kellyayo
New
Hello,
I have a unique scenario:
PREOPERATIVE DIAGNOSES:
1. Septic arthritis, left hip, chronic.
2. Degenerative joint disease, left hip, secondary to post-septic
arthritis.
.
POSTOPERATIVE DIAGNOSES:
1. Septic arthritis, left hip, chronic.
2. Degenerative joint disease, left hip, secondary to post-septic
arthritis.
.
PROCEDURE:
1. Left conversion to total hip arthroplasty with antibiotic impregnated
cement spacer device.
2. Application of antibiotic cement spacer device.
.
IMPLANTS:
1. DePuy Prostalac size 4, high, short stem with a 32+9 metal 12/14 head,
43/32 semi-constraint cemented PROSTALAC liner.
.
Cement was three commercially available tobramycin impregnated antibiotic
cement each bag with 1 g of vancomycin and 1.2 g of tobramycin for a total
antibiotic dosage of 3 g of vancomycin and 6.6 g of tobramycin.
.
INDICATIONS: XXXXXX is a 55-year-old gentleman who had an acute
septic arthritis of the left hip approximately 7 or 8 months ago. He had
an urgent irrigation and debridement in the operating room by one of my
colleagues. He subsequently recovered from this, but developed post-septic
arthritis with complete loss of the articular cartilage of the hip. Prior
to surgery, his workup was equivocal for eradication of infection with
significant inflammation and a question of osteomyelitis in the femoral
head and acetabular bone on MRI scan from October. Sed rate and CRP had
not normalized by December. So, it was felt that appropriate surgical
intervention to address his severe pain, degenerative arthrosis and erosion
of the femoral head would be a stage total hip arthroplasty. It was
decided to convert him to a total hip arthroplasty with the cement
articulating high-dose antibiotic cement spacer and a complete debridement
of the tissues followed by a total hip arthroplasty once confirmed
eradication of the infection was completed. The patient understood the
plan and risks and benefits associated with this procedure and freely
signed the consent.
.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and
placed in the supine position on the operating room table. General
endotracheal anesthesia was induced. The patient was placed in the right
lateral decubitus position and the left lower extremity was prepped and
draped in the usual sterile fashion. A 5-point check was carried out to
confirm site verification. The patient received Ancef and vancomycin for
antibiotic prophylaxis.
.
After confirmation of site, an 18 cm posterolateral incision was made
directly over the left hip. Sharp dissection was carried down to the level
of fascia. The IT band and gluteus maximus fascia was incised
longitudinally and the GMax muscle was split bluntly. The short external
rotators were identified, tagged, and taken down as a sleeve. A posterior
trapezoidal capsular flap was made and tagged. The superior and inferior
capsular remnant was excised and the hip was dislocated with flexion,
abduction and internal rotation.
.
The proximal femoral anatomy was examined. There appeared to be erosive
biofilm type of appearance with a chronic infectious appearance as well as
significant sinotubular irritation and inflammation. There was
considerable oozing until the blood loss was higher than normal with this
debridement. We did not use the Cell Saver device for concern of a chronic
persistent low-grade infection.
.
The femoral neck resection was made approximately 1.2 cm proximal to the
level of the lesser trochanter. The femoral head had multiple pitting
areas that appeared to be erosions from infectious material and this was
sent for culture. The femoral head was sent for pathology. The bone
quality at the femoral neck seemed appropriate on the femoral side to
handle a PROSTALAC articulating stem.
.
Attention was then turned to the acetabulum. Retractors were placed.
There is a considerable amount of debridement carried out circumferentially
that reestablished the acetabular margin. There was considerable amount of
erosion and active inflammation that was carefully debrided as well and
hemostasis was attained. There was diffuse erosive change of the
acetabular subchondral bone and a reamer was used to tough this gently to
debride some of the irregularities, but I was careful not to remove any
particular bone. The pelvic bone was in continuity and did not have any
column deficiencies. Pulse irrigation now at this point was used to
debride and irrigate the deep and superficially for approximately 3 liters.
The sponge was placed in the acetabulum. Attention was turned back to the
femur.
.
The Box chisel opened the canal proximally and the awl opened the canal
distally. Sequential broaches were used starting with size 1 up to size 4.
The size 4 had appropriate medial lateral fit and fill. Pulse irrigation,
removed fat and blood from bony track into the femur.
.
At this point, the size 4, high offset PROSTALAC stem was opened and the
43/32 cemented PROSTALAC liner was opened. Three bags of tobramycin
impregnated cement were mixed each bag with 1 g of vancomycin and 1.2 g of
tobramycin additional. This was then used to fabricate the stem using the
appropriate PROSTALAC molds. The remaining cement was then gently
pressurized into the acetabular bed and the liner was held in place at
about 45 degrees of abduction and 30 degrees of anteversion. The cement
was allowed to harden.
