ReignRuby
Contributor
Any help would be appreciated. Please see operative note below. I have coded this with CPT 27654, 27691 & 28118. Would you include 27680 as well? Thank you.
I started by exsanguinating the left lower extremity using a 6-inch Esmarch and elevating the tourniquet to 290 mmHg. I then made approximately 6 cm longitudinal incision just anterior to the medial border of the Achilles terminating about 1 cm distal to its insertion at the calcaneus. I did this sharply with a 15-blade. I then bluntly dissected through subcutaneous tissue using electrocautery for hemostasis and iris scissors for the dissection. I then used a wood handle elevator to develop a plane just anterior to the Achilles. There was a significant amount of retrocalcaneal bursal inflammatory tissue noted, which I debrided using a rongeur. I then incised the peritenon of the Achilles on the anterior aspect and identified the interstitial tearing and degenerative tissue noted there. I debrided this tissue and then used a #2 FiberWire in a running fashion to re-tubularize the torn area of the Achilles. Once this was done, I used a small microsaw to excise the large Haglund deformity in the posterior aspect of the Achilles anterior to the Achilles tendon. Once this was excised, I then smoothed out the edges using a hand rasp. I took care to stay well posterior to the subtalar joint.
I then bluntly dissected through the deep intermuscular membrane exposing the flexor hallucis muscle belly and tendon. I then plantar flexed the foot in great toe tracing the tendon anteriorly. I also flexed the lesser toes, which were also flexed the great toe, telling me that there was inter connections. I then sectioned the FHL tendon as far anterior as possible. I then bluntly dissected around the muscle belly delivering the tendon posteriorly into the superficial posterior compartment. I directly visualized the neurovascular bundle during this part of the procedure. I then drilled a 5-mm hole just anterior to the insertion of the Achilles and then sent a Beath needle through this out the plantar aspect of the calcaneus. I then loaded the whipstitch then I ran 2-0 FiberWire in the distal aspect of the FHL and delivered this through the tunnel pulling the sutures out through the plantar aspect of the heel. I then tensioned this into the hole and placed an interference screw 5-mm in diameter with excellent interference bite. I then trimmed the tails in subcutaneous nature on the volar aspect of the heel. Excellent transverse strength was obtained. I tensioned the muscle until prior to interference screw placement until the musculotendinous junction was at the aperture of this tunnel. I then used a #0 Vicryl suture to tag the muscle belly of the FHL to the Achilles to help increase the bone supply.
I started by exsanguinating the left lower extremity using a 6-inch Esmarch and elevating the tourniquet to 290 mmHg. I then made approximately 6 cm longitudinal incision just anterior to the medial border of the Achilles terminating about 1 cm distal to its insertion at the calcaneus. I did this sharply with a 15-blade. I then bluntly dissected through subcutaneous tissue using electrocautery for hemostasis and iris scissors for the dissection. I then used a wood handle elevator to develop a plane just anterior to the Achilles. There was a significant amount of retrocalcaneal bursal inflammatory tissue noted, which I debrided using a rongeur. I then incised the peritenon of the Achilles on the anterior aspect and identified the interstitial tearing and degenerative tissue noted there. I debrided this tissue and then used a #2 FiberWire in a running fashion to re-tubularize the torn area of the Achilles. Once this was done, I used a small microsaw to excise the large Haglund deformity in the posterior aspect of the Achilles anterior to the Achilles tendon. Once this was excised, I then smoothed out the edges using a hand rasp. I took care to stay well posterior to the subtalar joint.
I then bluntly dissected through the deep intermuscular membrane exposing the flexor hallucis muscle belly and tendon. I then plantar flexed the foot in great toe tracing the tendon anteriorly. I also flexed the lesser toes, which were also flexed the great toe, telling me that there was inter connections. I then sectioned the FHL tendon as far anterior as possible. I then bluntly dissected around the muscle belly delivering the tendon posteriorly into the superficial posterior compartment. I directly visualized the neurovascular bundle during this part of the procedure. I then drilled a 5-mm hole just anterior to the insertion of the Achilles and then sent a Beath needle through this out the plantar aspect of the calcaneus. I then loaded the whipstitch then I ran 2-0 FiberWire in the distal aspect of the FHL and delivered this through the tunnel pulling the sutures out through the plantar aspect of the heel. I then tensioned this into the hole and placed an interference screw 5-mm in diameter with excellent interference bite. I then trimmed the tails in subcutaneous nature on the volar aspect of the heel. Excellent transverse strength was obtained. I tensioned the muscle until prior to interference screw placement until the musculotendinous junction was at the aperture of this tunnel. I then used a #0 Vicryl suture to tag the muscle belly of the FHL to the Achilles to help increase the bone supply.
