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Medical Transcription Orthopedic Surgical Procedure Transcribed Sample Report


PREOPERATIVE DIAGNOSIS:  Left rotator cuff tear.

POSTOPERATIVE DIAGNOSES:
1.  Left rotator cuff tear.
2.  Left labral tear, SLAP type 2.

OPERATIONS PERFORMED:
1.  Left arthroscopic rotator cuff repair with a double row fixation.
2.  Left arthroscopic subacromial decompression.
3.  Left arthroscopic SLAP type 2 repair.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Scalene block.

TOURNIQUET TIME:  None.

ESTIMATED BLOOD LOSS:  Less than 5 mL.

DRAINS:  None.

COMPLICATIONS:  None.

INDICATIONS FOR SURGERY:  The patient is a (XX)-year-old male who injured his left shoulder.  The patient was seen in my office, and after a detailed history, physical exam, review of plain film radiographs including an MRI scan, concerns of a rotator cuff tear was entertained. Because of continued pain complaints, despite physical therapy and corticosteroid injections, he presents now for above-mentioned operation.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and after scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a sitting position. Of note, preoperative antibiotics were given and the left shoulder was prescrubbed with Betadine. Next, the left upper extremity including the left 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 left shoulder was performed.

Under direct visualization, an anterior superior portal was created in a similar fashion and this was used for outflow and instrumentation. A superior labral tear was noted at the base of the biceps anchor, which included the biceps anchor. This started at the 12 o'clock position and extended anteriorly to about the 10 o'clock position. There was fraying and this was debrided with a radiofrequency device, and with further probing, there was noted to be a lift off and therefore it was felt that this was a repairable construct. The rest of the anterior labrum, inferior labrum and posterior labrum were within normal limits. There was a negative drive-through sign. The articular surface of the glenoid fossa and humeral head were within normal limits. The axillary pouch showed no loose bodies. Mild form of neovascularization was noted in the rotator interval. There was no defect. The intraarticular subscapularis was within normal limits. The biceps was medialized. There was no evidence of fraying or delamination laterally. A large tear of the supraspinatus was identified with fraying. The posterior rotator cuff was within normal limits.

Under direct visualization, a trans-rotator cuff portal was created through the rotator cuff tear to help with instrumentation. The edge of the glenoid rim was decorticated with a 5.5 full radius shaver to bleeding bone. A 3.0 BioRaptor suture anchor was then placed at the base of the biceps. Utilizing arthroscopic knot tying techniques, the superior labrum was repaired with a #2 Ultrabraid in a sliding knot fashion. A fourth portal was then created at the anterior-inferior aspect and this was used just superior to the intraarticular subscapularis. This was used for instrumentation. Utilizing the double-armed suture anchor, the anterior aspect of the labrum was repaired in a similar fashion with #2 Ultrabraid in a simple half-hitch fashion. This secured the biceps anchor and with probing noted to have no evidence of liftoff. It was felt by the operative team that an adequate SLAP repair had been performed. The arthroscope was then placed into the subacromial region. Significant amounts of neovascularization with thickening of the subacromial bursa was identified.

Under direct visualization, a lateral portal was created in a similar fashion. A formal bursectomy was performed with a 5.5 full radius shaver as well as a radiofrequency device. Hypertrophic thickened coracoacromial ligament was identified and this was incised and released. A small enthesophyte was identified. A formal acromioplasty was performed with a 5.5 full radius shaver. Resection was carried to a smooth, flat surface. The arthroscope was then placed in direct lateral portal and visualization demonstrated a large rotator cuff tear, which measured almost 5 cm. This started anteriorly and extended posteriorly to just about the level of the infraspinatus. The edge of the greater tuberosity was decorticated with a 5.5 full radius shaver to bleeding bone. A 5.0 TwinFix suture anchor was then placed at the posterior aspect of the tuberosity near the rotator cuff.

Utilizing arthroscopic knot tying techniques, a rotator cuff repair was performed posteriorly with the double-armed TwinFix with #2 Ultrabraid in a simple half-hitch fashion. This repaired the posterior aspect of the rotator cuff. This converted the rotator cuff to a small crescent shape anteriorly. A second suture anchor was then placed at the articular margin at the medial footprint. Utilizing arthroscopic knot tying techniques, a mattress suture was passed and secured with #2 Ultrabraid in a simple half-hitch fashion. This now secured the entire medial footprint of the rotator cuff. A third 5.0 TwinFix suture anchor was placed more laterally, and with arthroscopic knot tying techniques, a simple suture was passed with the double-arm and secured with #2 Ultrabraid in a simple half-hitch fashion. This reconstructed the lateral footprint. With probing, there was now no liftoff and it was felt by the operative team that an adequate concomitant subacromial decompression and rotator cuff repair 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 were correct and estimated blood loss was less than 5 mL. The wounds were then cleaned and dressed under sterile field. A Polar Care ice machine and a shoulder immobilizer were placed to the left upper extremity. The patient was then escorted to the recovery room in a stable condition.