27134 & 27269


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The doctor want to bill for both of these procedures, but Im not sure if theyre allowed. Has anyone come across this before?

1. Failed right cemented stem.
2. Periprosthetic proximal femur fracture.

1. Revision of right failed total hip replacement.
2. Open reduction and internal fixation of proximal femur
fracture with cables.

1. DePuy due to Duraloc 62 mm x 36 mm. Acetabular component, 4
mm lateralized.
2. The Zimmer femoral stem with a 19 mm tapered body x 185 mm
and a 103 mm XL proximal body high offset.
3. 36 mm cobalt chrome head with + 3.5 mm neck segment.
4. Multiple Exactech palmar cables.

The patient is a 58-year-old gentleman who comes total hip
replacement some 10 years ago. His hip gone bad the last year or
so. He had a fall which gave him a lot more pain. He had
basically had become nonambulatory. His radiographs demonstrated
the proximal periprosthetic femur fracture. About half way down
the femoral stem. There was moderate displacement. We discussed
at length the risks and benefits of revision surgery. We
discussed the increased complexity. His renal dialysis issues,
the potential for infection, his brittle bone, the possibility of
bleeding given dialysis as well as a very complicated case. We
talked about fracture failure of the stem, leg length issues,
sciatic nerve issues, bleeding issues, blood clots, embolism,
infection, and dislocation. Understanding all this, he was
adamant that he could not continue along his current path with
severe pain. Both kin and his wife were onboard with the
potential for operative intervention, understood the complexity
high all the possible complications and risks involved.
Understanding all this, with informed consent, appropriate
medical clearance, he wished to proceed with the operation on
July 05, 2011.

After identification of the patient, induction with general
anesthetic, the patient was positioned on the left side. Bony
prominences were appropriately padded. The right hip was prepped
and draped in usual sterile fashion. His previous anterolateral
approach and skin incision was utilized. We curved this
posteriorly and extended a bit distally. Sharp dissection was
carried out down to the level of the fascia. The fascia was
split in line with the lateral aspect of the femur. Anterior
posterior flaps were elevated. The Charnley retractor was
placed. Our plan was to go posteriorly. We identified the
posterior structures. We directly palpated the sciatic nerve.
Deep benign the acetabulum traced this down to the gluteal
sling. Part of the gluteal sling was released. We opened up the
posterior capsule along the back of the gluteus medius, along the
back of the trochanter down the lesser trochanter. His
hypertension was uncontrolled. He bled an awful amount from the
soft tissues at this point. Once we got down around to the femur
and opened up the hip joint itself, he bled again from the hip
joint and the femoral canal as well. While his pressure was
running quite high and was quite difficult to control, he lost a
fair amount of blood. He continued to lose blood during the
operation especially when we worked the femoral canal removing
all of the debris and membrane present in there. Overall he lost
over 2200 cc of blood. Once we had exposed to the posterior
aspect of the hip joint, it took quite a bit of time to shell out
the pseudoscar from around his hip. There was more heterotopic
ossification here then on the x-rays. We exposed the acetabular
rim and we exposed down the lesser trochanter. His proximal
femur was extremely destroyed with a lot of membrane present. We
curetted out a lot of this osteolysis material from all around
the acetabulum from inferior to the acetabulum as well as the
bone on the proximal femur. It was clear the proximal femur was
loose. Once we had good exposure around the acetabulum and
around the proximal femur, the hip was dislocated. The femoral
head ball was removed. We used curettes to clear out the
proximal femur which clearly loosened up the stem and ultimately
it was removed with a lot of the cement intact. We curetted out
and used the Moreland extractors to bring all the membrane in the
femoral canal and bring out some of the cement as well. We were
left with about a 3 cm junk of cement distally that we just could
not get past or get out. We turned our attention to the
acetabulum. The acetabular extractor was then utilized. We were
able to pull the acetabulum without much difficulty. We cleaned
up the bone cleaned up the soft tissues around the rim.
Ultimately we impacted the 62 mm Duraloc acetabular component
which was 4 mm lateralized. It was quite solid. It required
replacement of the locking ring as well which was done without
difficulty. Happy with the acetabulum we turned our attention
back to the femur. At this point, given the distal cement plug
as well as the inspecting the proximal femur. It was clear that
the proximal fracture. He had sort of a lateral piece of the
proximal piece. These were sort of displaced away where they
covered the canal would not give us a straight shot to do
adequate reaming at the canal. For that reason, a posterior
osteotomy was performed around the back cortex and we
incorporated the fracture planes. This gave us more or less a
lateral piece and a medial piece that was loose. This gave us
good access down the canal. We could actually see the cement.
It was drilled center-center under direct vision. We were able
to remove all the cement. Could not quite get the cement plug
which ultimately pushed down easily. Happy with this, we now had
the canal exposed. We reamed up with conical reamers to a 19
reamer and had a pretty good bite. A 19 trial prosthesis was
tapped into place about level of our templating. Intraoperative
x-ray showed that we had a nice tight fit and did not violate
into the cortices. We were right down the middle. We were able
to use the temporary body to sort of mark out anteversion and our
overall length. It was apparent that we would be probably in the
middle segment of the XL bodies. For this reason, a 19 stem was
then chosen. It was impacted into place and was quite tight. It
would not go any further. We undertook multiple trial reductions
with multiple body segments and marking our rotation. We
ultimately settled on XL body segment of 103 mm. We required
this for soft tissue tension and offset. The trochanter portion
could easily be reduced with this in place. The sciatic nerve
was directly palpated and was not unduly tight at this length.
All of our indicators of leg length appeared that we were
probably within 45 mm of where we had started just a little bit
longer for soft tissue tension. Happy with this, the final body
segment was put in place appropriately as well as locked down
with the locking screw. We undertook multiple trial ball length
as well. Starting with the -2. We worked our way up and seemed
to have the best soft tissue tension and range of motion. With
the 3 mm ball segment. We actually to get quite good flexion and
internal rotation. We did not fully externally rotated just
owing to the intact capsule. Happy with this, with the final
ball was impacted into place. It was reduced into the
acetabulum. We then turned our attention to the fixation of the
fracture. The fracture fragments were slightly mobilized. The
leg was abducted up on the malar and properly padded. We were
then able to pass to the ExacTech cables around the femur and
over the fracture fragment. Between the osteotomy and the
fracture fragments we reduced it quite nicely with full contact
distally and all along the posterior area. The cables were
tightened down and gave us quite nice reduction. We were able to
move the entire femur as an unit with good range of motion and
stability. At this point, we could not really shake much and
soft tissue tension appeared to be right on. Cables were finally
tightened and then cut. We had quite nice reduction. The wound
was again copiously irrigated. A single drain was placed. The
entire posterior sleeve capsule was reapproximated to itself and
the back surface of the trochanter. The gluteal sling was
repaired as well. The wound was copiously irrigated.