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Orthopedic Medical Transcription Transcribed Surgical Sample Report


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left shoulder full-thickness rotator cuff tear.
2.  Left shoulder subacromial impingement and rotator cuff tendonitis.

POSTOPERATIVE DIAGNOSES:
1.  Left shoulder full-thickness rotator cuff tear.
2.  Left shoulder subacromial impingement and rotator cuff tendonitis.

OPERATIONS PERFORMED:
1.  Left shoulder arthroscopic rotator cuff repair.
2.  Left shoulder arthroscopic subacromial decompression.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia with regional interscalene nerve block.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS:  The patient is a pleasant (XX)-year-old male who injured his left shoulder. Preoperative workup both clinically and radiographically including an MRI were consistent with a complete full-thickness tear of the rotator cuff along with excrescence of the acromion consistent with subacromial impingement and rotator cuff tendonitis. Given that it is a full-thickness rotator cuff tear with mild retraction, nonoperative and operative treatment options were discussed, but operative intervention was recommended. The patient considered all of the options and elected to proceed with surgical intervention.

DESCRIPTION OF OPERATION:  After obtaining informed consent and correctly identifying the patient, the patient was brought to the operating room and placed on the operating room table in a supine position. After adequate anesthesia was obtained and intravenous antibiotics were given, the patient was then placed in a well-padded lateral decubitus position with the right upper extremity up. A time-out was then taken to confirm the identity of the patient, consented procedure and correct extremity. After this time-out, the left upper extremity was prepped and draped in the usual sterile fashion and placed in 10 pounds of balanced suspension traction. The bony landmarks of the shoulder were then marked out in the skin, 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion, was injected with 0.5% bupivacaine. A small stab incision was then made. The arthroscopic camera was introduced into the joint. The joint was then distended and diagnostic arthroscopy then ensued. The most notable thing was a full-thickness tear of the rotator cuff with retraction of the rotator cuff midway to the level of the glenoid. The biceps tendon and the biceps root appeared to be intact with mild tenosynovitis surrounding the base of the biceps. The articular cartilage of the glenoid and humeral head was otherwise quite pristine. There was no evidence of a labral tear.

Attention was then focused to the subacromial compartment. The arthroscopic camera was introduced posteriorly and pushed through the veil of tears in the subacromial compartment. Abundant hypertrophic bursitis was encountered. A spinal needle was inserted laterally at the junction of the anterior and middle thirds of the acromion for localization of the lateral portal. The skin was then injected with 0.5% bupivacaine and small stab incisions were then made. Arthroscopic shaver was used to debride and excise the hypertrophic bursa to expose the underlying rotator cuff. The full-thickness rotator cuff tear was again visualized and confirmed medial retraction midway to the level of the glenoid. There is immediately overhanging the area of the rotator cuff tear a large subacromial spur and the soft tissue on the undersurface of the subacromial spur was abraded, consistent with a kissing lesion seen with chronic subacromial impingement. Given these findings, decision was made to proceed with an arthroscopic subacromial decompression. The arthroscopic shaver was used to debride and excise the soft tissue and periosteum on the undersurface of the acromion, to expose the anterior and lateral borders of the acromion. The coracoacromial ligament was then released using Bovie cautery. The overhanging free edge of the ligament was excised. Then, using arthroscopic 6 mm bur, approximately 7 mm of the large subacromial spur was excised beginning anteriorly and laterally and progressing posteriorly and medially until the undersurface of the acromion was converted to a flat type I acromion. Upon completion of the subacromial decompression, attention was then re-focused back to the rotator cuff tear.

The arthroscopic shaver was used to debride and freshen the free edge of the rotator cuff in preparation for the repair. The articular margin was also debrided to create and prepare a bleeding bony bed for the rotator cuff repair. A spinal needle was then used as needle localization for the most optimal location of insertion of the suture anchor corresponding with the apex of the crescent tear. A small stab incision was then made, and through this stab incision, the arthroscopic punch was used to create a pilot hole, followed by insertion of the Arthrex Bio-Corkscrew 5.5 suture anchor. Excellent bony purchase was noted. Strong longitudinal traction was applied on the sutures to confirm excellent fixation of the anchor. An Arthrex cannula was inserted via the lateral portal. Needle localization was used to create the anterior portal through which a second Arthrex cannula was inserted. Then, using an Arthrex suture lasso instrument threaded in reverse as a suture shuttle, the four limbs of the #2 FiberWire sutures of the anchor were then passed through the rotator cuff in two horizontal mattress-type fashion. The sutures, once passed through the rotator cuff, were then re-grasped out of the lateral portal. Each suture pair was then tied using an arthroscopic sliding locking technique, each followed by 3-1/2 inches on alternating posts. Upon completion of the rotator cuff repair, the repair site was probed to confirm excellent reduction and fixation back down to the articular margins of the greater tuberosity. The shoulder was then gently internally and externally rotated to confirm no gapping was noted of the rotator cuff. Inflow was then stopped to check for any bleeders and meticulous hemostasis obtained using Bovie cautery. The subacromial space was then copiously irrigated and then drained free of any fluid and debris. The portals were then closed using buried simple interrupted sutures of 4-0 Monocryl. Steri-Strips were applied. Sterile dressings were applied. The patient tolerated the procedure well. There were no complications. All needle, sponge and instrument counts were correct and the patient was transported stable and extubated to the postanesthesia care unit.