Open Shoulder procedure Operative report
- Medycoding Expert
- 1 day ago
- 19 min read
Operative report 1
Preoperative Diagnosis
Chronic full-thickness degenerative tear of the right supraspinatus tendon.
Chronic right shoulder pain.
Shoulder weakness with loss of overhead function.
Subacromial impingement syndrome.
Postoperative Diagnosis
Chronic full-thickness degenerative supraspinatus tendon tear measuring approximately 3.5 cm.
Partial-thickness degeneration of the anterior infraspinatus tendon.
Chronic subacromial bursitis.
Type III hooked acromion with anterior acromial spur.
Successful open rotator cuff repair.
Procedure performed
Open repair of chronic degenerative right rotator cuff tear.
Open extensive subacromial bursectomy.
Open subacromial decompression with anterior acromioplasty.
Preparation of the greater tuberosity footprint.
Repair of deltoid origin.
Indication
The patient is a 64-year-old male with a several-year history of progressively worsening right shoulder pain, weakness, night pain, and inability to perform overhead activities. The patient had failed extensive conservative management including oral anti-inflammatory medications, multiple corticosteroid injections, supervised physical therapy, activity modification, and home exercise program for more than one year. MRI demonstrated a chronic full-thickness degenerative tear of the supraspinatus tendon with tendon retraction and fatty degeneration. Because of persistent pain and functional limitation despite exhaustive conservative treatment, surgical repair was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.
Description of the procedure
The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics were administered prior to skin incision.
The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all required implants and instrumentation.
A standard anterolateral shoulder incision measuring approximately 7 cm was made beginning just anterior to the anterolateral corner of the acromion and extending distally over the proximal humerus. Sharp dissection was carried through the subcutaneous tissues. Hemostasis was maintained throughout the procedure using electrocautery.
The deltoid fascia was identified and incised longitudinally in line with its fibers. The anterior deltoid origin was carefully elevated from the anterior acromion with preservation of an adequate cuff of tissue for later repair. Self-retaining retractors were placed to optimize exposure.
The subacromial space was entered. Extensive hypertrophic inflamed bursal tissue consistent with chronic subacromial bursitis was encountered. An extensive bursectomy was performed utilizing electrocautery, rongeurs, and scissors until complete visualization of the rotator cuff was obtained.
Inspection of the undersurface of the acromion demonstrated a prominent anterior-inferior acromial spur with a Type III hooked acromion contributing to chronic impingement. Using an oscillating saw and high-speed burr, an anterior acromioplasty was performed to convert the acromion to a smooth Type I configuration while preserving the integrity of the coracoacromial ligament. Adequate subacromial decompression was confirmed.
Attention was then directed toward the rotator cuff. A chronic full-thickness degenerative tear involving the supraspinatus tendon extending into the anterior infraspinatus was identified. The tendon edges were markedly thickened, frayed, and degenerative with moderate medial retraction.
The torn tendon margins were sharply debrided to healthy viable tissue. Extensive releases were performed on both the bursal and articular surfaces utilizing blunt and sharp dissection to restore tendon mobility. Adhesions between the cuff and surrounding soft tissues were completely released, allowing an anatomic reduction to the greater tuberosity without excessive tension.
The greater tuberosity footprint was prepared using curettes, rasps, and a high-speed burr to remove fibrous tissue and expose healthy bleeding cancellous bone, thereby optimizing tendon-to-bone healing.
Two double-loaded bio-composite suture anchors were inserted into the medial aspect of the greater tuberosity with excellent fixation. Using a free needle and suture-passing technique, multiple horizontal mattress sutures were sequentially passed through healthy rotator cuff tissue while maintaining balanced tension across the repair.
The mattress sutures were securely tied, restoring the medial footprint of the tendon. Additional simple side-to-side sutures were placed to reinforce the repair and eliminate residual gaps. The repaired tendon demonstrated excellent compression against the prepared greater tuberosity with restoration of normal tendon anatomy.
The repair was carefully inspected while the shoulder was gently taken through passive forward elevation, abduction, and external rotation. The repair remained stable without gapping or excessive tension throughout the range of motion.
