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February 19, 2015
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Code This!

Current Scenario Week of February 19, 2015:
View Answer From Last Scenario

Assign the correct ICD-9-CM and CPT codes for the following inpatient coding scenario:

Operation Performed

  1. Right shoulder arthroscopy with internal fixation of glenoid fracture
  2. Right Bankart repair with capsulorrhaphy
  3. Right removal of loose body including large osteochondral fragment 5 x 8 mm

Postoperative Diagnosis

  1. Right shoulder dislocation with anterior instability
  2. Right glenoid fracture
  3. Right osteochondral loose body

Anesthesia: General

Indications for Surgery
This is a 63-year-old female, right hand dominant, who slipped and fell on an icy sidewalk dislocating her right shoulder. In the emergency department she had a reduction of the shoulder. X-rays revealed a bony defect of the anterior inferior aspect of the glenoid. CAT scan and MRI were obtained and confirmed this with significant displacement medially and instability of the shoulder with a secondary dislocation and reduction prior to her follow-up visit. After review of the MRI and the patient’s instability symptoms, we discussed surgery including right shoulder arthroscopy, internal fixation of the glenoid fracture, as well as arthroscopic capsulorraphy and Bankart repair. The risks of surgery were discussed with the patient including infection, bleeding, blood clot, stiffness, postoperative changes, degenerative changes of the shoulder, instability, nerve or vessel injury, and the possibility of additional surgery. She understood and desired to proceed.

Operative Summary
The patient was positioned in the lateral decubitus position on the beanbag. All bony prominences were padded. Pillows were placed between the knees and the patient was secured in place with safety straps. The right arm and shoulder were prepped and draped in sterile fashion.

The portal sites were injected with 1% Xylocaine with epinephrine. A small tab incision was made posteriorly and the trocar was introduced into the glenohumeral joint. Within the glenohumeral joint there was notable Hill-Sachs lesion on the posterior aspect of the humeral head. There was some reactive synovitis in the anterior and superior aspect of the shoulder. The chondral surface was in good condition except for the Hill-Sachs lesion. The rotator cuff tendon also appeared in good condition. The anterior Bankart injury was identified with some fracture hematoma within the glenoid. The subscapularis was intact. The anterior portal was identified with a spinal needle. A small stab incision was made and the trocar was introduced for the anterior portal making sure this is very low and just above the subscapularis to allow room for the anterior superior portal. Then the anterior superior portal was identified with a spinal needle just in front of the biceps tendon and a twisting cannula was place in this portal site.

The fracture hematoma, scar tissue of the labrum, and the glenoid fracture were all debrided. The anterior labrum was released and the Bankart injury from the anterior aspect of the glenoid and scapula was released down to the point where the subscapularis muscle was visualized. A traction stitch was placed in the most inferior aspect of the labrum for use as a suture passer. The glenoid labrum was debrided to bony bed to prepare for the anchors. I then placed a very inferior double loaded anchor at the crotch of the labral tear, about the 5 o’clock position.

The suture lasso was used to shuttle the suture limb under the labrum to complete the labral repair at the anterior inferior aspect of the labrum. A second stitch was placed through the labrum from the double loaded anchor. A second anchor was placed in the face of the glenoid fracture for reduction of the glenoid. The glenoid was lifted with a traction stitch and the cuff grasper and sutures were placed in a mattress configuration around the glenoid fracture. A more superior stitch was passed to allow for the mattress stitch that would buttress the glenoid fracture and provide compression through the fracture for healing. A third and final 3.0 SuturTek anchor at about the 3 o’clock position was placed for a final capsulorraphy repair. This was placed through the middle glenohumeral ligament and capsule as well as some of the anterior labrum. Once the sutures had been passed I tied the sutures as the glenoid fragment was reduced with the cuff grasper. After this repair a loose osteochondral fragment within the axillary pouch was visualized. This was retrieved with the Kingfisher through the anterior portal. It was a comminuted piece of glenoid with some articular surface that had detached from both the glenoid as well as the labral attachment leaving it as a devascularized bony fragment.

The joint was evacuated of all arthroscopic fluid and debris. The portal sites were then closed with 3-0 Monocryl and Steri-Strips. A dry sterile dressing was applied. The patient was extubated and transferred to the postoperative recovery room in stable condition.

Code this scenario with ICD-9-CM and CPT codes.

 

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