Could you please look at this and let me know what you think?
POSTOPERATIVE DIAGNOSES:
1. Very chronic irreparable tear of rotator cuff
2. Chronic moderate impingement
3. Minimal osteoarthritis
4. Mild chronic degenerative labral tearing
OPERATION PERFORMED:
1. Arthroscopic, left shoulder, with arthroscopic attempted release of retracted, immovable rotator cuff
2. Open attempted repair as above
3. Open subacromial decompression
FINDINGS: The patient had a badly retracted tear on MRI, but did not have any atrophy. It was unknown whether this was because the tear was relatively recent as the patient described or if it was because of the patient?s heavy weight-lifting. Unfortunately at the time of surgery, the large tear was very, very old, retracted, and immovable after multiple attempts to try to release the tissue and perform some type of repair. In addition, there was some evidence of impingement. There was minimal evidence off glenohumeral arthritis and some mild degenerative labral tearing. The biceps tendon was intact. There were noted two relatively large flaps of tendon out in the footprint. One of these was a large chunk of the supraspinatus and the other the infraspinatus. I am surmising that the recent painful pop that the patient felt in his shoulder may well have been one of these residual lateral flaps.
DESCRIPTION OF PROCEDURE: He was given an interscalene block followed by a general anesthetic. He was placed in the beach chair position. All areas were appropriately padded and protected. The subacromial space was instilled with 0.25% Marcaine with epinephrine. A sterile prep and drape was carried out. The joint was filled with Ringer?s and the joint fluid was just slightly bloody.
The scope was then passed through a posterior portal. The above findings were noted. The entire supraspinatus and infraspinatus were retracted actually medial to the glenoid labrum. These tissues were very badly stuck down. I finished the diagnostic scope and really didn?t find any other abnormalities of note except these large flaps out laterally in the footprint.
We then created a lateral portal and came in and worked very extensively on the tear inferiorly and superior. I tried to loosen up this tissue as much as possible and placed a clamp on this tissue several times and found it immovable even after extensive releases. I then took the scope in the lateral portal and created a posterolateral portal and once again did some release. I just wasn?t successful in getting this tissue to move.
Because of this patient?s weight-lifting hobby, I thought it best to give him every opportunity to repair this tissue, so I removed the scope and made an anterior incision over the front of the acromion and carried it down over the deltoid. I did a blunt dissection through the deltoid but released the deltoid right off the most anterior aspect of the acromion. I then did a decompression with rongeurs and a rasp. Once again I grabbed the tissue and tried to work it out laterally and was completely unsuccessful.
I then removed these flaps of retained tendon out laterally in the footprint so they would not act as impinging tissues in trying to help alleviate pain in this gentlemen down the road.
At this point, copious irrigation was carried out. I created three holes in the acromion using a towel clip and repaired the deltoid anatomically back to the front of the acromion using Ethibond and then did an Ethibond figure-of-eight stitch out at the corner of the acromion, successfully pulling the deltoid anatomically back together. The subcu and skin were closed in standard fashion. A sterile dressing was applied. He was placed into a sling. Sponge and needle counts were good.
Shoulder surgery -deltoid/ open SAD
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