Shoulder Arthroscopy/Rotator Cuff Repair Operative Report

Laterality: [Left / Right / Bilateral]

Date/Time of Procedure: [Date and time]

Facility: [Facility name]

Patient Name: [Patient full name]

MRN: [Medical record number]

Primary Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s) and role(s)]

Preoperative Diagnosis

• [Diagnosis with laterality and specificity]
• [Additional diagnoses as applicable]

(Use clinical diagnoses with laterality and anatomic specificity. Do not copy imaging impressions verbatim.)

Postoperative Diagnosis

• [Diagnosis with laterality and specificity]
• [Additional diagnoses as applicable]

(Update based on arthroscopic findings. If unchanged, state "Same as preoperative diagnosis" instead of list.)

Procedures Performed

• [Procedure with laterality, approach (arthroscopic/open), and qualifiers (e.g., double-row, suture-bridge, partial repair, revision)]
• [Additional procedures as applicable]

(List chronologically. Only include procedures actually performed.)

Anesthesia

[Type of anesthesia (general / regional / MAC)]; [Regional block type if applicable]; [Surgeon-administered local injection at end of case with agent and volume, if used]

Indications

[Presenting symptoms, failure of nonoperative treatment if applicable, and objective findings (exam/imaging) supporting surgery]

(1–3 sentences.)

Informed Consent

[Statement confirming informed consent obtained including laterality and planned procedure(s); note any case-specific risks discussed such as revision risk, irreparability, or biceps options]

Positioning and Exam Under Anesthesia

Position: [Beach chair / Lateral decubitus] with [arm holder/traction details, padding, head/neck precautions]

EUA: [Forward elevation, ER at side, ER in abduction, IR; stability findings if assessed]

(Omit EUA line entirely if not performed.)

Operative Findings

Glenohumeral Joint

• Humeral head cartilage: [Normal / Grade and location of changes / Not visualized]
• Glenoid cartilage: [Normal / Grade and location of changes / Not visualized]
• Labrum: [Normal / Tear location, SLAP type and stability on probing / Not visualized]
• Biceps tendon and pulley: [Tendon quality, stability in groove, pulley integrity / Not visualized]
• Subscapularis: [Intact / Partial or full-thickness tear with extent and location / Not visualized]
• Supraspinatus/Infraspinatus (articular view): [Intact / Tear characteristics / Not visualized]
• Capsule/synovitis: [Normal / Synovitis location and severity / Capsular changes]
• Loose bodies: [None / Size, location, and disposition]

Subacromial Space

• Bursal tissue: [Inflammation/thickening characteristics]
• Rotator cuff bursal surface: [Tear confirmation and characteristics]
• Coracoacromial ligament: [Intact / Frayed / Released]
• Acromion undersurface: [Flat / Curved / Hooked; spur/impingement findings]
• AC joint: [Findings if assessed / Not assessed]

Rotator Cuff Tear Characterization

• Tendons involved: [Supraspinatus / Infraspinatus / Subscapularis / Teres minor]
• Thickness: [Partial (articular / bursal / intratendinous) / Full-thickness / Not assessed]
• Pattern: [Crescent / U-shaped / L-shaped / Massive-contracted / Not assessed]
• Size: [AP × ML in cm / Estimated size with context / Not measured]
• Retraction: [Minimal / Moderate / Severe / Not assessed]
• Mobility after releases: [Mobile to footprint / Residual tension / Unable to reduce]
• Tissue quality: [Good / Fair / Poor; delamination if present]

Procedure Description

Portals and Diagnostic Arthroscopy

[Portals created (posterior, anterior, lateral, accessory); diagnostic arthroscopy with systematic evaluation of glenohumeral joint and subacromial space]

Glenohumeral Work

[Debridement, chondroplasty, synovectomy, labral work, subscapularis management as performed]

(Omit section if no glenohumeral work performed.)

Biceps Management

[For tenotomy: release location, stump management. For tenodesis: location, fixation method, implant details, tensioning]

(Omit section if no biceps procedure performed.)

Subacromial Work

[Bursectomy extent; decompression/acromioplasty rationale, technique, and bone removed; CA ligament release if performed; distal clavicle excision amount if performed]

Rotator Cuff Repair

Footprint preparation: [Debridement to bleeding bone; marrow stimulation if performed]

Tendon mobilization: [Interval slide, capsular releases, margin convergence; final mobility achieved]

Repair configuration: [Single-row / Double-row / Suture-bridge; partial vs complete repair with rationale if incomplete]

Anchors: [Number by row; placement locations; knotless vs knotted; suture configuration (simple / mattress / rip-stop)]

Augmentation: [None / Graft or bioinductive implant details]

Final assessment: [Repair stability through gentle ROM; footprint coverage achieved]

Hemostasis and Closure

[Hemostasis method; portal closure technique; dressing applied]

Implants

• [Device type/name], [Manufacturer], [Size], [Quantity], [Anatomic location], [Lot/Serial number]
• [Additional implants as applicable]

(If no implants used, state "None.")

Specimens

[Specimen description and destination (pathology / microbiology)]

(If none, state "None" or omit per facility preference.)

Estimated Blood Loss

[EBL in mL]; [Drain type and location / No drain placed]

Complications

[None / Complication description and management]; [Instrument and sponge counts correct]

Disposition

Condition: [Stable / Description]

Destination: [PACU / Other]

Neurovascular status: [Intact / Motor and sensory limited by regional block; hand warm and well-perfused]

Postoperative Plan

• Immobilization: [Sling type (standard / abduction pillow)]; [Wear schedule]; [Duration]
• Rehabilitation: [Protocol tier or facility standard]; [PT start timing]; [ROM restrictions (PROM only, ER limits, avoid behind-back)]; [Strengthening restrictions with timeframe]
• Weight-bearing: [No lifting/pushing/pulling with operative arm; additional restrictions]
• Follow-up: [Timeframe for first postoperative visit]

(Use specific, actionable instructions. Reference facility standard protocol if specific restrictions not determined intraoperatively.)

Surgeon Signature

____________________________________
[Surgeon Name, Credentials]
[Date and time of authentication]