Help, lots going on here. See report. calcific tendinopathy

NAME OF PROCEDURE:  Right shoulder diagnostic arthroscopy with limited debridement, arthroscopic subacromial decompression without arthroplasty, and mini open calcium deposit excision with rotator cuff repair of both the supraspinatus and infraspinatus tendons.

IMPLANTS:  Two 5.5 mm Bio-Corkscrew anchors from Arthrex to my medial row and two 4.75 mm SwiveLock for my lateral row.  For my infraspinatus repair we used two #2 Fiber wires without anchors.

OPERATIVE FINDINGS:  Exam under anesthesia of the right shoulder shows a full passive range of motion.  Right shoulder diagnostic arthroscopy revealed the following.  The patient had a normal cartilage both the humeral and glenoid articular surface.  She had some mild degenerative tearing of the anterior superior labrum.  She had a type 1 degenerative SLAP tear, which had a stable biceps anchor.  The biceps tendon was unremarkable.  The subscapularis tendon was normal.  Rotator interval showed some mild synovitis, but otherwise was normal.  Axillary recess was benign.  The articular rotator cuff showed some mild fraying along the posterior aspect of the supraspinatus tendon and anterior aspect of the infraspinatus tendon.  This was a low-grade finding.  This was tagged with #1 PDS intraarticularly.  In the subacromial space, the patient had obvious calcium deposits posteriorly.  I did not appreciate any calcium deposits anteriorly.  She had significant fraying of the rotator cuff bursa.  The undersurface of the anterolateral acromion was benign, which included an almost coracoacromial ligament.  She did not have an appreciable downsloping acromion.  We then approached the calcium deposits excision through a mini open approach.  She had a very large classic calcium deposit posteriorly in the cuff.  We did not find similar findings anteriorly on the cuff, although she had what appear to be a significantly mature calcium deposit, which had fused to the greater tuberosity anteriorly.  There was a small amount of calcium deposits within the cuff itself, but again the majority of the deposit anteriorly was fused and quite mature.

INDICATIONS FOR PROCEDURE:  The patient is a 48-year-old patient seen for impingement of right shoulder.  She was diagnosed with a heavy burden of calcium deposit over the rotator cuff tendon.  Given failure of conservative treatment, I recommend proceeding with a right shoulder arthroscopic versus mini open calcium deposit excision with likely rotator cuff repair.  I discussed the full risks and benefits of procedure preoperatively.  Please see H and P for details.  Knowing these risks, the patient wished to proceed with surgery.

PROCEDURE IN DETAIL:   I then proceeded with diagnostic shoulder arthroscopy per above.  External rotator interval portal was made using outside-in technique without complication.  We then adequately probed the superior labrum and believe that the anchor was intact and mild changes of the superior labrum did not rule in any specific surgery.  We did perform debridement of the anterior superior labrum to a stable edge.  Again, the biceps anchor complex was stable.  We very closely probe the biceps tendon and not appreciate a tear.  We did tag the mild fraying of the anterior aspect of the infraspinatus tendon with #1 PDS using a spinal needle.  This was later done on the bursal side.  The arthroscope was then placed into the subacromial space using posterior portal.  A standard 50 yard line portal was made using an outside-in technique.  We then performed an arthroscopic subacromial bursectomy.  We resect the bursitis over the cuff itself was quite frayed.  There was a small amount of calcium deposit appreciated within the bursal space.  As stated above, we did see the calcium deposit posteriorly, but nothing anteriorly.  We then decided given the large calcium burden to proceed with a mini open approach.  My standard 50 yard line portal was then extended both superiorly and inferiorly.  Deltoid fascia was cut in line with the prior portal.  We had excellent exposure to the greater tuberosity and rotator cuff laterally.  We then performed an additional bursectomy laterally.  We had an excellent exposure of the tuberosity and cuff.  With internal rotation of the shoulder, we easily palpate the calcium deposit on the posterior cuff.  We incised the calcium deposit longitudinally with a #15 blade.  We then were able to scoop out a large calcium burden within this area.  We then debrided any degenerative tissue to healthy tissue.  That area was thoroughly irrigated.  Given that there was no footprint exposed, we decided to close this area with two simple #2 FiberWire sutures.  We then turned our attention to the anterior aspect of the cuff as in accordance with preoperative MRI.  We felt fairly hard deposit in accordance with the preoperative MRI findings.  There were no other appreciable calcium deposits within the cuff itself that we could identify by palpation and/or by needling.  The calcium deposit that I believe to correspond with the MRI findings appeared to have fuse into the tuberosity laterally.  There was an obvious interface between this hard piece of calcium in underlying bone.  It was removed with a curved osteotome to what I believe was normal tuberosity.  It did appear to have some cuff fibers underneath this piece, thus confirming that this was likely a very mature calcium deposit, which again had fused into the tuberosity laterally.  There is a similar area anteriorly that we smoothed down with a combination of curettes, rongeurs, and shaver.  Once these were removed, we did certainly have a significant defect within the cuff itself.  It was not a full-thickness defect, but a high-grade partial bursal sided defect. I believe therefore this warranted a double row transosseous equivalent rotator cuff repair.  Two 5.5 mm Bio-Corkscrew anchors were placed along the medial aspect of the exposed footprint both anteriorly and posteriorly and well spaced apart.  These were placed without complication.  We then placed horizontal mattress sutures within the cuff medially.  We also placed two cinched FiberLink on the anterior and posterior edges of the cuff tear to prevent dog ears and help reduce the tear repair.  Medial row was then tied as the cuff was reduced without complication.  The tails of the medial row horizontal mattress sutures were then incorporated into two lateral 4.75 mm SwiveLock in a crisscrossing fashion.  We included the cinched FiberLink in the lateral row.  This allowed for excellent compression of the repair.  I was quite happy with the rotator cuff repair.  We ensured that no other obvious calcium deposits were left behind through direct palpation of the cuff in its entirety.  The wound was thoroughly irrigated throughout the case prior to skin closure.  The deltoid fascia was closed with interrupted 0-Vicryl sutures.  Subcutaneous tissue was closed with interrupted 2-0 Vicryl sutures.  Skin was closed with running 3-0 Monocryl subcuticular stitch.  Dermabond was applied.  Portal sites were closed with 3-0 nylon sutures.

Comments

  • What is your question?
  • Rotator cuff repair was due to the excision of calcareous deposits code 23000 which is included in RCR 23412, 29822 bundled as well.  I was wondering if anyone had an opinion as to charging 23412 or 23000 with modifier 22 instead since the repairs were needed due to the excisions.
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