HeatherLaCoss
New
I have the calcaneal osteotomy coded 28300 but I need help with finding a code for the Modified Kidner posterior tibial tendon. Below is what the doctor sent to me.
Operative Report
Preoperative Diagnosis:
#1 left adult acquired flat foot deformity.
#2 left posterior tibial tendinopathy/synovitis.
ICD: 734, 726.72
Post Operative Diagnosis:
Same with notable synovitis involving the distal portion of the posterior tibial tendon and sheath and chronic insufficiency of posterior tibial tendon/variant soft tissue accessory navicular disorder
Surgical Procedure(s):
#1 left medial displacement calcaneal osteotomy with internal fixation
#2 left modified Kidner-posterior tibial tendon debridement and advancement
#3 left posterior tib tendon sheath synovectomy
CPT: 28300, 28238, 28232
Anesthesia: General
Estimated Blood Loss: Minimal
Surgical Technique: The patient was taken the operating room where general anesthesia was performed. He was placed in right lateral decubitus position on a beanbag roll with an axillary roll placed. The left lower extremity was prepped and draped in usual sterile fashion and a prophylactic dose of IV antibiotic was administered. An oblique incision under tourniquet control with the left thigh was carried out over the left hindfoot from a lateral approach. Intraoperative fluoroscopy was used to help guide placement of the approach. Dissection proceeded down to the lateral calcaneus. A sagittal saw was used to perform a coronal osteotomy. A medial displacement of the posterior aspect of the calcaneus was carried out using manual technique. After displacement approximately 3/8-inch, a fixation pin was used to fix this displacement and position followed by careful posterior counterincision over the calcaneus with placement of a 2.8 mm drill followed by a larger drill bit for subsequent placement of a 55 mm partially-threaded cancellous screw. Excellent fixation was achieved with appropriate placement of the screw verified radiographically and grossly. The osteotomy site was firmly held in position and the remaining fixation pin removed. The wound laterally was then irrigated and closed in a layer manner. At this point, the patient was repositioned in a more of a supine alignment. This allowed for access to the medial ankle and posterior tibial tendon. A 15 cm extensile incision was made. Dissection. Down carefully through subcutaneus tissues to identify the posterior tibial tendon sheath which was opened. It revealed gross synovitis over the course of a 5 cm area. The tendon itself was intact but deficient consistant with variant-soft tissue accessory navicular disorder. The distal portion of the tendon did not reveal gross accessory bone, but did have tendonosis and cartilaginous changes consistent with an accessory navicular-like disorder. Care was taken to expose the tendon from its navicular insertion as well as investing inferior attachments. It was traced proximally back to the medial malleolus. At this point following the synovectomy using a rongeur, a longitudinal split in the tendon was made and there was evidence of central tendinosis which was excised sharply. The tendon itself was intact but deficient consistant with variant-soft tissue accessory navicular disorder. The distal portion of the tendon did not reveal gross accessory bone, but did have tendonosis and cartilaginous changes consistent with an accessory navicular-like disorder. Following this the decision advancement of the deficient tendon was made. Instead of advancing the tendon at the navicular insertion, a modified advancement was permed to shorten the tendon, just adjacent to the navicular. This allowed for debridement of tendinosis/cartilaginous changes just adjacent to the navicular. A step cut approach was utilized along with excision of the variant /diseased accessory navicular ?like abnormal tissue. Approximately 3/8 inch of the tendon was shortened on each side. The step cut portion of the tendon was then reapproximated using #2 Ethibond suture at each end and then a side-to-side repair was performed using 0 Vicryl suture. Excellent repair was noted with this shortening tenotomy approach. The wound was irrigated followed by closure of the peroneal tendon sheath with 3-0 Vicryl suture on a mattress stitches followed by closure of the skin using interrupted skin staples. After set Marcaine was injected in the wound sites. Tourniquet time was 60 minutes. Blood loss is minimal. The patient's left leg was then placed in a well-padded posterior mold splint carefully inverting the foot to reduce tension across the repair site of the tendon. The patient was awakened and transferred stable to recovery room. There were no locations.
