brandi1030
New
Hello. I am struggling with coding the diagnosis as well as the procedures performed. If someone can give me some advise, I would truly be grateful!
Post Operative Diagnosis:
Posterior thoracic complex wound with necrotic skin and chronic infection with history of osteomyelitis and posterior segmental instrumentation
Procedure Performed:
1. Sharp debridement of complex posterior thoracic wound to include skin, subcutaneous tissue, and fascia
2. Removal of posterior segmental instrumentation from T3 to the ilium
3. Complex repair of posterior thoracolumbar wound, length of wound is 40 cm, repair of fascia with extensive undermining, subcutaneous tissue, and skin
4. Exploration of fusion
PROCEDURE IN DETAIL:
After general anesthesia, the patient was positioned prone The patient was several years out from a complex deformity correction associated with an osteomylitis. The patient had segmental instrumentation, pedicle screw fixation from T3 to the ilium. He had developed a dehiscence of the skin with necrotic skin at the center, The necrotic skin was diameter of approximately 15 x 10 cm. One could see exposed hardware and exposed bone. To correct this, what we did is we opened the length of the thoracolumbar incision and this was a length of about 40 cm. There was evidence of communication between this area of dehiscence in the entirety of prior operation. We excised circumferentially the necrotic skin about 1 cm lateral to excise this defect. This included skin and subcutaneous tissue. We next opened remaining of the fascia to expose the spine completely and expose the hardware. The hardware had fibrous debris with chronic purulence. The rods were removed bilaterally. The connector rods were removed. All the pedicle screws from T3 to the ilium were then removed. At this point, we had a wound which was approximately 40 cm in length and 15 cm in diameter. It was associated with some chronically necrotic tissue. All this tissue was sharply debrided. This was debrided back to healthy tissue. For closure, we had to do extensive undermining. We undermined the fascia circumferentially to gain loosening, so that the fascia could cover the spine. We irrigate copiously the spine prior to closure with the Pulsavac. We also used a curette and Leksell bone rongeur to clean the bone of any nonviable tissue on the length f this exposure. We then did a complex re-closure with multiple layers of interrupted suture. Using interrupted Vicryl suture in the fascia to reclose the fascia. Interrupted 0 Vicryl suture in the superficial fascia to reclose this fascia. To close the skin, we had to make a lateral incision, so that we could dog-ear and rotate the skin flap to gain closure. We are able to get a good closure of the entire wound using the 3-0 Vicryl and then nylon on the skin. Two subfascial drains were placed. I would note that prior to closure, we also explored the spine to determine that the fusion was solid and felt fairly comfortable that the entire fusion construct was solid with evidence of posterior arthrodesis. The sponge and needle counts were correct x2.
Post Operative Diagnosis:
Posterior thoracic complex wound with necrotic skin and chronic infection with history of osteomyelitis and posterior segmental instrumentation
Procedure Performed:
1. Sharp debridement of complex posterior thoracic wound to include skin, subcutaneous tissue, and fascia
2. Removal of posterior segmental instrumentation from T3 to the ilium
3. Complex repair of posterior thoracolumbar wound, length of wound is 40 cm, repair of fascia with extensive undermining, subcutaneous tissue, and skin
4. Exploration of fusion
PROCEDURE IN DETAIL:
After general anesthesia, the patient was positioned prone The patient was several years out from a complex deformity correction associated with an osteomylitis. The patient had segmental instrumentation, pedicle screw fixation from T3 to the ilium. He had developed a dehiscence of the skin with necrotic skin at the center, The necrotic skin was diameter of approximately 15 x 10 cm. One could see exposed hardware and exposed bone. To correct this, what we did is we opened the length of the thoracolumbar incision and this was a length of about 40 cm. There was evidence of communication between this area of dehiscence in the entirety of prior operation. We excised circumferentially the necrotic skin about 1 cm lateral to excise this defect. This included skin and subcutaneous tissue. We next opened remaining of the fascia to expose the spine completely and expose the hardware. The hardware had fibrous debris with chronic purulence. The rods were removed bilaterally. The connector rods were removed. All the pedicle screws from T3 to the ilium were then removed. At this point, we had a wound which was approximately 40 cm in length and 15 cm in diameter. It was associated with some chronically necrotic tissue. All this tissue was sharply debrided. This was debrided back to healthy tissue. For closure, we had to do extensive undermining. We undermined the fascia circumferentially to gain loosening, so that the fascia could cover the spine. We irrigate copiously the spine prior to closure with the Pulsavac. We also used a curette and Leksell bone rongeur to clean the bone of any nonviable tissue on the length f this exposure. We then did a complex re-closure with multiple layers of interrupted suture. Using interrupted Vicryl suture in the fascia to reclose the fascia. Interrupted 0 Vicryl suture in the superficial fascia to reclose this fascia. To close the skin, we had to make a lateral incision, so that we could dog-ear and rotate the skin flap to gain closure. We are able to get a good closure of the entire wound using the 3-0 Vicryl and then nylon on the skin. Two subfascial drains were placed. I would note that prior to closure, we also explored the spine to determine that the fusion was solid and felt fairly comfortable that the entire fusion construct was solid with evidence of posterior arthrodesis. The sponge and needle counts were correct x2.