University of Washington

Department of Orthopaedics & Sports Medicine

Surgical Worksheet

Surgery Date______

Surgeon:Winston J Warme

Pav OKR2 OK Main Only

Dx:

Surgical Procedure:ScopeOpen

Required Information:

Interpreter:NoLanguage:
Diabetic:NoYes
Latex allergy: NoYes
Transmission Issues:No(MRSATB)
Sleep Apnea: NoYes / Developmental Delay:NoYes
Pacer or defiber:NoYes
Pt > 400 lbs:NoYes
Mobility/transportation issues:No
Issues impacting Pre-op prep time day of surgery:

Length of Stay:(1-2 Days 2-3 Days)Length of Surgery: (1 Hour 1.5 Hours 2 Hours)

Admission:OPLS  AM Admit  IPDay Before Surgery

First Post-op:Same Week2 Week1 WeekNoOther:

Anesthesia: ChoiceScalene BlockOther:

Labs:Routine: CBCArthroplasty or >40y/o: CBC/CMP/COAGS/Hep C/HCG/UAcC&SSed/CRP

Transfusion:None T + S Units (Arthroplasty) T + C Units (2 if Arthroplasty and pt of concern)

Consult:NoneMedicineSocial Work OrthoticsOther:

PAT Position:LateralBeach ChairSupineProneOther:

O/R Table:RegularFx TableRA TableC-ArmOther:

O/R X-ray:NoneC-ArmRegularHealthmateOther:

Special Equip:NoneCPM BedScope BoomMcConnellOther:

IMPLANTS:

Acumed
 Locking Clavicle Plate
Biomet
Bio-Modular Shoulder System
Bi-Angular/Bi-Polar Shoulder System
Dahl Miles cable system
Depuy
Global AdvantageTSA
Global Advantageand Ream and Run
Global Advantage CTA
Global Advantage Fx
Delta Shoulder
Delta XTend Shoulder
 HRP & Global Shld Impl.
Rockwood Clavicle Screw
Rockwood Clavicle Pin
Exactech
Equinoxe Shoulder Fracture System
InterSpace Shoulder Cement Spacer
Encore
Reverse Shoulder Prosthesis System
Smith&Nephew
Cofield 2 TSA / Stryker
 Solar TSA
Tornier
 Aequalis Shoulder System
Synthes
Periarticular Plates
 Lg Frag Screw Set Implant
 Mini Frag Set: 1.5, 2.0, 2.7 mm Screws
 Sm Frag Set: 3.5, 4.0 mm Tit Screws
Modular Hand Impl/Instr Set
 LC-DCP Plates: 3.5, 4.5 Narw & 4.5 Broad
 DCP Plates: 3.5, 4.5 Narrow & 4.5 Broad
 Pelvic Recon Screws & Plates 3.5, 4.5, 6.5
 Recon Plate Set 2.7, & 3.5
 Kirschner “K” Wires
 Long 2.7 Plates
Wright Medical
 Evolve Radial Heads
Olympia Shoulder System
Zimmer
Coonrad-Moorey Elbow Impl
 Olecranon Elbow
 Humeral Plates
 Bigliani/Flatow Shoulder
Anatomical Shoulder System
 Trabecular Metal Humeral Stem / Arthroscopy Gear
Arthrex
5.5mm FT Bio-Corkscrew Anchor(RCR)
 3.0mm Bio-SutureTak (Bankart/SLAP)
STaR Sleeve
Hardware Removal Tools
 Snap-On Extraxtion Set (drivers)
Spine Implant Removal Set (drivers and easy outs)
Broken Screw Removal Set
Cement Removal Set
Moreland Cementless Removal Set
Other Tools
Midas Rex
Assortment of Metal Burrs
High speed cutoff wheel
Sterile x-ray film (protect from metal debris)
ConMed Linvatec
Tendon Stripper
Smith & Nephew
Acufex Graftmaster II
NW TissueCenter
Allografts:
 Hamstring Allograft
 Cancellous Chips 15 cc & 30 cc

PLEASE COMPLETE BOTH SIDES Filled out by/Date:
Please circle all Procedures that apply

CPT / Common Procedures / CPT / Common Procedures
23472 / Total Shoulder Arthroplasty / 23020 / Capsular Release
23472 / Delta Arthroplasty
23472 + 23332 / Revision Total Shoulder Arthroplasty / 23700 / MUA of Shoulder
23470 / Hemiarthroplasty Shoulder / 24300 / MUA of Elbow
23470 + 23331 / Revision Shoulder Hemiarthroplasty
23420 / Biceps Tenodesis (long head)
23150 / Osteophyte Resection - Humerus / 24342 / Reinsertion distal biceps tendon
24363 / Total Elbow Arthroplasty / 23120 / Clavicle Resection
24363 + 24160 / Revision Total Elbow Arthroplasty
23455 / Open Bankart Repair / 23800 / Shoulder Fusion
23412 / Open RCR - Chronic
23410 / Open RCR - Acute / 20900 / ICBG (iliac crest bone graft)
23130 / Smooth and Move (Acromioplasty) / 20680 / Hardware Removal

Please also circle all Diagnoses that apply

ICD-9 / Common Diagnosis / ICD-9 / Common Diagnosis
Arthritis / Stiffness
715.31 / DJD/OA Shoulder / 726.0 / Adhesive capsulitis of shoulder "frozen shoulder"
716.11 / Traumatic OA Shoulder / 718.41 / Contracture of shoulder
715.32 / DJD/OA Elbow / 718.42 / Contracture of elbow
714.0 / Rheumatoid Arthritis - Any Joint / 719.51 / Stiffness of shoulder, not elsewhere classified
719.52 / Stiffness of elbow, not elsewhere classified
716.91 / Cuff Tear Arthropathy
Infections
996.47 / Failed Total Joint (See long list below) / 711.9 / Unspecified infective arthritis
733.41 / AVN Shoulder / 996.66 / Infected Total Joint
998.59 / Post Op Infection
Sprains and strains
840.4 / Rotator cuff / Other
840.6 / Supraspinatus / 726.10 / Rotator cuff syndrome NOS
840.3 / Infraspinatus / 726.11 / Calcifying tendinitis of shoulder
840.5 / Subscapularis / 726.12 / Bicipital tenosynovitis
718.11 / Loose body in shoulder
Nontraumatic rupture of tendon / 729.5 / Pain in limb
727.61 / Complete rupture of rotator cuff, nontraumatic
727.62 / Tendons of biceps (long head)
Closed Dislocation of shoulder / Failed Arthroplasty
718.31 / Recurrent dislocation of shoulder / 996.41 / Mechanical loosening of prosthetic joint
831.00 / shoulder, unspecified / 996.42 / Dislocation of prosthetic joint
831.01 / anterior dislocation of humerus / 996.43 / Prosthetic joint implant failure
831.02 / posterior dislocation of humerus / 996.44 / Peri-prosthetic fracture around prosthetic joint
831.03 / inferior dislocation of humerus / 996.45 / Peri-prosthetic osteolysis
831.04 / acromioclavicular joint / 996.46 / Articular bearing surface wear of prosthetic joint
839.61 / sternoclavicular joint / 996.47 / Other mechanical complication of prosthetic joint implant
718.81 / Shoulder instability / 996.49 / Other mechanical