The operative field was thoroughly irrigated with copious sterile normal saline. Meticulous hemostasis was achieved.
The anterior deltoid origin was anatomically repaired back to the acromion utilizing multiple heavy nonabsorbable transosseous sutures. Excellent stability of the deltoid repair was confirmed.
The deltoid fascia was reapproximated with interrupted absorbable sutures. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.
Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer with an abduction pillow.
The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.
Findings
Chronic full-thickness supraspinatus tendon tear measuring approximately 3.5 cm.
Moderate tendon retraction with degenerative tendon tissue.
Partial-thickness degeneration of the anterior infraspinatus tendon.
Extensive chronic subacromial bursitis.
Type III hooked acromion with prominent anterior acromial spur.
Intact subscapularis tendon.
Intact long head of the biceps tendon.
Successful anatomic open rotator cuff repair with excellent tendon fixation.
Implants
Two double-loaded bio-composite suture anchors.
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CPT
23412-RT
No need to code 23130
From a coding perspective, code 23410, Repair of musculotendinous cuff (eg, rotator cuff); acute, includes the work involved in performing a partial acromionectomy. Therefore, it would not be appropriate to report 23130 separately.
Operative report 2
Preoperative Diagnosis
Right shoulder adhesive capsulitis (frozen shoulder).
Chronic right shoulder pain.
Severe restriction of active and passive range of motion.
Failure of conservative treatment.
Postoperative Diagnosis
Right shoulder adhesive capsulitis.
Global glenohumeral capsular contracture.
Successful closed manipulation of the right shoulder under anesthesia with restoration of range of motion.
Procedure performed
Manipulation of the right shoulder under general anesthesia.
Intra-articular corticosteroid injection of the right glenohumeral joint.
Indication
The patient is a 58-year-old female with a one-year history of progressively worsening right shoulder pain and stiffness. She experienced significant limitation of both active and passive range of motion, resulting in difficulty performing activities of daily living including overhead reaching, dressing, and grooming. Conservative treatment consisting of oral anti-inflammatory medications, supervised physical therapy, home stretching exercises, and corticosteroid injections failed to provide significant improvement. Clinical examination was consistent with adhesive capsulitis, demonstrating marked restriction of forward elevation, abduction, and both internal and external rotation. After discussion of the risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications, manipulation under anesthesia was recommended. Informed consent was obtained.
Description of the procedure
The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, complete muscular relaxation was achieved. Intravenous prophylactic antibiotics were not indicated for this procedure.
The patient was positioned supine with all bony prominences carefully padded. A final surgical timeout was performed confirming the patient's identity, operative extremity, and planned procedure.
Pre-manipulation examination demonstrated severe global restriction of passive shoulder motion. Passive forward elevation was limited to approximately 90 degrees, abduction to 70 degrees, external rotation at the side to approximately 10 degrees, and internal rotation was markedly restricted. The shoulder remained stable without evidence of instability.
The scapula was stabilized throughout the manipulation to prevent excessive scapulothoracic motion. Gentle, controlled manipulation was initiated with gradual forward elevation. Progressive stretching of the contracted capsuloligamentous structures was performed while avoiding excessive force. Palpable and audible releases of the contracted capsule were appreciated as motion progressively improved.
The shoulder was then gently manipulated into abduction while maintaining stabilization of the scapula. Gradual improvement in glenohumeral mobility was achieved without excessive resistance.
External rotation was carefully increased with the arm at the patient's side followed by external rotation in approximately 90 degrees of abduction. Progressive capsular release was appreciated without evidence of fracture, instability, or soft tissue injury.
Internal rotation was subsequently performed with the shoulder in both adduction and abduction to achieve circumferential stretching of the contracted anterior, posterior, and inferior capsule.
Cross-body adduction was then performed to address the posterior capsular contracture. Multiple gentle stretching maneuvers were repeated until smooth unrestricted glenohumeral motion was achieved.