Addendum: 2 views of the left os calcis taken today shows signs of appropriate placement of hardware and alignment of the calcaneus post osteotomy.
Operative Report
Preoperative Diagnosis:
#1 left adult acquired flat foot deformity.
#2 left posterior tibial tendinopathy/synovitis.
ICD: 734, 726.72
Post Operative Diagnosis:
Same with notable synovitis involving the distal portion of the posterior tibial tendon and sheath and chronic insufficiency of posterior tibial tendon/variant soft tissue accessory navicular disorder
Surgical Procedure(s):
#1 left medial displacement calcaneal osteotomy with internal fixation
#2 left modified Kidner-posterior tibial tendon debridement and advancement
#3 left posterior tib tendon sheath synovectomy
CPT: 28300, 28238, 28232
Anesthesia: General
Estimated Blood Loss: Minimal
Surgical Technique: The patient was taken the operating room where general anesthesia was performed. He was placed in right lateral decubitus position on a beanbag roll with an axillary roll placed. The left lower extremity was prepped and draped in usual sterile fashion and a prophylactic dose of IV antibiotic was administered. An oblique incision under tourniquet control with the left thigh was carried out over the left hindfoot from a lateral approach. Intraoperative fluoroscopy was used to help guide placement of the approach. Dissection proceeded down to the lateral calcaneus. A sagittal saw was used to perform a coronal osteotomy. A medial displacement of the posterior aspect of the calcaneus was carried out using manual technique. After displacement approximately 3/8-inch, a fixation pin was used to fix this displacement and position followed by careful posterior counterincision over the calcaneus with placement of a 2.8 mm drill followed by a larger drill bit for subsequent placement of a 55 mm partially-threaded cancellous screw. Excellent fixation was achieved with appropriate placement of the screw verified radiographically and grossly. The osteotomy site was firmly held in position and the remaining fixation pin removed. The wound laterally was then irrigated and closed in a layer manner. At this point, the patient was repositioned in a more of a supine alignment. This allowed for access to the medial ankle and posterior tibial tendon. A 15 cm extensile incision was made. Dissection. Down carefully through subcutaneus tissues to identify the posterior tibial tendon sheath which was opened. It revealed gross synovitis over the course of a 5 cm area. The tendon itself was intact but deficient consistant with variant-soft tissue accessory navicular disorder. The distal portion of the tendon did not reveal gross accessory bone, but did have tendonosis and cartilaginous changes consistent with an accessory navicular-like disorder. Care was taken to expose the tendon from its navicular insertion as well as investing inferior attachments. It was traced proximally back to the medial malleolus. At this point following the synovectomy using a rongeur, a longitudinal split in the tendon was made and there was evidence of central tendinosis which was excised sharply. The tendon itself was intact but deficient consistant with variant-soft tissue accessory navicular disorder. The distal portion of the tendon did not reveal gross accessory bone, but did have tendonosis and cartilaginous changes consistent with an accessory navicular-like disorder. Following this the decision advancement of the deficient tendon was made. Instead of advancing the tendon at the navicular insertion, a modified advancement was permed to shorten the tendon, just adjacent to the navicular. This allowed for debridement of tendinosis/cartilaginous changes just adjacent to the navicular. A step cut approach was utilized along with excision of the variant /diseased accessory navicular ?like abnormal tissue. Approximately 3/8 inch of the tendon was shortened on each side. The step cut portion of the tendon was then reapproximated using #2 Ethibond suture at each end and then a side-to-side repair was performed using 0 Vicryl suture. Excellent repair was noted with this shortening tenotomy approach. The wound was irrigated followed by closure of the peroneal tendon sheath with 3-0 Vicryl suture on a mattress stitches followed by closure of the skin using interrupted skin staples. After set Marcaine was injected in the wound sites. Tourniquet time was 60 minutes. Blood loss is minimal. The patient's left leg was then placed in a well-padded posterior mold splint carefully inverting the foot to reduce tension across the repair site of the tendon. The patient was awakened and transferred stable to recovery room. There were no locations.
Addendum: 2 views of the left os calcis taken today shows signs of appropriate placement of hardware and alignment of the calcaneus post osteotomy.