CPT® Code 23921

1. Indications

The procedure of shoulder disarticulation, as described by CPT® Code 23921, is indicated for specific medical conditions that necessitate the removal of the arm at the shoulder joint. These indications include:

• Extensive Malignant Neoplasms - The presence of large tumors that affect the shoulder region and surrounding tissues, making limb preservation unfeasible.
• Severe Trauma - Significant injuries to the shoulder and arm that result in irreparable damage, necessitating amputation for the patient's health and safety.

2. Procedure

The procedure for shoulder disarticulation involves several critical steps, which are detailed as follows:

• Step 1: Incision and Dissection - A subclavicular incision is made along the lateral third of the clavicle. The pectoralis major muscle is dissected to create a window between the pectoralis minor and subclavian muscles, allowing access to the underlying structures.
• Step 2: Vascular Control - The subclavian vein is exposed, ligated with sutures, and divided below the entry point of the cephalic vein. Similarly, the subclavian artery is exposed, ligated, and divided at the exit point of the thoracoacromial artery. In some cases, these vessels may be divided more distally through the same incision.
• Step 3: Skin Incision and Flap Creation - A skin incision is made at the lateral edge of the pectoralis major and extended over the distal aspect of the deltoid muscle. An additional axillary incision is created, running from anterior to posterior, to facilitate the creation of skin flaps.
• Step 4: Muscle Detachment - The deltoid, supraspinatus, and infraspinatus muscles are detached from the humerus. The long head of the biceps, long head of the triceps, and teres minor are also severed. Additionally, the pectoralis major is detached from the humerus, and the conjoint tendon and subscapularis are severed to expose the neurovascular bundle.
• Step 5: Nerve Transection - The axillary nerve is identified and transected to prevent any potential nerve damage during the procedure.
• Step 6: Severing Posterior Structures - Posterior structures, including the long head of the triceps, latissimus dorsi, and teres major muscles, are severed to facilitate complete disarticulation.
• Step 7: Amputation and Closure - Once all soft tissues and the shoulder capsule are completely divided, the arm is removed. The remaining musculature is then closed, and the deltoid muscle is sutured over the underlying musculature. Drains may be placed as needed, and the skin flaps are sutured in place.

3. Post-Procedure

After the shoulder disarticulation procedure, patients will require careful monitoring and post-operative care. This includes managing any pain, preventing infection, and ensuring proper healing of the surgical site. The secondary closure or scar revision, as indicated by CPT® Code 23921, involves the removal of any necrotic or infected tissue at the site of the previous disarticulation. If scar revision is necessary, scar tissue will be excised, and the amputation site will be closed using grafts or flaps to promote optimal healing and restore the appearance of the area. Follow-up appointments will be essential to assess recovery and address any complications that may arise.