Following completion of the manipulation, passive forward elevation improved to approximately 175 degrees, abduction to 170 degrees, external rotation at the side to approximately 70 degrees, and internal rotation improved to allow the hand to reach the mid-thoracic spine. Excellent restoration of glenohumeral range of motion was confirmed without evidence of instability.
The shoulder was carefully examined fluoroscopically to exclude proximal humeral fracture, glenoid injury, or dislocation. No osseous injury was identified.
The skin overlying the posterior shoulder was prepared with antiseptic solution. Under sterile technique, the glenohumeral joint was injected with a mixture of long-acting local anesthetic and corticosteroid to minimize postoperative pain and inflammation.
The patient tolerated the procedure well without complications, was awakened from anesthesia, and transferred to the post-anesthesia care unit in stable condition. Immediate postoperative physical therapy emphasizing aggressive passive and active-assisted range of motion was initiated.
Findings
Severe adhesive capsulitis with global capsular contracture.
Marked restriction of passive glenohumeral motion prior to manipulation.
Successful circumferential capsular release achieved by closed manipulation.
Restoration of near full passive forward elevation, abduction, and rotation.
Stable glenohumeral joint following manipulation.
No evidence of fracture, instability, or iatrogenic injury.
Implants
None.
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CPT -
Operative report 3
Preoperative Diagnosis
Right shoulder chronic biceps tendinopathy.
Partial-thickness tear of the long head of the biceps tendon.
Chronic right shoulder pain.
Biceps tenosynovitis.
Postoperative Diagnosis
Chronic degenerative tendinopathy of the long head of the biceps tendon.
Partial-thickness tear involving approximately 50% of the long head of the biceps tendon.
Marked bicipital tenosynovitis.
Successful open biceps tenotomy.
Procedure performed
Open tenotomy of the long head of the right biceps tendon.
Indication
The patient is a 65-year-old male with a prolonged history of progressively worsening anterior right shoulder pain associated with lifting, overhead activities, and repetitive use. Conservative treatment including activity modification, oral anti-inflammatory medications, supervised physical therapy, corticosteroid injections into the bicipital groove, and home exercise program failed to provide lasting relief. MRI demonstrated advanced degeneration with a partial-thickness tear of the long head of the biceps tendon and significant tenosynovitis within the bicipital groove. Because of persistent pain and failure of conservative management, open biceps tenotomy was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications including cosmetic deformity, cramping, weakness, stiffness, infection, and neurovascular injury were discussed in detail with the patient, and informed consent was obtained.
Description of the procedure
The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics were administered prior to skin incision.
The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, and planned procedure.
A longitudinal incision measuring approximately 4 cm was made directly over the proximal aspect of the bicipital groove. Sharp dissection was carried through the subcutaneous tissues with meticulous hemostasis maintained using electrocautery.
The deltopectoral interval was identified and developed. The cephalic vein was identified and protected throughout the procedure. The clavipectoral fascia was incised, providing exposure to the proximal humerus and bicipital groove.
The transverse humeral ligament was carefully incised, exposing the long head of the biceps tendon within the bicipital groove. Inspection demonstrated marked degenerative tendinopathy with longitudinal splitting of the tendon, fraying of the tendon fibers, and extensive surrounding tenosynovitis. The tendon demonstrated poor tissue quality and significant degeneration.
The surrounding inflamed synovial tissue was sharply excised, and the bicipital groove was thoroughly debrided to remove hypertrophic inflammatory tissue and degenerative debris.
The long head of the biceps tendon was mobilized using blunt dissection. The tendon was then sharply divided at its proximal attachment utilizing a scalpel, completing the tenotomy. The released tendon was allowed to retract distally in a controlled manner without excessive traction. The remaining proximal tendon stump was inspected and demonstrated a smooth stable margin without residual fraying.
The bicipital groove was again irrigated and carefully inspected. No remaining loose tendon fragments or inflamed tissue were identified. Hemostasis was achieved with electrocautery.
The operative field was thoroughly irrigated with copious sterile normal saline. Final inspection confirmed complete release of the long head of the biceps tendon without injury to the surrounding neurovascular structures.
The deltopectoral interval was allowed to return to its normal anatomic position. The clavipectoral fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.
