DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tendinopathy.
POSTOPERATIVE DIAGNOSES:
1. Right rotator cuff tendinopathy.
2. Right biceps tendinopathy.
3. Right superior labral tear.
OPERATION PERFORMED:
1. Right arthroscopic subacromial decompression.
2. Right arthroscopic extensive debridement to include the labrum and biceps anchor and biceps tendon.
SURGEON: John Doe, MD
ANESTHESIA: Scalene block.
TOURNIQUET TIME: None.
ESTIMATED BLOOD LOSS: Less than 5 mL.
DRAINS: None.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who came in for continued right shoulder pain. The patient has a remote history of a dislocation of his shoulder but never had recurrent instability or mechanical symptoms. More recently, his pain has been down the lateral side of his arm, and after a detailed history, physical exam, and review of plain film radiographs, concerns of rotator cuff tendinopathy was entertained. Because of his chronicity, the patient presents for the above-mentioned operation.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and after a scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a sitting position. Preoperative antibiotics had been given. The right shoulder was prescrubbed with Betadine.
Next, the right upper extremity, including the right base of the neck and shoulder, was prepped and draped in the usual sterile fashion. After bony palpation, a posterior portal was created with a 15 scalpel blade, and this was used for the arthroscope. The arthroscope was placed and a complete inventory of the right shoulder was performed. Under direct visualization, an anterior superior portal was created in a similar fashion and this was used for outflow and instrumentation. Significant degenerative changes were seen of the superior labrum, which involved the biceps anchor. This started at the 11 o’clock position and extended anteriorly to almost the 2 o’clock position. This involved slightly off the biceps anchor tendon itself. With the debridement, there was some liftoff but, because of the degenerative nature of the tissue, it was felt that no formal repair would be needed. There were significant amounts of degenerative changes of the biceps as well, and this was debrided with a radiofrequency device as well as a 5.5 full radius shaver. This represented about 25% of the biceps.
Consideration of a biceps release was entertained to help treat this entire construct, but after discussion in the operating room, it was felt that this would be left intact in fear of creating a deformity of the anterior arm. The anterior inferior labrum did show some irregularities and some mild scuffing of the articular surface but no subchondral bone exposure. There was no liftoff of the labrum. The inferior labrum and posterior labrum was within normal limits. Erosive changes were also noted on the articular surface of the humeral head and this was debrided with a 5.5 full radius shaver. Rotator interval showed no defects. The subscapularis showed no tears. The supraspinatus and posterior cuff showed no tearing or fraying. There was no sign of Hill-Sachs lesion. There was a negative drive-through sign and the axillary pouch showed no loose bodies.
The arthroscope was then placed into the subacromial region. Moderate form of a hypertrophic subacromial bursa was identified but minimal neovascularization. A direct lateral portal was created with a 15 scalpel blade after marking with a spinal needle. A formal bursectomy was performed. Moderate thickened coracoacromial ligament was identified, and this was incised and released. A minimal enthesophyte was seen and a formal acromioplasty was performed removing approximately 2 mm of bone. The arthroscope was then placed into the direct lateral portal and visualization demonstrated a smooth flat acromion. Inspection of the bursal side of the rotator cuff demonstrated no tears. It was felt by the operative team that an adequate subacromial decompression, extensive debridement of labrum and biceps tendon had been performed.
The instruments were removed, and the portal sites were closed with 4-0 nylon in a simple interrupted fashion. All sponge and instrument counts proved to be correct and estimated blood loss was less than 5 mL. The wounds were then cleaned and dressed under the sterile field. A Polar Care ice machine and a shoulder immobilizer were placed to the right upper extremity. The patient was then escorted to the recovery room in a stable condition. Exam in the recovery room revealed that radial pulse was 4/4; however, due to scalene block, neurological exam could not be completely done.
