Hi list,
I am at a loss what other codes to select. I am still fairly new to ortho. I am needing some guidance.
TIA,
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Left Patella dislocation/MPFL tear with loose body Left Knee.
POSTOPERATIVE DIAGNOSIS:
Same,plus Chondral defect/injury L patella
PROCEDURES:
1. Arthroscopic Left Medial Patellofemoral Ligament Reconstruction
2. ORIF Osteochondral fragment Left Patella
3. Arthroscopic shaving chondroplasty Left lateral femoral condyle.
SURGEON:
ASSISTANT:
was crucial for the entirety of the procedure.
There was no qualified resident available.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
150cc
IV FLUIDS:
1500cc
INDICATIONS FOR PROCEDURE:
is a 13-year-old volleyball player at middle school, with right MPFL repair, ORIF of an osteochondral
fragment on September 27, 2013, on her right knee. She was
doing well with that knee; however, sustained a volleyball
injury to her left knee 3 weeks ago with a patellar
dislocation. She currently reports sharp medial-sided pain
along with swelling and mechanical symptoms of locking and
Catching. She had an MRI that showed a MPFL tear and a loose body. She and her parents were advised the risks and benefits of operative versus nonoperative treatment. They understood those risks and benefits and agreed to proceed with surgery today.
DESCRIPTION OF PROCEDURE:
She was brought to the operating room, placed supine on the OR
table, underwent general anesthesia without difficulty. Preop time-out was
done identifying her Left knee as the operative knee. She was given preoperative antibiotics in the holding area.
Her examination under anesthesia revealed a stable Lachman, stable to varus
and valgus stress, stable anterior and posterior drawer.
She was placed in nonsterile tourniquet and prepped and draped in sterile fashion using ChloraPrep. His limb was elevated, exsanguinated and tourniquet was raised.
Standard diagnostic arthroscopy was begun using anteromedial and anterolateral portals with the following findings:
There was grade 4 chondromalacia on her patella that was debrided back to stable rim creating a well shouldered lesion using an oscillating shaver. She had no chondromalacia involving the trochlea that was debrided back to stable rim creating a well shouldered lesion using an oscillating shaver and a ring curette. The medial joint had no chondromalacia on the medial femoral condyle and no chondromalacia on the medial tibial plateau. The meniscus was not torn. The intercondylar notch revealed an intact ACL and PCL. The lateral joint had grade 2/3 chondromalacia on the lateral
femoral condyle that was debrided back to a stable rim using the shaver and no chondromalacia on the lateral tibial plateau. The meniscus was not torn. We examined the medial and lateral gutter for any further
Pathology or loose bodies.
An osteochondral fragment was found in the anterior portion of the lateral gutter and removed carefully with a loose body grasper. He was taken to the back table and after examination was found to have bone on the back side and therefore repairable to the defect in the inferior patella. We then turned attention back to the defect in the anterior patella and debrided back to a stable rim using the oscillating shaver. We then found an additional lesion over the lateral femoral condyle along the distal trochlea and proximal lateral femoral condyle. This is likely the site of impact for the patella on the lateral femoral condyle dislocation. There is a small fully cartilaginous fragment that was partially attached from the lateral femoral condyle. It was removed using a loose body grasper and a 2 x 1 cm full-thickness osteochondral injury was noted. We turned our attention to the repair of the osteochondral fragment from the patella.
We then made a 10 cm incision over the medial portion of the patella. Thick soft tissue flaps were elevated and a mini parapatellar incision was made through the capsule. We then able to even with the patella to examine the osteochondral defect/injury. The defect was prepared to accept the fragment. We then placed a K wire through the fragment into the defect and drilled and tapped the fragment appropriately for a 3 bioabsorbable 20 mm threaded screws. The screws is gave us good reduction and fixation of the fragment into the lesion. The screws were recessed below the chondral surface. We then turned our attention to the MPFL reconstruction using an allograft semitendinosus tendon.
We identified the medial superior border of the patella and elevated the soft tissue down to bone. We then placed 2 double loaded 3.0 suture tack anchors into the patella. Each limb was passed through the soft tissue anteriorly and posteriorly respectively so there were 4 limbs anterior 4 limbs posterior to the anchors. We then placed the semitendinosus and the bony bed and tied the sutures over the tendon. This gave us excellent control of the patella medially. We then with the aid of C-arm image intensifier drilled our Beath pin at the anatomic attachment site of the MPFL and and the pin anterolaterally. We then overreamed it with a 7 mm reamer to a depth of 65 mm. We then partially closed the capsule with interrupted #2 Vicryl stitches so we can attention the MPFL. appropriately. With the knee flexed 60? we verified isometry through full range of motion. With hand-held tension we also had a proximally 5-7 mm of lateral translation and 30?. We then used a 7 x 23 mm bioabsorbable interference screw to fix the 2 limbs of the graft into the pilot hole at that level. Once that was done we again did isometry through full range of motion with good control of the patella medially. The wound was copiously irrigated and the capsule layer was closed using interrupted 2 Vicryl stitches in a figure-of-eight fashion. 2.0 Vicryl stitches were used to the subcutaneous layer, and a 3.0 Surgipro in a subcuticular fashion on the skin. The other incisions and portals were closed using interrupted 3.0 nylon stitches. Xeroform was placed over those incisions and Steri-Strips over the longer anterior incision. Dressing sponges ABDs web roll and Ace wrap were applied. The patient was placed in a hinged knee brace from 0-40?.
The patient tolerated the procedure well and was transferred to
recovery room in stable condition.
Postoperatively, xx can be touch down weightbearing on her Right lower extremity. We will see her back in 10-14 days for repeat evaluation and suture removal. She can start physical therapy in 1-3 days on my MPFL reconstruction protocol.
