kkindle1807
Contributor
Can someone please assist with coding this shoulder surgery. Physician supplied codes 23335, 23470, 20680 but 23335 & 23470 bundle.
Patient is going on 3rd surgery after TSA and a 2nd surgery for infection
Op report reads as follows:
Utilized prior deltopectoral incision and incised with scalpel. Distally, I did excise the area of very unhealthy skin. Then encountered dishwater appearing purulence, this was sent for culture. I then irrigated this layer. Then opened up the deltopectoral interval vanc again. I removed all previous sutures. Immediately it was very clear that patient had already developed quite a bit of scar tissue in the subdeltoid space and within glenohumeral joint. This was all loosened bluntly.
Then utilized a bone hook to dislocate shoulder. Axillary nerve palpated inferiorly and protected throughout. Retractors were placed. I then removed the polyethylene. I then once again irrigated. I then attempted to remove the stem which was well fixed. I then utilized a flexible osteotome, I utilized the osteotome around the metaphyseal portion of the stem, I then attached the stem inserter from DJO, and I was able to back slap this relatively easily without all that much trauma. I sent a culture from within humerus.
I then removed the glenosphere. I removed the screws from the baseplate. The baseplate was well fixed still. Therefore, utilized the flexible osteotome to break loose the on growth, I was then able to easily remove the baseplate.
I then proceeded on with a thorough debridement. I utilized rongeur, curette and Cobb to debride unhealthy soft tissue and bone from within humeral canal, proximal humerus, baseplate and the screw tracts. I think irrigated with saline. I then placed a trial hemiarthroplasty as I transitioned to work on acromial side.
I then incised previous ORIF incision, the draining sinus tract was excised. I then once again encountered purulence, sent for culture. I then removed the plate and 2 screws. I debrided bone from underneath the plate and sent this for culture. Incision and tissues were once again debrided with rongeur, curette & Cobb to get back to healthy tissue. Sutures removed once more.
I determined that the trial implant matching the final size was stable without dislocation with external rotation to 30 degrees and forward elevation to 90, patient significant stiffness did not allow me to forward elevate more than this. I then removed the trial implant and performed thorough irrigation with 3L saline, Bactisure then another 3L saline via Pulsavac throughout both wounds.
I then proceeded on with final implant. I chose a size 6 DJO Turon stem and size 54x26 neutral humeral hemiarthroplasty head and assembled this on the back table. I did utilize fresh retractors after the thorough irrigation. I then made an antibiotic spacer that was functional. I utilized 1 batch of medium viscosity cement and mixed 3g of Vancomycin and 2.4g of Tobramycin with this, mixed in bowl. This allowed me to coat the stem and the metaphyseal region and I inserted the stem so that the top of the humeral head was approximately 5.5cm superior to the superior edge of the pectoralis major, I put this in 30 degree retroversion. I then placed in this up and down as the cement was drying to allow this to match the contour of the remaining proximal humerus and once it was nearly dried I held this in place. I then once more reduced the shoulder and it was stable throughout range of motion with no dislocation.
I then once more irrigated both wounds with IrriSept followed by Pulsavac saline. I then placed a medium Hemovac drain within the deltopectoral incision. Then proceeded with layered closure.
Any help would be greatly appreciated!
Patient is going on 3rd surgery after TSA and a 2nd surgery for infection
Op report reads as follows:
Utilized prior deltopectoral incision and incised with scalpel. Distally, I did excise the area of very unhealthy skin. Then encountered dishwater appearing purulence, this was sent for culture. I then irrigated this layer. Then opened up the deltopectoral interval vanc again. I removed all previous sutures. Immediately it was very clear that patient had already developed quite a bit of scar tissue in the subdeltoid space and within glenohumeral joint. This was all loosened bluntly.
Then utilized a bone hook to dislocate shoulder. Axillary nerve palpated inferiorly and protected throughout. Retractors were placed. I then removed the polyethylene. I then once again irrigated. I then attempted to remove the stem which was well fixed. I then utilized a flexible osteotome, I utilized the osteotome around the metaphyseal portion of the stem, I then attached the stem inserter from DJO, and I was able to back slap this relatively easily without all that much trauma. I sent a culture from within humerus.
I then removed the glenosphere. I removed the screws from the baseplate. The baseplate was well fixed still. Therefore, utilized the flexible osteotome to break loose the on growth, I was then able to easily remove the baseplate.
I then proceeded on with a thorough debridement. I utilized rongeur, curette and Cobb to debride unhealthy soft tissue and bone from within humeral canal, proximal humerus, baseplate and the screw tracts. I think irrigated with saline. I then placed a trial hemiarthroplasty as I transitioned to work on acromial side.
I then incised previous ORIF incision, the draining sinus tract was excised. I then once again encountered purulence, sent for culture. I then removed the plate and 2 screws. I debrided bone from underneath the plate and sent this for culture. Incision and tissues were once again debrided with rongeur, curette & Cobb to get back to healthy tissue. Sutures removed once more.
I determined that the trial implant matching the final size was stable without dislocation with external rotation to 30 degrees and forward elevation to 90, patient significant stiffness did not allow me to forward elevate more than this. I then removed the trial implant and performed thorough irrigation with 3L saline, Bactisure then another 3L saline via Pulsavac throughout both wounds.
I then proceeded on with final implant. I chose a size 6 DJO Turon stem and size 54x26 neutral humeral hemiarthroplasty head and assembled this on the back table. I did utilize fresh retractors after the thorough irrigation. I then made an antibiotic spacer that was functional. I utilized 1 batch of medium viscosity cement and mixed 3g of Vancomycin and 2.4g of Tobramycin with this, mixed in bowl. This allowed me to coat the stem and the metaphyseal region and I inserted the stem so that the top of the humeral head was approximately 5.5cm superior to the superior edge of the pectoralis major, I put this in 30 degree retroversion. I then placed in this up and down as the cement was drying to allow this to match the contour of the remaining proximal humerus and once it was nearly dried I held this in place. I then once more reduced the shoulder and it was stable throughout range of motion with no dislocation.
I then once more irrigated both wounds with IrriSept followed by Pulsavac saline. I then placed a medium Hemovac drain within the deltopectoral incision. Then proceeded with layered closure.
Any help would be greatly appreciated!