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#1
07-22-2011, 01:37 PM
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Surgery Help Distal Femoral
I was lookign at CPT 27514, but Im just not sure. Does anyone have any suggestions on how this surgery should be coded?
POSTOPERATIVE DIAGNOSIS: Distal femoral fracture, comminuted, osteopenic. OPERATION PERFORMED: 1. Open reduction and internal fixation of distal femoral fragment pieces. 2. Distal femoral replacing hinged knee replacement. PROSTHESES: 1. DePuy LPS distal femoral replacing hinged knee replacement, left-sided, extra small, with a 31 mm sleeve and a 16 x 75 mm stem. 2. DePuy MBT size 3 revision tibial component with a 29 mm sleeve and a 13 x 30 mm stem. 3. Extra small 12 mm thick LPS hinged polyethylene insert. 4. A 35 mm oval dome patella. DESCRIPTION OF OPERATION: The extensor mechanism was opened through a standard medial parapatellar approach. A large hemarthrosis was evacuated. Additional exposure was gained by elevating the tissue off the proximal medial tibia around to the midline. We split the suprapatellar pouch which was already split and edematous. The fracture hematoma was evacuated. She had significant comminution. There was a sagittal split right down to the condyles. There was a transverse fracture at the metaphyseal flare on the medial side. There were 2 large fragments going up the medial and lateral side. We spent painstaking effort and time shelling out the portions of the distal femur, removing the anterior cruciate ligament, posterior cruciate ligament, and meniscus. We were able to reduce the fracture fragments on the medial side and placed a cerclage cable, both to release hoop stresses as well as to retain some of the medial side of the bone. With the fracture more reduced, we were able to bring the leg out to length. We measured from the joint line 100 mm up the femur, which encompassed most of the fracture pieces. The femoral shaft was marked here. We reduced the trochlea as best as was possible and assessed our overall rotation off the tibial tubercle and the patella and marked our trochlear groove, Whiteside's line on this proximal portion of the femur as well. We were then able to shell out most of the femur and ultimately cut what remained of the shaft at 100 mm. The cerclage wire was tightened but not crimped, and it kept all the pieces together. We then turned our attention to the tibia. The tibia was exposed. The meniscal remnants were removed. The proximal tibia was cut using an extramedullary guide. These bony surfaces were obviously pristine as the primary area. We prepared it for size 3 MBT tibia and a 29 mm sleeve. Trial was inserted. We turned our attention back to the femur. The femoral shaft was reamed to accept a 16 mm stem. The small 31 mm broach was seated nicely at the 100 mm cut. It was quite tight and rotationally solid here. We went back and forth with multiple trials. It appeared that we needed 100 mm of distal length with plus or minus 0 or 5 adapter. For that reason, we dropped down to a 35 mm segment to give us 95 mm of implant and we could use the 0, 5, or 10 mm adapter. It appeared that we had good rotation, good femoral and tibial tracking, and not over lengthening as we could still separate the 12 mm polyethylene tibial tray. At this time, we prepared the patella as well. It was measured and cut to accept a 35 mm patella. We then cemented the tibial component in place and the patella component in place. The tourniquet was ultimately deflated, and hemostasis was achieved. We assembled the femoral component on the back table. We chose a 5 mm adapter with 95 mm of length to get us back on 100. We were able to impact this into place. It was extremely tight. The sleeve was extremely solid. It actually countersunk 1 mm or 2 mm, and it clearly stopped and would not go any further. We undertook multiple trials of polyethylene and settled on a 12. The 14 just seemed a little bit tight. 
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