.
The mold was removed from the stem and the stem was carefully applied into
the proximal femur and had excellent intrinsic stability. The hip was
reduced and I felt that overall was short by about a cm due to the
patient's high offset enlarged relatively femoral anatomy. The +9 femoral
head trial was also showing shortening, so we decided to cement the
proximal portion of the stem proud by a cm to allow for appropriate leg
length reconstitution and stabilization of the hip. One bag of tobramycin
impregnated cement were mixed and placed around the top 2 cm of the femoral
stem. This was then pressurized into the canal proximally. The cement was
allowed to harden. The hip was reduced down and the leg lengths were equal
at the knee and the foot. The overall offset and stability was much
improved. The 32+9 metal 12/14 head was tamped on a clean trunnion and the
hip was reduced. It was snapped into the stem constraint liner
appropriately. The stability was improved with flexion in 90, IR 60
hyperextension and external rotation was appropriate and shuck was
nonexistent due to the semi-constraint liner.
.
Copious irrigation, removed debris again. Hemostasis was obtained. A #2
Quill closed the capsule in a running fashion. #3 Vicryl repaired the
posterior trapezoidal capsular flap as well as the short external rotators.
The sciatic nerve was palpated and felt to be intact with no evidence for
undue tension. #1 PDS was run deep, 2-0 Vicryl subcutaneously, 3-0
Monocryl subcuticularly. A sterile bandage was applied. The patient
tolerated the procedure well, was allowed to awaken from anesthesia and
transferred to recovery room in stable condition.
When I queried the doctor, he explained:
I did not explant any components on this patient. He had a recurrent hip infection of a native hip, and so he was converted to a prostalac. He did have a prior infection I&D done, so this surgery represents a surgery subsequent to a prior surgery. The prostalac implant is nearly identical to a total hip implant, so I felt the operation that was closest to the operation performed was conversion to total hip. I put the 11981 code as well because the prostalac is fabricated out of antibiotic cement so it is also an antibiotic cement spacer device.
The other option I was considering would be a resection arthroplasty (girdlestone procedure) and antibiotic spacer placement, which would also be reasonable for the surgery performed.
Should I submit this as an unlisted procedure?
A Girdlestone procedure w) 11981?
I don't think this should be submitted as a conversion to a THR because it is only an articulating antibiotic spacer.
Am I wrong with this logic?
I have hit a wall - any advice would be greatly appreciated.
Thank you!
I have a unique scenario:
PREOPERATIVE DIAGNOSES:
1. Septic arthritis, left hip, chronic.
2. Degenerative joint disease, left hip, secondary to post-septic
arthritis.
.
POSTOPERATIVE DIAGNOSES:
1. Septic arthritis, left hip, chronic.
2. Degenerative joint disease, left hip, secondary to post-septic
arthritis.
.
PROCEDURE:
1. Left conversion to total hip arthroplasty with antibiotic impregnated
cement spacer device.
2. Application of antibiotic cement spacer device.
.
IMPLANTS:
1. DePuy Prostalac size 4, high, short stem with a 32+9 metal 12/14 head,
43/32 semi-constraint cemented PROSTALAC liner.
.
Cement was three commercially available tobramycin impregnated antibiotic
cement each bag with 1 g of vancomycin and 1.2 g of tobramycin for a total
antibiotic dosage of 3 g of vancomycin and 6.6 g of tobramycin.
.
INDICATIONS: XXXXXX is a 55-year-old gentleman who had an acute
septic arthritis of the left hip approximately 7 or 8 months ago. He had
an urgent irrigation and debridement in the operating room by one of my
colleagues. He subsequently recovered from this, but developed post-septic
arthritis with complete loss of the articular cartilage of the hip. Prior
to surgery, his workup was equivocal for eradication of infection with
significant inflammation and a question of osteomyelitis in the femoral
head and acetabular bone on MRI scan from October. Sed rate and CRP had
not normalized by December. So, it was felt that appropriate surgical
intervention to address his severe pain, degenerative arthrosis and erosion
of the femoral head would be a stage total hip arthroplasty. It was
decided to convert him to a total hip arthroplasty with the cement
articulating high-dose antibiotic cement spacer and a complete debridement
of the tissues followed by a total hip arthroplasty once confirmed
eradication of the infection was completed. The patient understood the
plan and risks and benefits associated with this procedure and freely
signed the consent.
.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and
placed in the supine position on the operating room table. General
endotracheal anesthesia was induced. The patient was placed in the right
lateral decubitus position and the left lower extremity was prepped and
draped in the usual sterile fashion. A 5-point check was carried out to
confirm site verification. The patient received Ancef and vancomycin for
antibiotic prophylaxis.
.