Sterile dressings were applied, and the right upper extremity was placed into a simple arm sling for comfort.
The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.
Findings
Advanced chronic degeneration of the long head of the biceps tendon.
Partial-thickness longitudinal tear involving approximately 50% of the tendon.
Extensive bicipital tenosynovitis.
Marked tendon fraying and degeneration.
No complete tendon rupture.
Successful complete open tenotomy of the long head of the biceps tendon.
Implants
None.
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CPT -
Operative report 4
Preoperative Diagnosis
Recurrent anterior instability of the right shoulder.
Bankart lesion of the anterior-inferior glenoid labrum.
Chronic right shoulder pain.
Recurrent anterior shoulder dislocations.
Postoperative Diagnosis
Chronic Bankart lesion involving the anterior-inferior glenoid labrum extending from the 3 o'clock to the 6 o'clock position.
Redundant anterior capsule with capsular laxity.
Small non-engaging Hill-Sachs lesion.
Intact rotator cuff.
Successful open Bankart repair with anterior capsulorrhaphy.
Procedure performed
Open anterior capsulorrhaphy of the right shoulder.
Open Bankart repair with reattachment of the anterior-inferior labrum to the glenoid.
Glenoid rim preparation.
Anterior capsular shift.
Indication
The patient is a 27-year-old male with a history of recurrent traumatic anterior dislocations of the right shoulder over the past three years. The patient reported multiple episodes of instability despite supervised physical therapy, activity modification, strengthening exercises, and bracing. Clinical examination demonstrated a positive apprehension and relocation test with persistent anterior instability. MRI arthrogram demonstrated a chronic detached anterior-inferior labral tear consistent with a Bankart lesion and capsular redundancy without significant glenoid bone loss. Because of persistent instability and failure of nonoperative treatment, open Bankart repair with anterior capsulorrhaphy was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.
Description of the procedure
The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics were administered prior to skin incision.
The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of implants and instrumentation.
A standard deltopectoral incision measuring approximately 8 cm was made beginning just inferior to the coracoid process and extending distally along the deltopectoral interval. Sharp dissection was carried through the subcutaneous tissues. Hemostasis was maintained throughout the procedure utilizing electrocautery.
The cephalic vein was identified and preserved. The deltopectoral interval was developed. The clavipectoral fascia was incised, exposing the conjoined tendon and subscapularis tendon. The musculocutaneous and axillary nerves were protected throughout the procedure.
The subscapularis tendon was identified and divided approximately 1 cm medial to its insertion on the lesser tuberosity while preserving sufficient tendon for later repair. Heavy nonabsorbable stay sutures were placed for later anatomic repair. The underlying anterior joint capsule was exposed.
A vertical capsulotomy was performed. The capsule was elevated from the anterior glenoid neck, exposing the glenohumeral joint. Inspection demonstrated a chronic detached anterior-inferior labrum extending from approximately the 3 o'clock to the 6 o'clock position with associated capsular attenuation and medial healing of the capsulolabral complex. A small non-engaging Hill-Sachs lesion was noted on the posterolateral humeral head. The glenoid articular surface demonstrated minimal chondral wear without significant anterior glenoid bone loss. The rotator cuff and long head of the biceps tendon were intact.
The detached labrum and capsulolabral complex were carefully mobilized from the anterior glenoid neck using elevators and periosteal dissectors until adequate excursion for an anatomic repair was obtained.
Attention was then directed toward preparation of the anterior glenoid rim. A curette and high-speed burr were utilized to remove fibrous tissue and lightly decorticate the anterior glenoid neck, exposing healthy bleeding cancellous bone to optimize healing of the repaired labrum.
Three bio-composite suture anchors were sequentially inserted into the anterior-inferior glenoid rim beginning at the inferior aspect of the Bankart lesion and progressing superiorly. Excellent fixation of each anchor was confirmed.
Using a suture-passing device and free needle technique, each suture limb was passed through the detached labrum and anterior capsule, restoring the capsulolabral complex to its native anatomic position along the glenoid rim. The sutures were sequentially tied with secure arthroscopic knots while maintaining appropriate tension. Excellent restoration of the labral bumper and anterior glenohumeral ligament complex was achieved.
