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Arthroscopic Subacromial Decompression Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right rotator cuff tear.

POSTOPERATIVE DIAGNOSES:
1.  Right rotator cuff tear, subscapularis and supraspinatus.
2.  Right labral tear.

OPERATION PERFORMED:
1.  Right arthroscopic subacromial decompression.
2.  Right arthroscopic extensive debridement to include the labrum, subscapularis and supraspinatus tendons.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Scalene.

TOURNIQUET TIME:  None.

ESTIMATED BLOOD LOSS:  Less than 5 mL.

COMPLICATIONS:  None.

DRAINS:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male who injured his right shoulder when doing therapy for his cervical spine. The patient felt a pulling sensation and pain down the lateral side of his arm. He has continued to have pain complaints and was sent to our office where, after a detailed history, physical examination and review of plain film radiographs, including an MRI scan, concerns of a rotator cuff tear was entertained. Because of continued pain complaints, the patient presents now for the 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. The right shoulder was prescrubbed with Betadine. 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. Next, a true anterolateral portal was created in a similar fashion, and this was used for outflow and instrumentation. The superior labrum demonstrated significant fraying, which involved the biceps anchor, which started at the 11 o'clock position and extended to about the 1 o'clock position. A radiofrequency device was utilized to debride this area. With lifting, it was noted that there was some detachment, but the degenerative nature demonstrated that no formal repair would be required. The anteroinferior, inferior and rest of the posterior labrum were within normal limits. There was a negative drive-through sign, and the axillary pouch showed no loose bodies. The humeral head and glenoid fossa showed no significant degenerative changes. There was significant fraying representative of a partial tear of the subscapularis, and this was debrided with a 5.5 full radius shaver.

Further probing demonstrated some mild delamination, but it was not felt to be repairable in nature. The rotator interval showed no defects. The superior glenohumeral ligament, middle glenohumeral ligament, and the anterior band of the inferior glenohumeral ligament showed no tearing. The biceps was medialized. There was no fraying. The supraspinatus was visualized, and there was some mild delamination at the articular surface representative of a PASTA lesion. This was debrided with a radiofrequency device, and this only represented 5%, and therefore, it was felt that no formal repair would be needed. The posterior cuff and the rest of the supraspinatus were visualized, and there was no tearing. The arthroscope was then placed into the subacromial region. Significant amounts of neovascularization with a hypertrophic, thickened subacromial bursa was identified.

Under direct visualization, a direct lateral portal was created in a similar fashion, and this was used for instrumentation. A formal bursectomy was performed. A moderately thickened coracoacromial ligament was seen, and this was incised and released. A moderate-sized enthesiophyte was identified. A formal acromioplasty was performed with a 5.5 full radius shaver. Approximately 6 mm of bone was resected. Resection was carried to a smooth, flat surface. The arthroscope was placed in the direct lateral portal, and visualization demonstrated a flat smooth acromion. Inspection of the bursal side of the rotator cuff demonstrated no partial tears. It was felt by the operative team that an adequate subacromial decompression as well as extensive debridement of the labrum, supraspinatus and subscapularis 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 stable condition. Examination in the recovery room revealed that the radial pulse was 4/4; however, due to scalene block, neurologic examination could not be completely assessed.