After confirmation of site, an 18 cm posterolateral incision was made
directly over the left hip. Sharp dissection was carried down to the level
of fascia. The IT band and gluteus maximus fascia was incised
longitudinally and the GMax muscle was split bluntly. The short external
rotators were identified, tagged, and taken down as a sleeve. A posterior
trapezoidal capsular flap was made and tagged. The superior and inferior
capsular remnant was excised and the hip was dislocated with flexion,
abduction and internal rotation.
.
The proximal femoral anatomy was examined. There appeared to be erosive
biofilm type of appearance with a chronic infectious appearance as well as
significant sinotubular irritation and inflammation. There was
considerable oozing until the blood loss was higher than normal with this
debridement. We did not use the Cell Saver device for concern of a chronic
persistent low-grade infection.
.
The femoral neck resection was made approximately 1.2 cm proximal to the
level of the lesser trochanter. The femoral head had multiple pitting
areas that appeared to be erosions from infectious material and this was
sent for culture. The femoral head was sent for pathology. The bone
quality at the femoral neck seemed appropriate on the femoral side to
handle a PROSTALAC articulating stem.
.
Attention was then turned to the acetabulum. Retractors were placed.
There is a considerable amount of debridement carried out circumferentially
that reestablished the acetabular margin. There was considerable amount of
erosion and active inflammation that was carefully debrided as well and
hemostasis was attained. There was diffuse erosive change of the
acetabular subchondral bone and a reamer was used to tough this gently to
debride some of the irregularities, but I was careful not to remove any
particular bone. The pelvic bone was in continuity and did not have any
column deficiencies. Pulse irrigation now at this point was used to
debride and irrigate the deep and superficially for approximately 3 liters.
The sponge was placed in the acetabulum. Attention was turned back to the
femur.
.
The Box chisel opened the canal proximally and the awl opened the canal
distally. Sequential broaches were used starting with size 1 up to size 4.
The size 4 had appropriate medial lateral fit and fill. Pulse irrigation,
removed fat and blood from bony track into the femur.
.
At this point, the size 4, high offset PROSTALAC stem was opened and the
43/32 cemented PROSTALAC liner was opened. Three bags of tobramycin
impregnated cement were mixed each bag with 1 g of vancomycin and 1.2 g of
tobramycin additional. This was then used to fabricate the stem using the
appropriate PROSTALAC molds. The remaining cement was then gently
pressurized into the acetabular bed and the liner was held in place at
about 45 degrees of abduction and 30 degrees of anteversion. The cement
was allowed to harden.
.
The mold was removed from the stem and the stem was carefully applied into
the proximal femur and had excellent intrinsic stability. The hip was
reduced and I felt that overall was short by about a cm due to the
patient's high offset enlarged relatively femoral anatomy. The +9 femoral
head trial was also showing shortening, so we decided to cement the
proximal portion of the stem proud by a cm to allow for appropriate leg
length reconstitution and stabilization of the hip. One bag of tobramycin
impregnated cement were mixed and placed around the top 2 cm of the femoral
stem. This was then pressurized into the canal proximally. The cement was
allowed to harden. The hip was reduced down and the leg lengths were equal
at the knee and the foot. The overall offset and stability was much
improved. The 32+9 metal 12/14 head was tamped on a clean trunnion and the
hip was reduced. It was snapped into the stem constraint liner
appropriately. The stability was improved with flexion in 90, IR 60
hyperextension and external rotation was appropriate and shuck was
nonexistent due to the semi-constraint liner.
.
Copious irrigation, removed debris again. Hemostasis was obtained. A #2
Quill closed the capsule in a running fashion. #3 Vicryl repaired the
posterior trapezoidal capsular flap as well as the short external rotators.
The sciatic nerve was palpated and felt to be intact with no evidence for
undue tension. #1 PDS was run deep, 2-0 Vicryl subcutaneously, 3-0
Monocryl subcuticularly. A sterile bandage was applied. The patient
tolerated the procedure well, was allowed to awaken from anesthesia and
transferred to recovery room in stable condition.
When I queried the doctor, he explained:
I did not explant any components on this patient. He had a recurrent hip infection of a native hip, and so he was converted to a prostalac. He did have a prior infection I&D done, so this surgery represents a surgery subsequent to a prior surgery. The prostalac implant is nearly identical to a total hip implant, so I felt the operation that was closest to the operation performed was conversion to total hip. I put the 11981 code as well because the prostalac is fabricated out of antibiotic cement so it is also an antibiotic cement spacer device.
The other option I was considering would be a resection arthroplasty (girdlestone procedure) and antibiotic spacer placement, which would also be reasonable for the surgery performed.
Should I submit this as an unlisted procedure?
A Girdlestone procedure w) 11981?
I don't think this should be submitted as a conversion to a THR because it is only an articulating antibiotic spacer.
Am I wrong with this logic?
I have hit a wall - any advice would be greatly appreciated.
Thank you!
