Can anyone help me with this?
PREOP DIAGNOSIS: Left distal femur nonunion.
PROCEDURE: Left distal femur hardware removal, irrigation and debridement, and antibiotic rod placement.
FINDINGS: The patient had intraoperative cultures and fresh frozen white blood cell count sent, which came back with 10 white blood cells per high-power field. There was a nonunion of the distal femur, with the most medial fracture fragment extending 13 cm from the joint line.
HPI: This is a very pleasant female who had undergone ORIF of her right distal tibia fracture on 07/21/2014. She did well after surgery until approximately 7 months postoperatively, when she had increasing pain. It was noted then that the distal screws had cut out of the plate itself and they were broken. Therefore after all risks and benefits were discussed with the patient, it was elected to take her the operating room with the plan to undergo hardware removal and distal femoral rod placement total knee arthroplasty.
PROCEDURE:
We then proceeded to utilize the most proximal aspect of her lateral incision and we were able to remove the 4 proximal screw holes without incident. I then turned my attention the joint itself making a midline incision, followed by a medial parapatellar arthrotomy. She had abundant metallosis present upon this. We excised some of this tissue. We then exposed the screws and the plate. I was then able to remove the plate without issue. We then sent off fresh frozen sections and waited for these to come back, while debriding and further exposing the distal femur. She had complete loss of the cartilage involving the superior lateral femoral condyle. The nonunion extended proximally as stated above. White blood cell count fresh from the fresh frozen saline came back at 10 white blood cells per high-power field. I then elected at that time to debride the nonunion site well, which I did with the use of the rongeurs and curettes. We irrigated 3 L of normal saline fluid through this. I then was able to place the entry reamer, followed by a guidewire and reamed proximally up to an 11.5 mm reamer. I then used a chest tube to make an antibiotic intramedullary rod, using the guide rod and the 9.5 mm chest tube. We put tobramycin and vancomycin into the antibiotic cement itself. Once this was accomplished, I was able to place this up across the fracture site. We then copiously irrigated with normal saline fluid again, closed the extensor mechanism with a 2-0 ethibond, followed by 2-0 Vicryl subcutaneously, and staples placed on the skin. She was placed in a soft sterile dressing and a knee immobilizer, and brought to PACU in stable condition.
I was thinking 27506 vs nonunion repair 27470? The hardware removal is included with both of these.
Also would I bill anything for the antibiotic cement...11981?
Any help would be greatly appreciated!!
PREOP DIAGNOSIS: Left distal femur nonunion.
PROCEDURE: Left distal femur hardware removal, irrigation and debridement, and antibiotic rod placement.
FINDINGS: The patient had intraoperative cultures and fresh frozen white blood cell count sent, which came back with 10 white blood cells per high-power field. There was a nonunion of the distal femur, with the most medial fracture fragment extending 13 cm from the joint line.
HPI: This is a very pleasant female who had undergone ORIF of her right distal tibia fracture on 07/21/2014. She did well after surgery until approximately 7 months postoperatively, when she had increasing pain. It was noted then that the distal screws had cut out of the plate itself and they were broken. Therefore after all risks and benefits were discussed with the patient, it was elected to take her the operating room with the plan to undergo hardware removal and distal femoral rod placement total knee arthroplasty.
PROCEDURE:
We then proceeded to utilize the most proximal aspect of her lateral incision and we were able to remove the 4 proximal screw holes without incident. I then turned my attention the joint itself making a midline incision, followed by a medial parapatellar arthrotomy. She had abundant metallosis present upon this. We excised some of this tissue. We then exposed the screws and the plate. I was then able to remove the plate without issue. We then sent off fresh frozen sections and waited for these to come back, while debriding and further exposing the distal femur. She had complete loss of the cartilage involving the superior lateral femoral condyle. The nonunion extended proximally as stated above. White blood cell count fresh from the fresh frozen saline came back at 10 white blood cells per high-power field. I then elected at that time to debride the nonunion site well, which I did with the use of the rongeurs and curettes. We irrigated 3 L of normal saline fluid through this. I then was able to place the entry reamer, followed by a guidewire and reamed proximally up to an 11.5 mm reamer. I then used a chest tube to make an antibiotic intramedullary rod, using the guide rod and the 9.5 mm chest tube. We put tobramycin and vancomycin into the antibiotic cement itself. Once this was accomplished, I was able to place this up across the fracture site. We then copiously irrigated with normal saline fluid again, closed the extensor mechanism with a 2-0 ethibond, followed by 2-0 Vicryl subcutaneously, and staples placed on the skin. She was placed in a soft sterile dressing and a knee immobilizer, and brought to PACU in stable condition.
I was thinking 27506 vs nonunion repair 27470? The hardware removal is included with both of these.
Also would I bill anything for the antibiotic cement...11981?
Any help would be greatly appreciated!!