Shoulder Arthroscopy Medical Transcription Operative Example Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right shoulder, rule out type 2 SLAP lesion with acromioclavicular degenerative joint disease.
POSTOPERATIVE DIAGNOSIS: Right shoulder type 4 SLAP lesion with biceps degeneration, anterior labral tear, acromioclavicular degenerative joint disease.
OPERATION PERFORMED:
1. Right shoulder arthroscopy.
2. Labral debridement.
3. Subacromial bursectomy.
4. Distal clavicle resection.
5. Biceps tenodesis.
SURGEON: John Doe, MD
COMPLICATIONS: None.
CONDITION: Stable to the recovery room.
INDICATION FOR OPERATION: The patient is a (XX)-year-old male who has had longstanding problems with his shoulder, and he elected operative intervention with a right shoulder arthroscopy among other procedures mentioned above. All the risks and complications of the shoulder arthroscopy were explained to him in great detail and the patient understood and elected to proceed. Among the risks explained to him were infection, bleeding problems, nerve problems, persistent pain, loss of motion, failure of the procedure to live up to his expectations, and possible need for further surgical procedures.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position for right shoulder arthroscopy. Interscalene block was inserted. He was then put to sleep by general anesthesia by endotracheal intubation. He was secured in the Schlein shoulder holder and placed in a sitting position. A gram of Ancef was given intravenously as prophylaxis, and the shoulder was then prepped and draped free in the normal fashion. Examination under anesthesia showed good stability of the shoulder.
The arthroscope was inserted into the shoulder joint through the posterior portal, which was created approximately 1 cm medial and 1 cm inferior to the posterolateral tip of the acromion. We then used the blunt to pierce the capsule. Once we were inside of the shoulder joint, we used a Wissinger rod technique to go above the subscapularis and below the biceps tendon to create anterior portal. We then probed and noted there was no Bankart lesion, but there was a lot of labral fraying inferiorly, which was debrided with a shaver.
The biceps tendon was an obvious type 2 which, actually when we probed, we thought maybe it was even a type 4 lesion and there was some degeneration and detachment at the insertion of the biceps. We took arthroscopic photos showing that and then felt at this point that he would be better off with a tenodesis. We looked at the rotator cuff and the rotator cuff itself was absolutely intact.
At this point, we put the arthroscope into the subacromial space. We created a lateral portal as a working portal and we did a bursectomy, again noting the rotator cuff was intact. We went over to the AC joint, which was a painful area for him and resected the capsule, and anteriorly, we then worked with a bur to resect 1 cm distal clavicle, making sure with a 70-degree arthroscope that the superior acromioclavicular ligament was intact as well as the posterior ligament was intact. We looked anteriorly to make sure, at 90 degrees of abduction, there were no potential problems and that the interval was excellent. Therefore, we went ahead and did a bursectomy but not an acromioplasty, as we did not feel it was necessary, and a clavicle resection.
At this point, we went ahead and we made a skin incision over the biceps, bicipital groove, and we carried down to subcutaneous tissue, creating hemostasis along the way. We split the deltoid, got right down to the groove, opened up the groove and then used a Prolene suture to tag the biceps tendon. We then put the arthroscope back into the shoulder joint and we then used a cautery to tenotomize the biceps and bring it out through the anterior wound. We felt as we looked at the biceps the attachment was really pretty degenerative and problematic and therefore repairing this as a SLAP lesion we do not think is appropriate. Therefore, we did feel we made the right decision.
We closed the posterior portal with 4-0 Monocryl. We placed the patient flat and we then exposed the groove and we measured the tendon. The tendon was kind of small, about a 5, but we wanted to use a 7 mm Bio-Tenodesis screw by Arthrex. We used a 7 x 23 screw and we placed our guidewire. We reamed it and then we placed a whipstitch and it cut off the rest of the tendon and then appropriately with a FiberWire suture placed the tendon deep into the tunnel and we sutured the Bio-Tenodesis screw down so it was flush and the tunnel was sitting in there. We then tied the FiberWire suture over the top with adjunctive fixation.
At this point, with good tenodesis, we irrigated the wounds out. We closed the portals with 4-0 Monocryl and 2-0 Vicryl was used with 4-0 Monocryl on the anterior wound. Sterile dressings were applied with a sling. The patient was then placed supine. He was awakened, extubated, and transferred in stable condition.