I am at a loss what other codes to select. I am still fairly new to ortho. I am needing some guidance.
TIA,
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Left Patella dislocation/MPFL tear with loose body Left Knee.
POSTOPERATIVE DIAGNOSIS:
Same,plus Chondral defect/injury L patella
PROCEDURES:
1. Arthroscopic Left Medial Patellofemoral Ligament Reconstruction
2. ORIF Osteochondral fragment Left Patella
3. Arthroscopic shaving chondroplasty Left lateral femoral condyle.
SURGEON:
ASSISTANT:
was crucial for the entirety of the procedure.
There was no qualified resident available.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
150cc
IV FLUIDS:
1500cc
INDICATIONS FOR PROCEDURE:
is a 13-year-old volleyball player at middle school, with right MPFL repair, ORIF of an osteochondral
fragment on September 27, 2013, on her right knee. She was
doing well with that knee; however, sustained a volleyball
injury to her left knee 3 weeks ago with a patellar
dislocation. She currently reports sharp medial-sided pain
along with swelling and mechanical symptoms of locking and
Catching. She had an MRI that showed a MPFL tear and a loose body. She and her parents were advised the risks and benefits of operative versus nonoperative treatment. They understood those risks and benefits and agreed to proceed with surgery today.
DESCRIPTION OF PROCEDURE:
She was brought to the operating room, placed supine on the OR
table, underwent general anesthesia without difficulty. Preop time-out was
done identifying her Left knee as the operative knee. She was given preoperative antibiotics in the holding area.
Her examination under anesthesia revealed a stable Lachman, stable to varus
and valgus stress, stable anterior and posterior drawer.
She was placed in nonsterile tourniquet and prepped and draped in sterile fashion using ChloraPrep. His limb was elevated, exsanguinated and tourniquet was raised.
Standard diagnostic arthroscopy was begun using anteromedial and anterolateral portals with the following findings:
There was grade 4 chondromalacia on her patella that was debrided back to stable rim creating a well shouldered lesion using an oscillating shaver. She had no chondromalacia involving the trochlea that was debrided back to stable rim creating a well shouldered lesion using an oscillating shaver and a ring curette. The medial joint had no chondromalacia on the medial femoral condyle and no chondromalacia on the medial tibial plateau. The meniscus was not torn. The intercondylar notch revealed an intact ACL and PCL. The lateral joint had grade 2/3 chondromalacia on the lateral
femoral condyle that was debrided back to a stable rim using the shaver and no chondromalacia on the lateral tibial plateau. The meniscus was not torn. We examined the medial and lateral gutter for any further
Pathology or loose bodies.
An osteochondral fragment was found in the anterior portion of the lateral gutter and removed carefully with a loose body grasper. He was taken to the back table and after examination was found to have bone on the back side and therefore repairable to the defect in the inferior patella. We then turned attention back to the defect in the anterior patella and debrided back to a stable rim using the oscillating shaver. We then found an additional lesion over the lateral femoral condyle along the distal trochlea and proximal lateral femoral condyle. This is likely the site of impact for the patella on the lateral femoral condyle dislocation. There is a small fully cartilaginous fragment that was partially attached from the lateral femoral condyle. It was removed using a loose body grasper and a 2 x 1 cm full-thickness osteochondral injury was noted. We turned our attention to the repair of the osteochondral fragment from the patella.
We then made a 10 cm incision over the medial portion of the patella. Thick soft tissue flaps were elevated and a mini parapatellar incision was made through the capsule. We then able to even with the patella to examine the osteochondral defect/injury. The defect was prepared to accept the fragment. We then placed a K wire through the fragment into the defect and drilled and tapped the fragment appropriately for a 3 bioabsorbable 20 mm threaded screws. The screws is gave us good reduction and fixation of the fragment into the lesion. The screws were recessed below the chondral surface. We then turned our attention to the MPFL reconstruction using an allograft semitendinosus tendon.
We identified the medial superior border of the patella and elevated the soft tissue down to bone. We then placed 2 double loaded 3.0 suture tack anchors into the patella. Each limb was passed through the soft tissue anteriorly and posteriorly respectively so there were 4 limbs anterior 4 limbs posterior to the anchors. We then placed the semitendinosus and the bony bed and tied the sutures over the tendon. This gave us excellent control of the patella medially. We then with the aid of C-arm image intensifier drilled our Beath pin at the anatomic attachment site of the MPFL and and the pin anterolaterally. We then overreamed it with a 7 mm reamer to a depth of 65 mm. We then partially closed the capsule with interrupted #2 Vicryl stitches so we can attention the MPFL. appropriately. With the knee flexed 60? we verified isometry through full range of motion. With hand-held tension we also had a proximally 5-7 mm of lateral translation and 30?. We then used a 7 x 23 mm bioabsorbable interference screw to fix the 2 limbs of the graft into the pilot hole at that level. Once that was done we again did isometry through full range of motion with good control of the patella medially. The wound was copiously irrigated and the capsule layer was closed using interrupted 2 Vicryl stitches in a figure-of-eight fashion. 2.0 Vicryl stitches were used to the subcutaneous layer, and a 3.0 Surgipro in a subcuticular fashion on the skin. The other incisions and portals were closed using interrupted 3.0 nylon stitches. Xeroform was placed over those incisions and Steri-Strips over the longer anterior incision. Dressing sponges ABDs web roll and Ace wrap were applied. The patient was placed in a hinged knee brace from 0-40?.
The patient tolerated the procedure well and was transferred to
recovery room in stable condition.
Postoperatively, xx can be touch down weightbearing on her Right lower extremity. We will see her back in 10-14 days for repeat evaluation and suture removal. She can start physical therapy in 1-3 days on my MPFL reconstruction protocol.
