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Shoulder Arthroscopic Decompression Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right shoulder impingement syndrome.
2.  Right shoulder acromioclavicular joint arthritis.
3.  Right shoulder rotator cuff tear.

POSTOPERATIVE DIAGNOSES:
1.  Right shoulder impingement syndrome.
2.  Right shoulder acromioclavicular joint arthritis.
3.  Right shoulder rotator cuff tear.

OPERATION PERFORMED:
1.  Right shoulder arthroscopic decompression.
2.  Right shoulder arthroscopic distal clavicle excision.
3.  Right shoulder arthroscopic rotator cuff repair.

SURGEON:  John Doe, MD

ASSISTANT:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female with long-standing pain in her right shoulder with an MRI proving a full-thickness tear of the rotator cuff. She is very symptomatic and presents today for arthroscopic surgery to improve her pain.

DESCRIPTION OF OPERATION:  Informed consent was obtained. She was taken to the operating room and was given interscalene as well as general anesthesia. We placed her into the lateral position with her right shoulder up. Her fingers were placed in finger traps and attached to the lateral arm holder. We prepped and draped the shoulder in routine fashion.

We made a small posterior incision and placed the arthroscope into the glenohumeral joint. She had a full-thickness tear of the supraspinatus with a lot of granulation tissue present within the tear. This tear was somewhat more medial and not really insertional. She had a lot of synovitis in her joint. We placed a shaver in the joint to perform a synovectomy and debridement of some frayed portions of her labrum. Her articular surfaces were healthy, and her biceps was intact.

We then placed the arthroscope into the subacromial space. She had a thickened bursa. We made a lateral portal and performed a complete bursectomy. The CA ligament was very thickened and calcified. We released the ligament portion to reveal a large anterior spur, and we used a motorized shaver on high speed to resect this spur. The AC joint was also very tight and arthritic. We made a direct anterior portal and used a shaver to resect the distal clavicle. This relieved the impingement.

The rotator cuff tear was in the supraspinatus, and it was a more medial side-to-side type tear. We placed a disposable cannula and performed this in a side-to-side fashion; first piercing the more lateral edge of the tendon and then grasping that suture and passing it through the more medial leaf of the tendon using a Scorpion suture Passer. We passed two sutures. These were #2 FiberWire sutures with arthroscopic knots tied more laterally, giving secure repair of tendon-to-tendon. There was no gapping and no motion at the repair site.

We then removed the instruments and closed the portals. We applied sterile dressings and a sling, and she was awakened and taken to the recovery room in good condition.