dsibley67
Networker
I need help verifying that I haven't missed anything. I have read this op note several times. I am thinking the code should be 28086, straight synovectomy. Originally, I had 27658, 28086, & 28261. After reading the description of the codes and the op note, I feel the best code is 28086. If you can review and verify that I haven't missed anything, I would greatly appreciate it. Thanks!!
1. Repair posterior tibial tendon.
2. Tenosynovectomy.
3. Repair flexor retinaculum and posterior tib tendon sheath.
4. FDL tenosynovectomy.
5. TN join capsule repair
The patient was identified and placed on the treatment table in supine
position. Following general endotracheal intubation, right foot was scrubbed, prepped and draped in usual
aseptic manner. Right thigh tourniquet placed on the right thigh. The patient's right thigh tourniquet
inflated to 250 mmHg. Attention was directed to the posterior tibialis tendon over the medial portion of the
tibia. Linear incision placed over that area. Blunt dissection was carried down to the posterior tib tendon
sheath. Posterior tib tendon sheath was then opened and upon opening, rhe patient had tenosynovium,
fatty infiltration and infiltration the skin on the posterior tib tendon sheath that was removed and cleaned
from proximal to distal. We did make an incision all the way to insertion at the medial navicular. There
was no tear behind the tendon or on the tendon itself. We took the tendon proximal past the medial
malleolus where there were no evidence of the tendon being torn. It was, however full of tenosynovium
or fatty infiltration of the sheath. Upon debriding the sheath, there were two notable locations, one at the
posterior to the malleable groove where the posterior tib course. There was a moderate-to-severe
dimpling of the sheath as it attached to the posterior wall of the tibia. It seemed loose almost as if a blunt
trauma had occurred and stretched or tore that side. It was essentially like a wrinkle in a carpet where
wrinkle in a towel for example. That was examined, excised and then sutured back together to create a
smooth firm gliding surface. We used 2-0 Vicryl with hidden stitch to pull back tightly back together.
There was another side at the medial talonavicular joint, moved like early tearing of the medial
talonavicular joint behind the posterior tib tendon. It was similar in its presentation to the other tear. We
debrided that and utilized the Vicryl suture with buried hidden knot to create a smooth gliding surface over
that site as well. The distal one was the larger of the two. Following completion of those repairs, it was
notable remove or clean the posterior tib tendon that there was a hemorrhage in the FDL sheath proximal.
At the proximal incision, we made a small opening in the FDL tendon sheath where immediately there was
bloody fatty infiltrate again around the hemorrhage. We cleaned and washed that out. We released more
of the tendon as we noted that the FDL had a distal excursion of muscle belly that was historically longer
than usually seen, I would consider it peroneal quartus as it went distal, it could have caused some level of
pinching of the FDL and could have also been part of her pain. We then seized the muscle belly off the
FDL tendon proximal to the malleolar groove with the posterior tib tendon to get it completely out of the
potential field. We irrigated with normal sterile saline. The FDL was in perfect condition. The FDL also
had tenosynovitis which was debrided out of the sheath. The patient had what appeared to have proximal
stenosis in the FDL while placing my pinky finger which is proximal on the FDL there was some adhesion
and that was freed bluntly with essentially finger mechanism under pressure. After examination of range
of motion and all bluntly had completed, and repaired what could have possibly caused her chronic pain.
Irrigated extensively with normal sterile saline, closed the posterior tibialis tendon sheath with 2-0 Vicryl.
We closed the subcu tissues with 3-0 Vicryl and the skin closed with 4-0 nylon. Following completion of
procedure, 50 cc of Bupivacaine/Ketorolac were infiltrated in the foot and ankle block.
1. Repair posterior tibial tendon.
2. Tenosynovectomy.
3. Repair flexor retinaculum and posterior tib tendon sheath.
4. FDL tenosynovectomy.
5. TN join capsule repair
The patient was identified and placed on the treatment table in supine
position. Following general endotracheal intubation, right foot was scrubbed, prepped and draped in usual
aseptic manner. Right thigh tourniquet placed on the right thigh. The patient's right thigh tourniquet
inflated to 250 mmHg. Attention was directed to the posterior tibialis tendon over the medial portion of the
tibia. Linear incision placed over that area. Blunt dissection was carried down to the posterior tib tendon
sheath. Posterior tib tendon sheath was then opened and upon opening, rhe patient had tenosynovium,
fatty infiltration and infiltration the skin on the posterior tib tendon sheath that was removed and cleaned
from proximal to distal. We did make an incision all the way to insertion at the medial navicular. There
was no tear behind the tendon or on the tendon itself. We took the tendon proximal past the medial
malleolus where there were no evidence of the tendon being torn. It was, however full of tenosynovium
or fatty infiltration of the sheath. Upon debriding the sheath, there were two notable locations, one at the
posterior to the malleable groove where the posterior tib course. There was a moderate-to-severe
dimpling of the sheath as it attached to the posterior wall of the tibia. It seemed loose almost as if a blunt
trauma had occurred and stretched or tore that side. It was essentially like a wrinkle in a carpet where
wrinkle in a towel for example. That was examined, excised and then sutured back together to create a
smooth firm gliding surface. We used 2-0 Vicryl with hidden stitch to pull back tightly back together.
There was another side at the medial talonavicular joint, moved like early tearing of the medial
talonavicular joint behind the posterior tib tendon. It was similar in its presentation to the other tear. We
debrided that and utilized the Vicryl suture with buried hidden knot to create a smooth gliding surface over
that site as well. The distal one was the larger of the two. Following completion of those repairs, it was
notable remove or clean the posterior tib tendon that there was a hemorrhage in the FDL sheath proximal.
At the proximal incision, we made a small opening in the FDL tendon sheath where immediately there was
bloody fatty infiltrate again around the hemorrhage. We cleaned and washed that out. We released more
of the tendon as we noted that the FDL had a distal excursion of muscle belly that was historically longer
than usually seen, I would consider it peroneal quartus as it went distal, it could have caused some level of
pinching of the FDL and could have also been part of her pain. We then seized the muscle belly off the
FDL tendon proximal to the malleolar groove with the posterior tib tendon to get it completely out of the
potential field. We irrigated with normal sterile saline. The FDL was in perfect condition. The FDL also
had tenosynovitis which was debrided out of the sheath. The patient had what appeared to have proximal
stenosis in the FDL while placing my pinky finger which is proximal on the FDL there was some adhesion
and that was freed bluntly with essentially finger mechanism under pressure. After examination of range
of motion and all bluntly had completed, and repaired what could have possibly caused her chronic pain.
Irrigated extensively with normal sterile saline, closed the posterior tibialis tendon sheath with 2-0 Vicryl.
We closed the subcu tissues with 3-0 Vicryl and the skin closed with 4-0 nylon. Following completion of
procedure, 50 cc of Bupivacaine/Ketorolac were infiltrated in the foot and ankle block.