstruction left shoulder. He had done excellent until he had a

work-related injury June 26, 2000. His shoulder slipped out of joint and he has had

a couple of other episodes of dislocations of the shoulder which required reduction

in the emergency room, so he was admitted for elective reconstruction.

His exam under general anesthesia revealed significant anterior instability, some

subluxation posteriorly. Negative sulcus sign.

PROCEDURE/FINDINGS: The skin was prepped and draped in a sterile fashion. The

original surgical incision over the anterior left shoulder was excised. The

deltopectoral interval was developed. The cephalic vein was not encountered, I would

probably say it had been previously ligated. There was significant scar tissue adjacent to

the conjoined tendon. It was carefully separated. The underlying subscapularis muscle

was identified. The subscapularis muscle was transected 1 cm medial to its insertion on

the humerus and then carefully dissected free of the capsule and retracted so that the

capsule could be identified. The previously placed capsular stitches were still in place

and identified. The capsule was split longitudinally to the glenoid at the junction of the

proximal two-thirds and lower third of the capsule and a Bankart lesion encountered.

The labrum was excised additionally inferiorly and the glenoid rim and neck were

roughened with a rasp. Mitek SuperAnchors were placed, one at about 5:30 and the

other at approximately 8:30 on the glenoid, and then these anchors and attached

stitches were used to reattach the inferior capsule and labrum to the glenoid, pulling

it superiorly and then using previously placed #2 Ethibond sutures, the inferior

capsule was pulled and reefed superiorly underneath the superior capsule. Stitches

were placed but not tied and then with the arm in the neutral position and some slight

abduction, the stitches were tied. This gave excellent stability to the shoulder. The

superior capsule was then pulled inferiorly further reinforcing the repair.




At this point then soft tissues were injected with quarter-percent Marcaine with

epinephrine and the subscapularis muscle was reattached to the humerus with #2

Ethibond and some #1 Vicryl suture. Subcutaneous tissue was closed with 2-0 Vicryl

and the skin with skin clips. Sling-and-swathe were applied and the patient returned to

the recovery room in satisfactory condition.




this case: _____________________________________________________________.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Left posterior shoulder instability.

POSTOPERATIVE DIAGNOSIS: Left posterior shoulder instability.

OPERATION: Left posterior capsulorrhaphy.

INDICATIONS: The patient is 20-years-old and right hand dominant who sustained a

traumatic posterior shoulder dislocation while doing martial arts training earlier this year.

The patient has had an extensive period of rest, modified activity and physical therapy,

and continues to have functional posterior instability.

PROCEDURE/FINDINGS: The patient was brought to the main operating room and

placed supine on the operating table on a beanbag. After satisfactory endotracheal

intubation with general anesthetic, the patient is placed in the lateral decubitus position

with the left side up. The patient was secured in this position. All bony prominences

padded. The patient was then prepped and draped in a sterile fashion and placed on a

_____ stand in front of the table holding his arm in neutral rotation. Approximately an 8

cm incision was made posteriorly from approximately 2 cm medial to the posterior

corner of the acromion from the spine down to the axillary crease. This was secured

down through the soft tissues, identifying the deltoid fascia. This was incised, in line

with the skin incision. The deltoid muscles were then split over the posterior joint.

These were retracted exposing the posterior rotator cuff. Incision between his

infraspinatus and teres minor was developed and carried down through the

posterior capsule. Once this was identified, Cobb elevator was used to lift the muscle

and pin it off the posterior capsule. This gave us actually very nice visualization of the

posterior capsule. This retraction was held with an innovative self-retaining retractor.

The arm was then manipulated abduction and adduction and internal and external

rotation to further delineate the margins of the posterior capsule. A transverse incision

was then made. The capsule was very thin. Posterior labrum was inspected and there

was no evidence of a posterior Bankart lesion. The shoulder drum was irrigated out.

Then using a #1 Ethibond on an OS1, four imbrication stitches were placed

posteriorly mobilizing inferior capsule superiorly and the superior capsule

inferiorly. Then with the arm in neutral position and about 30 degrees abduction, wound

was irrigated out. Self-retaining retractor was removed. Hemostasis was adequate.

Superficial fascia with deltoid was closed with running #1 Vicryl suture, subcutaneous

tissues were reapproximated with 3-0 Vicryl suture. The skin was closed with a running

subcuticular 3-0 Prolene reinforced with Steri-Strips. Wound edges were infiltrated with

20 cc of 0.25% Marcaine with epinephrine.




