Question femoral nail removal with revision one component total knee


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Hi, I'm really hoping someone one here has seen this situation before. The patient has a retained femoral nail that needs to be removed in order to have a total hip replacement. One surgeon took her to the OR, but could not remove the nail via the hip. Another surgeon took her to the OR to remove the femoral nail. In order to do this, he had to remove the femoral component of the patient's total knee to be able to access the nail. He removed the nail and then replaced the femoral component with new parts. The surgeon wants to bill 27486 and 20680.

I am unsure if I can bill for the partial knee revision.

Pre-Op Diagnosis: Retained femoral nail right femur, right total knee arthroplasty, severe right hip degenerative joint disease

Post-Op Diagnosis: Retained femoral nail right femur, right total knee arthroplasty, severe right hip degenerative joint disease   


The patient was identified preoperatively where consent was obtained, placed on the chart.  The procedure was described.  The patient's questions were answered.  All details of the procedure, as well as risks, benefits and alternatives, including the option of non operative versus operative treatment were discussed.  The patient understands that risks of the surgery include but are not limited to: bleeding, malunion/nonunion, loss of fixation, loss of reduction, hardware failure, angular or rotational deformity, length discrepancy, limp, transfusion, skin blistering or breakdown, progressive post traumatic degenerative joint disease, possible need for further surgery, bone grafting, infection, nerve injury, paralysis, numbness, blood vessel injury, excessive scaring, wound complication or breakdown, failure of symptoms to improve or actual deterioration in condition, significant acute and/or chronic pain, possible need for amputation, permanent loss of motion, and permanent loss of function.  As well as the general complications of anesthesia, which include but are not limited to: myocardial infarction and/or heart attack, stroke, multi organ system failure or even possible death, prolonged hospital stay, blood clots, pulmonary embolism, abnormal reaction to and osteotomes ileus and mental status changes.  No guarantees were made.

A regional block to the right lower extremity was affected in the preoperative holding area by the anesthesia team.  Patient was then taken the operative theater she was placed upon upon the operative table and general anesthesia was affected.  Preoperative antibiotic was given IV as well as 1 g of IV tranexamic acid being given IV just prior to the incision and a second 1 g aliquot being administered just after closure of incision.  The right lower extremity was then prepped and draped in a sterile fashion.

After an appropriate surgical timeout incision was made over the previous anterior knee midline scar.  Sharp incision was carried through the skin and subcutaneous tissue.  Full-thickness skin flaps were raised over the extensor mechanism and a medial parapatellar arthrotomy was affected to the knee.  A complete synovectomy was affected.  Subperiosteal dissection was made over the proximal medial tibia to the posterior medial corner.  The tibial component was noted to be well fixed.  Patella was placed in the lateral gutter and retractors were placed to protect the collateral ligaments.  The knee was flexed.  Attention was drawn to removal of the femoral nail which could not be attained with the femoral component in place.  As a result the femoral component was removed carefully using curettes, small and large sawblades, and osteotomes.  The femoral component was removed with just a little bit of the anterior bone being removed and overtly with a femoral component.  Attention was then drawn to removing the femoral nail which could be visualized superior laterally.  A extraction device was connected to the nail and the nail was removed after multiple slaphammer flaps.  Fluoroscopic imagery showed no fractures of the femur.  Attention was then drawn to revision of the femoral component.  All bony cuts were freshened.  Reaming of the femoral canal was affected to the appropriately sized reamer.  A trial femoral component was then put in place after preparation of the distal femoral metaphysis with a for a small cone.  Once the trial was in place it was noted that an offset stem would be needed and this was placed and impacted till fully seated the knee was then put through range of motion with a trial polyethylene liner in place.  Attenuation of the medial collateral ligament made it so that the best implant choice was a constrained implant.

The trials were then removed.  The bony cuts were thoroughly irrigated and suctioned.  The femoral component was assembled on the back table.  The implantable metaphyseal cone for the distal femur was then placed and impacted till fully seated.  2 bags of cement were mixed on the back table and cement was pressurized along the backside of the femoral component as well as the bony femoral cut which was thoroughly irrigated, suctioned and dried.  The implantable femoral component was then placed and impacted till fully seated.  Marginal cement was removed from the periphery of the implant and a trial polyethylene liner was placed and the knee was put in full extension until the cement fully polymerized.  The trial was then removed and the implantable constrained liner was placed and impacted till fully seated and the screw for the constrained liner was engaged

The knee was put through range of motion and felt was found to be stable throughout the arc of range of motion.

The knee was then thoroughly irrigated and suction.  1/2 L of irrisept irrigation was placed within the knee for 90 seconds and then suctioned.  Final fluoroscopic images were taken and saved to the full length of the femur showing the implant in good position without complications.  The medial parapatellar arthrotomy was closed using absorbable suture as was the subcutaneous tissue.  A running subcuticular strata fix suture was utilized for subcuticular closure.  Dermabond was used cutaneously.  Sterile dressing was applied.  Anesthesia was reversed.  Patient was taken to postop recovery room in stable condition.  There were no immediate postoperative complications and the procedure was tolerated well.​

Thanks in advance!