Following completion of the labral repair, attention was directed toward the anterior capsule. Redundant capsular tissue was advanced superiorly and laterally, and an anterior capsular shift was performed utilizing multiple interrupted high-strength nonabsorbable sutures. The capsule was securely imbricated, eliminating capsular redundancy while preserving physiologic external rotation.
The repair was carefully inspected. The humeral head remained concentrically reduced throughout passive forward elevation, abduction, and external rotation. Excellent restoration of anterior stability was demonstrated without excessive capsular tension.
The joint was thoroughly irrigated with copious sterile normal saline. Meticulous hemostasis was achieved.
The subscapularis tendon was anatomically repaired to its insertion utilizing multiple interrupted high-strength nonabsorbable transosseous sutures. Excellent tendon apposition and repair stability were confirmed.
The deltopectoral interval was allowed to return to its normal anatomic position. The clavipectoral fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.
Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer with the arm in slight internal rotation.
The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.
Findings
Chronic Bankart lesion extending from the 3 o'clock to the 6 o'clock position.
Detached anterior-inferior labrum with medial capsular healing.
Redundant anterior capsule with capsular laxity.
Small non-engaging Hill-Sachs lesion.
Minimal glenoid chondral wear.
Intact rotator cuff.
Intact long head of the biceps tendon.
Successful anatomic Bankart repair with anterior capsular shift restoring excellent glenohumeral stability.
Implants
Three bio-composite suture anchors for anterior glenoid labral repair.
Check your answer
23474-RT
Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component
Operative report 5
Preoperative Diagnosis
Recurrent anterior instability of the right shoulder.
Chronic anterior capsular laxity.
Recurrent anterior shoulder dislocations.
Chronic right shoulder pain.
Postoperative Diagnosis
Recurrent anterior glenohumeral instability.
Marked anterior capsular redundancy.
Attenuated subscapularis tendon.
Intact anterior glenoid rim without significant bone loss.
Successful open anterior capsulorrhaphy utilizing the Putti-Platt procedure.
Procedure performed
Open anterior capsulorrhaphy of the right shoulder utilizing the Putti-Platt procedure.
Imbrication and shortening of the subscapularis tendon.
Anterior capsular imbrication.
Indication
The patient is a 30-year-old male with a history of recurrent traumatic anterior dislocations of the right shoulder associated with chronic instability, pain, and apprehension during overhead and external rotation activities. Conservative treatment consisting of activity modification, supervised physical therapy, strengthening exercises, and bracing failed to restore stability. Clinical examination demonstrated a positive apprehension and relocation test with significant anterior capsular laxity. Advanced imaging demonstrated anterior capsular redundancy without significant glenoid bone loss or large engaging Hill-Sachs lesion. Because of persistent instability despite exhaustive conservative management, open anterior capsulorrhaphy utilizing the Putti-Platt procedure was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and possible complications including postoperative stiffness and loss of external rotation were discussed in detail with the patient, and informed consent was obtained.
Description of the procedure
The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics were administered prior to skin incision.
The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all required instrumentation.
A standard deltopectoral incision measuring approximately 8 cm was made extending from the coracoid process distally along the deltopectoral groove. Sharp dissection was carried through the subcutaneous tissues. Hemostasis was maintained throughout the procedure utilizing electrocautery.
The cephalic vein was identified and preserved. The deltopectoral interval was developed. The clavipectoral fascia was incised, exposing the conjoined tendon and subscapularis tendon. The musculocutaneous nerve and axillary nerve were carefully protected throughout the procedure.
The subscapularis tendon was identified and demonstrated mild attenuation with associated elongation. The tendon was divided vertically near its insertion on the lesser tuberosity while preserving adequate tissue for subsequent advancement and repair.
The underlying anterior joint capsule was exposed. A longitudinal capsulotomy was performed, revealing significant anterior capsular redundancy and generalized capsular laxity without significant labral detachment. Inspection of the glenohumeral joint demonstrated an intact anterior glenoid rim with preserved articular cartilage. The humeral head was concentrically reduced. A small non-engaging Hill-Sachs lesion was present. The rotator cuff and long head of the biceps tendon were intact.