The wound was dressed with plain dressing, sponges, ABD pads and foam tape. The

patient was then placed in an ultra sling with an abduction pillow keeping the arm in 0

degrees of rotation. The patient was then placed supine, extubated and brought to the

recovery room in stable condition.




this case: _____________________________________________________________.

OPERATIVE REPORT


Tear of right supscapularis tendon and subluxation of long-head biceps tendon (per MRI).


Tear of right subscapularis tendon and sublimation of long-head biceps tendon (per

MRI).

TITLE OF THE OPERATION:

Arthrotomy, right shoulder, implantation of long-head biceps tendon in humeral head and

reattachment of subscapularis tendon.

ANESTHESIA: General endotracheal.

OPERATIVE HISTORY: 58-year-old white male sustained injury to his right shoulder

with clinical impression of subscapularis tear almost five weeks earlier. He failed to

respond to therapy and symptomatic care. Hence MRI then obtained verifying the

diagnosis and also showing some subluxation of the biceps tendon. Now brought for

surgery.

OPERATIVE FINDINGS: Medial dislocation of the long-head biceps tendon, avulsion

of the subscapularis from the lesser tuberosity with only a few strands of tendonous tissue

remaining attached. The supraspinatus and infraspinatus appeared grossly intact.

There was retraction of about 2-3 cm of the subscapularis tendon and adhesion to

the underlying capsule. Articular surface that could be visualized was normal.

OPERATIVE PROCEDURE: Following administration of anesthesia, the patient in

the beach-chair position, the right shoulder area was prepped and draped in the usual

manner. Deltopectoral approach was made with skin incision starting at or just above the

level of the coracoid process and extending about 3-1/2 - 4 inches distally. The

deltopectoral grove was identified, cephalic vein retracted laterally, incision deepened

lateral to the conjoined tendon exposing the capsular tissue of the shoulder joint. This

was incised in the region of the rotator interval and the subscapularis tendon was

identified, retracted medially. There was separation of the undersurface of the

subscapularis and the capsule. Using scissor dissection, marking sutures were placed in

the subscapularis and the biceps tendon was relocated but would readily dislocate and

appeared there was no reasonable way to confine it to the groove without impingement.

Therefore, the biceps was released at its attachment to the superior labrum. The

portion of the bicipital groove was denuded using osteotome and, just above that, a 5.0

mm suture anchor, bioresorbable, was inserted with two #2 Mersilene sutures

through the eye. These were utilized to secure the tendon in what appeared to be an




appropriate amount of tension, and then the remaining proximal stump was curled

over and sutured through that stump, plus the long-head tendon distal to the

previous sutures and through the adjacent cuff tissue for re-enforcement. Then three #2

abraded Nylon sutures were woven through the subscapularis. Multiple holes were

drilled in the lesser tuberosity and the sutures were pulled through the prepared

drill-holes and were then tied which replace the subscapularis to the lesser tuberosity.

The repair was tested by abducting and externally rotating the shoulder, although not

taken to an extreme. The repair appeared very secure. Wound was irrigated with saline,

closed routinely, sterile bandage and shoulder immobilizer applied. The patient tolerated

the procedure well.



III. Answer Key

Case Study 1

23700-RT

20610

Case Study 2

23120-RT

Case Study 3

23120-RT

23420-RT

Case Study 4

23420-RT

Case Study 5

29825-LT

Case Study 6

29826-RT

23120-RT

Case Study 7

29826-RT

23120-RT

64415

Case Study 8

29826-LT

29822-59-LT

Case Study 9

29823-RT

29826-RT



Case Study 10

29826-RT

29824-RT

29822-59-RT

Case Study 11

29826-RT

29827-RT

Per the American Academy of Orthopaedic Surgeons’ Global Service Data for

Orthopaedic Surgery 2004 , code 29827 includes a partial synovectomy.

Case Study 12

29807-RT

29826-RT

29824-RT

Case Study 13

29807-LT

29824-LT

29826-LT

20610

Case Study 14

29826-50

23412-50

29807-RT

Case Study 15

29824-RT

29826-RT

29999-RT

Case Study 16

23420-RT

23430-59-RT

23120-RT



Case Study 17

29806-LT

29999

Case Study 18

23455-LT

Case Study 19

23455-LT

Case Study 20

23465-LT

Case Study 21

23450-RT

23440-RT

certificate of attendance -...

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