Wiki 27445-Knee Arthroplasty with hinge prosthesis

[adunlap23]

Can someone verify if the following procedure qualifies as 27445-Knee Arthroplasty with hinge prosthesis? I've never had use this code before, so I just want to be certain this is correct.


Pre and Postop Diagnosis: Comminuted intracondylar left distal femur fracture
Procedure: Left total knee arthroplasty/distal femoral replacement

Operative note:
Patient was appropriately marked and identified in the preoperative holding area. They awere then taken back to the operative suite where they received antibiotics per protocol as well as regional anesthesia and spinal anesthesia. They were transferred to the regular OR table and positioned supine. Patient was then prepped and draped in the standard orthopedic fashion. Timeout was then performed.
Midline incision was made. Electrocautery was used to then dissect down to the joint to capsule and a medial parapatellar arthrotomy was performed. fracture hematoma was immediately encountered. There was noted to be comminuted intercondylar distal femur fracture with five segments. Using a tenaculum to hold the bone fragments and a cobb elevator sub-periosteal dissection was perfumed with electrocautery to remove the fracture fragments. Resection was made along the metaphysis of the distal femur. Reaming was performed up to 19 mm. An overall collar was selected. Trial implant was placed and the knee was extended. This was noted to have satisfactory tracking with the paella and also not to overstuff the joint. Rotation was marked using electrocautery on the femoral shaft. Trial femoral component was then removed.
Attention was turned to preparation of the tibial canal. Residual meniscus was then removed. A canal opening reamer was then used and the canal was sequentially reamed up to a size 16mm reamer. Cutting guide was then placed and resection was performed off the proximal tibia. Residual bone fragments were then removed as well as the reamer and cutting guide. A size 4 baseplate was noted to have excellent coverage. A size 4 baseplate was then assembled with 65 mm stem extension. Keel was impacted to secure rotation. Trial distal femur was then placed and a rotational hinge was then insterted. Components were then connected using an axial pin. Stability leg length and patellar tracking were noted to be satisfactory.
At this point, trial components were removed. Knee was irrigated using dilute betadine solution followed by normal saline solution. Canals were then prepared and femoral and tibial cement restrictors were then placed. Components were then assembled on the back table and cement was mixed. Cement was pressurized in the tibial canal and the tibial component was then inserted. Any excess cement was removed. Attention was turned to the insertion of the femoral component. Once again, any excess cement was removed. Polyethylene piece was then impacted into the tibia and rotational hinge was then placed. The distal femur was aligned with the rotational pins and the axial pin was then inserted and secured into position. Knee was held in extension while cment was allwed to harden. Femoral rotation and patellar tracking were noted to be satisfactory.
It then goes on to describe irrigation and wound closure.

 

[NRaizman]

This is kinda controversial. This is not a Walldier-type prosthesis, which is obsolete and hasn't been routinely implanted since the early 1980's. I understand that the code descriptor uses "eg" not "ie" but this is really a very different procedure. This is a distal femoral replacement with a linked prosthesis and is substantially more work than a standard TKA.

I would generally code this, as would most of the AAOS tumor and hip/knee coding experts, as 27447+22 for the extra work of distal femoral replacement in the setting of intercondylar fracture. You might need an addendum to justify the 22.

25445 isn't wrong, it's merely obsolete, describes a legacy procedure, and the linking of femur and tibia in this type of case is reflective of additional work to provide a stable construct when soft tissue balancing is not adequate (because the collateral insertions were damaged by the fracture), and so selecting a code that has fewer wRVU than a standard TKA seems inappropriate. This is a Harvard code, never surveyed, no vignette, and thus there is really nothing canonical to go upon other than history, as recounted by grumpy, grey-haired orthopods.

In this setting, the surgeon did you no favors in dramatizing the extensiveness of the procedure to justify the -22, but this is significantly more difficult than a standard TKA.
N

 

[adunlap23]

This is kinda controversial. This is not a Walldier-type prosthesis, which is obsolete and hasn't been routinely implanted since the early 1980's. I understand that the code descriptor uses "eg" not "ie" but this is really a very different procedure. This is a distal femoral replacement with a linked prosthesis and is substantially more work than a standard TKA.

I would generally code this, as would most of the AAOS tumor and hip/knee coding experts, as 27447+22 for the extra work of distal femoral replacement in the setting of intercondylar fracture. You might need an addendum to justify the 22.

25445 isn't wrong, it's merely obsolete, describes a legacy procedure, and the linking of femur and tibia in this type of case is reflective of additional work to provide a stable construct when soft tissue balancing is not adequate (because the collateral insertions were damaged by the fracture), and so selecting a code that has fewer wRVU than a standard TKA seems inappropriate. This is a Harvard code, never surveyed, no vignette, and thus there is really nothing canonical to go upon other than history, as recounted by grumpy, grey-haired orthopods.

In this setting, the surgeon did you no favors in dramatizing the extensiveness of the procedure to justify the -22, but this is significantly more difficult than a standard TKA.
N

Thank you. Your explanation was really helpful. I'm glad I asked before billing out!