The redundant anterior capsule was mobilized and imbricated using multiple interrupted high-strength nonabsorbable sutures. The capsule was advanced superiorly and laterally to eliminate excess capsular volume while restoring appropriate anterior tension.
Attention was then directed toward the Putti-Platt reconstruction. The lateral portion of the divided subscapularis tendon was advanced medially and overlapped with the medial portion of the tendon. The tendon was shortened and imbricated using multiple interrupted heavy nonabsorbable sutures, effectively reinforcing the anterior capsule and limiting excessive anterior translation of the humeral head.
Additional interrupted sutures were placed between the subscapularis tendon and the anterior capsule to create a strong layered anterior soft tissue repair. The repair was carefully tensioned with the shoulder positioned in approximately 30 degrees of abduction and neutral rotation to provide excellent stability while minimizing excessive postoperative restriction.
The repair was carefully inspected. Passive forward elevation and abduction were satisfactory. External rotation was intentionally limited to approximately 30 degrees, consistent with the goals of the Putti-Platt procedure. The humeral head remained concentrically reduced throughout passive motion with excellent restoration of anterior stability.
The operative field was thoroughly irrigated with copious sterile normal saline. Meticulous hemostasis was achieved.
The deltopectoral interval was allowed to return to its normal anatomic position. The clavipectoral fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers utilizing absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.
Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer with the arm maintained in internal rotation.
The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.
Findings
Marked anterior capsular redundancy.
Chronic anterior glenohumeral instability.
Mild attenuation and elongation of the subscapularis tendon.
Small non-engaging Hill-Sachs lesion.
Intact anterior glenoid rim without significant bone loss.
Intact rotator cuff.
Intact long head of the biceps tendon.
Successful anterior capsular imbrication and subscapularis shortening utilizing the Putti-Platt procedure with excellent restoration of anterior shoulder stability.
Implants
None.
Check your answer
23473-52-RT
Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component
Operative report 6
Preoperative Diagnosis
Recurrent anterior instability of the right shoulder.
Chronic anterior glenoid bone loss.
Recurrent anterior shoulder dislocations.
Chronic Bankart lesion.
Chronic right shoulder pain.
Postoperative Diagnosis
Recurrent anterior glenohumeral instability.
Anterior-inferior glenoid bone loss involving approximately 22% of the glenoid surface.
Chronic Bankart lesion with capsular insufficiency.
Small off-track Hill-Sachs lesion.
Successful open anterior capsulorrhaphy with coracoid process transfer (Latarjet procedure).
Procedure performed
Open anterior capsulorrhaphy of the right shoulder.
Coracoid process transfer (Latarjet procedure).
Coracoid osteotomy.
Transfer and fixation of the coracoid bone block to the anterior glenoid.
Repair of the anterior capsule to the coracoacromial ligament stump.
Glenoid preparation.
Indication
The patient is a 29-year-old male with a long-standing history of recurrent traumatic anterior dislocations of the right shoulder associated with pain, instability, and inability to participate in work and sporting activities. The patient had experienced numerous episodes of dislocation despite activity modification, supervised physical therapy, strengthening exercises, and bracing. Clinical examination demonstrated a positive apprehension and relocation test with persistent anterior instability. Computed tomography demonstrated approximately 22% anterior-inferior glenoid bone loss with a chronic bony Bankart lesion. MRI further demonstrated capsulolabral insufficiency and a small off-track Hill-Sachs lesion. Because of significant glenoid bone loss, isolated soft tissue stabilization was considered insufficient. Open anterior capsulorrhaphy with coracoid process transfer utilizing the Latarjet technique was recommended to restore glenoid bone stock and provide dynamic anterior shoulder stability. Risks, benefits, alternatives, expected postoperative rehabilitation, and possible complications including neurovascular injury, graft nonunion, hardware failure, infection, recurrent instability, and postoperative stiffness were discussed in detail with the patient, and informed consent was obtained.
