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Arthroscopic Rotator Cuff Repair Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right shoulder rotator cuff tear.
2.  Right shoulder impingement.

POSTOPERATIVE DIAGNOSES:
1.  Right shoulder rotator cuff tear.
2.  Right shoulder impingement.
3.  Degenerative tears of anterior and posterior glenoid labrum.

OPERATION PERFORMED:
1.  Right shoulder arthroscopy with arthroscopic rotator cuff repair.
2.  Right arthroscopic subacromial decompression.
3.  Right limited glenohumeral debridement.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA

ANESTHESIA:  General endotracheal plus scalene.

TOURNIQUET TIME:  None.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

DRAINS:  None.

IMPLANTS:  Arthrex 6.5 metallic suture anchor.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old male who has had atraumatic shoulder pain for over eight months.  He has had weakness and his pain has continued to bother him despite conservative management.  MRI showed rotator cuff tear.  Risks, benefits, and alternatives of surgery were explained to him, and he is here for operative intervention.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the table in the supine position.  An adequate level of general endotracheal and scalene block anesthesia was obtained.  He was then placed in the beach-chair position, and all bony prominences were padded.

The right upper extremity was then prepped and draped in the normal sterile fashion.  The site was verified prior to beginning the incision.  A standard posterior portal was then made and diagnostic arthroscopy of the glenohumeral joint performed.  There were no significant abnormalities of the biceps.  There was a tear of the anterior lateral portion of the supraspinatus.  The subscapularis had synovitis throughout its surface but appeared to be intact.  The posterior rotator cuff was intact.  The patient had degenerative tears of the superior and posterior labrum with free flaps.  This was debrided through the anterior portal with motorized shaver.  No significant chondromalacia and no loose bodies.

The arthroscope was then placed in the subacromial space and a thorough bursectomy was performed.  Periosteum from the acromion undersurface was removed with cautery device.  Motorized shaver was then placed through the lateral portal, and acromioplasty was performed arthroscopically until a smooth level surface was achieved.  Distal clavicle was not violated.  The rotator cuff tear was then visualized and noted to be a U-type tear of the supraspinatus along its lateral insertion.

The bony bed was then prepared to bleeding bone with the motorized shaver.  The edges of the tear were debrided with a shaver as well.  A single anchor was placed through an anterolateral portal, and the anchor had excellent purchase.  Through the anterior and posterior portals, suture retrievers were then passed through the rotator cuff anteriorly and posteriorly and were retrieved.  Simple sutures were then tied with the arm in slight abduction and external rotation with sliding knot followed by three half hitches through the anterior and posterior portals.  It was excellent repair to the footprint.

Prior to tying the sutures, a side-to-side FiberWire stitch was then used to close the tear that went more medial.  This was tied with sliding knot followed by half hitches.  The repair was very secure at the end of the procedure with the arm at the side.  The humeral head was completely covered.

The arthroscope was then removed.  The portals were closed with subcu Monocryl followed by Steri-Strips. Sterile compressive dressings were then placed followed by an UltraSling.  The patient was extubated and transferred to the recovery room in good stable condition.  There were no complications.

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