DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left shoulder fracture dislocation with a large reverse Hill-Sachs lesion.
POSTOPERATIVE DIAGNOSIS: Left shoulder fracture dislocation with a large reverse Hill-Sachs lesion.
OPERATION PERFORMED:
1. Open reduction, left shoulder dislocation.
2. Left shoulder hemiarthroplasty with HemiCAP system.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old African-American male who sustained the above-noted injury, who came in for operative fixation. The risks, benefits, and alternatives of the procedure were discussed in detail. The patient was given the opportunity to ask questions, and all questions were answered, and informed consent was obtained.
OPERATIVE FINDINGS AND DESCRIPTION OF OPERATION: The patient was taken to the operating room. After induction of general anesthesia, the patient was placed in the captain’s chair. The left upper extremity was prepped and draped in the usual sterile fashion. A standard deltopectoral incision was made. Dissection was then carried down through the brachial vein. The conjoined tendon was retracted medially. The deltoid was retracted laterally. The deltopectoral fascia was incised. Dissection was then carried out down through the subscapularis tendon, which was separately released and tagged with sutures as well as the anterior capsular component, which was separately tagged. The Hill-Sachs lesion was identified. It was significantly comminuted and not amenable to fixation.
A HemiCAP system was then used along with 2.0 K wires in the center after appropriately templating to the appropriate size, 40 mm. HemiCAP bipolar resurfacing was then performed with cement impregnated with tobramycin in order to achieve good fixation. The patient was noted to be completely stable through the full arc of range of motion after HemiCAP hemiarthroplasty. The anterior capsule as well as subscapularis was repaired back to its original place. The wound was closed in a layer-like fashion. Sterile dressing was applied.