Description of the procedure
The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics were administered prior to skin incision.
The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all required implants and instrumentation.
A standard deltopectoral incision measuring approximately 8 cm was made beginning just inferior to the coracoid process and extending distally along the deltopectoral interval. Sharp dissection was carried through the subcutaneous tissues. Hemostasis was maintained throughout the procedure utilizing electrocautery.
The cephalic vein was identified and preserved. The deltopectoral interval was developed. The clavipectoral fascia was incised. The conjoined tendon, coracoid process, and surrounding anatomy were exposed. The musculocutaneous nerve and axillary nerve were carefully identified and protected throughout the procedure.
The coracoacromial ligament was divided approximately 1 cm from its coracoid attachment while preserving a stump attached to the coracoid for later capsular repair. The insertion of the pectoralis minor tendon on the medial aspect of the coracoid was released. Soft tissue surrounding the coracoid was carefully elevated while preserving the conjoined tendon attachment.
A coracoid osteotomy was performed at the base of the coracoid utilizing an oscillating saw. The coracoid graft measuring approximately 25 mm in length was removed with the attached conjoined tendon intact. The undersurface of the coracoid graft was decorticated using a high-speed burr to create a flat bleeding cancellous surface suitable for graft healing. Two parallel drill holes were placed through the graft in preparation for definitive fixation.
Attention was then directed toward the glenohumeral joint. The subscapularis muscle was identified and divided horizontally at the junction of its superior two-thirds and inferior one-third while preserving adequate tissue for later repair. The axillary nerve remained protected throughout the exposure.
A vertical capsulotomy was performed. Inspection of the glenohumeral joint demonstrated a chronic detached anterior-inferior labrum with marked capsular attenuation. Approximately 22% anterior-inferior glenoid bone loss was identified. A small off-track Hill-Sachs lesion was present. The articular cartilage was otherwise well preserved.
The anterior glenoid neck was exposed. Fibrous tissue was removed utilizing curettes and elevators. A high-speed burr was utilized to decorticate the anterior glenoid neck, exposing healthy bleeding cancellous bone while creating a flat recipient surface for graft placement.
The prepared coracoid graft was transferred through the subscapularis split and positioned flush with the anterior-inferior glenoid articular surface. Care was taken to avoid medialization or lateral overhang of the graft. Excellent restoration of the native glenoid contour was achieved.
Temporary fixation was obtained with Kirschner wires. Fluoroscopic imaging confirmed appropriate graft position. Two cannulated cortical screws with washers were inserted sequentially through the prepared coracoid graft into the glenoid neck, obtaining rigid bicortical fixation. Final fluoroscopic imaging confirmed excellent graft position, screw length, compression, and restoration of the glenoid arc.
The anterior capsule was then repaired to the preserved stump of the coracoacromial ligament utilizing multiple interrupted nonabsorbable sutures, effectively recreating the capsular restraint while leaving the coracoid graft extra-articular.
The repair was carefully inspected. Passive forward elevation, abduction, and external rotation demonstrated excellent glenohumeral stability with restoration of the anterior buttress effect. The humeral head remained concentrically reduced throughout the range of motion without excessive restriction.
The operative field was thoroughly irrigated with copious sterile normal saline. Meticulous hemostasis was achieved.
The subscapularis split was repaired utilizing interrupted absorbable sutures without undue tension. The deltopectoral interval was allowed to return to its normal anatomic position. The clavipectoral fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers utilizing absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.
Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.
The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.
Findings
Chronic recurrent anterior shoulder instability.
Chronic Bankart lesion with capsular insufficiency.
Approximately 22% anterior-inferior glenoid bone loss.
Small off-track Hill-Sachs lesion.
Well-preserved glenohumeral articular cartilage.
Successful coracoid process transfer with anatomic restoration of the anterior glenoid.
Rigid bicortical screw fixation of the coracoid graft.
Excellent restoration of anterior glenohumeral stability.
Implants
Two 4.0 mm cannulated cortical screws with washers for coracoid graft fixation.
Check your answer
23335-RT
11981-51
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