Hello everyone!
I have a really tough time coding for feet and need some assistance on the below op report. I was thinking of using codes 28270 for each MTP joint but not sure what to use for the tendon transfers? I believe the tenotomies would be inclusive, any assistance would be appreciated.
Procedure
Date: 1/18/2023.
Confirmed: patient, procedure, side, site, safety procedures followed.
Type of procedure:
1. Right foot dorsal metatarsophalangeal joint capsulotomy of toes 1–5
2. Right flexor to extensor tendon transfer of toes 2–4
3. Right extensor hallucis longus tendon Z-lengthening
4. Pinning of right toes 1–2
5. Extensor and flexor tenotomies of right fifth toe
6. Right extensor tendon tenolysis of the extensor hallucis longus tendon.
Description of procedure
Patient was met in the preoperative holding area and his operative extremity was marked by the surgical team. He was
then taken to the operating room and placed on the operating table in the supine position. Preoperative antibiotics
and anesthesia were administered by the anesthesia team. A thigh tourniquet was placed on the operative
extremity. The operative extremity was prepped and draped in standard sterile fashion. A final timeout was then
performed identifying the correct patient, operative extremity. An operative procedure. The Esmarch bandage was
used to exsanguinate the limb and the thigh tourniquet was elevated to 300 mmHg. We first made a longitudinal
dorsal incision centered over the great toe extending into his existing surgical scar. However at this point he began
to bleed through his tourniquet therefore at that time we decided to let the thigh tourniquet down and switch to a calf
tourniquet set at 250 mmHg. Once we inflated the Tourniquet we then proceeded with our dissection down to the
extensor hallucis longus tendon. We found that it was significantly scarred down and we performed a tenolysis
freeing up all the scar tissue so that there was good excursion. We found that the great toe MTP joint was dorsally
dislocated therefore we took down the dorsal metatarsophalangeal joint and excised a significant amount of scar
tissue. Once all the scar tissue was taken down we attempted to reduce the MTP joint however 1 were unable to
due to the EHL tendon. Therefore at this time we performed a Z-lengthening tenotomy of the EHL tendon. We were
then able to reduce the MTP joint. However we decided not to pain at this point as we wanted to proceed with the
other toes first.
Next we then moved to the second toe. We were able to access the second toe MTP joint through our existing
incision. Once again we found that the second MTP joint was completely dorsally dislocated and we had to take
down the dorsal capsule of the second MTP joint excising a severe amount of tissue and taken down the collateral
ligaments. The extensor tendon of the second toe was then identified and was also found to be significantly scarred
down. Rather than attempt to perform a tenolysis we performed a tenotomy as part of our flexor to extensor tendon
transfer anyway. With this we then used McGlamry in order to reduce the second toe. We made a separate medial
incision on the second toe at the level of the proximal phalanx. The brevis flexor tendons were transected and
excised. A slit was made in the distal stump of the extensor tendon and the FHL tendon of the second toe was then
transferred to the dorsum of the second toe and tenodesed using a 3-0 Vicryl to the extensor tendon.
We then moved onto the third fourth and fifth toes. For the third and fourth toes we made a curvilinear incision which
started approximately over the MTP joint and curved to the lateral aspects of the toes to the level of the proximal
phalanx. The third and fourth MTP joints were also dorsally subluxed. Dorsal capsulotomies were performed of the
MTP joints and significant scar tissue was excised and the collateral ligaments were taken down. Extensor
tenotomies were performed at the level of the MTP joint as well. A McGlamery tool was used to reduce the MTP
joints. On the lateral incisions at the level of the proximal phalanges, we excised the FDB tendon slips of each and
transected the FDL tendons and similar to the second toe we transfer them through a slit in the extensor tendon
distal stump and tenodesed them using 3-0 Vicryl.
For the fifth toe once again a curvilinear incision was made approximately starting at the MTP joint curving to the lateral
aspect of the proximal phalanx. Rather than performing a tendon transfer we simply performed a dorsal MTP joint
capsulotomy excising scar tissue and taken down the collateral ligaments and performing an extensor tenotomy as
well as tenotomy of the FDB and FDL tendons. A McGlamery toe was used to reduce the MTP joint. An iatrogenic
OCD lesion about 1 x 2 mm was made while using the McClamary and a 0.045 K wire was used to perform a
microfracture of the fifth metatarsal head.
Once all the MTP joints were reduced and the flexor and extensor tenotomy's or transfers were completed we then at
this point pin the first and second toes as they were the most deviated and would not stay reduced by itself. A
0.062 K wire was inserted at the tip of the great toe and fired into the first metatarsal this held the reduction well.
Similarly 0.062 K wire was introduced into the tip of the second toe and fired into the second metatarsal head as
well. At this point we then repaired our EHL Z-lengthening using 2-0 FiberWire. Final three-view x-ray of the right
foot was taken in order to confirm appropriate reduction and placement of our pins.
At this point the 2 K wires were cut and bent and wire caps were placed. Tourniquet was let down and all the toes
were observed to pink up appropriately. The second toe took some time as it was the most dislocated however once
we let the foot down to gravity and poured warm saline over the foot the toe pinked up. The incisions were copiously
irrigated and we closed in a layered fashion using 3-0 Vicryl and 3-0 nylon and staples. He was placed into a soft
dressing. All counts were correct at the end the case. Local anesthetic was injected for pain control. He was
awoke from anesthesia and taken to the PACU in stable condition..
I have a really tough time coding for feet and need some assistance on the below op report. I was thinking of using codes 28270 for each MTP joint but not sure what to use for the tendon transfers? I believe the tenotomies would be inclusive, any assistance would be appreciated.
Procedure
Date: 1/18/2023.
Confirmed: patient, procedure, side, site, safety procedures followed.
Type of procedure:
1. Right foot dorsal metatarsophalangeal joint capsulotomy of toes 1–5
2. Right flexor to extensor tendon transfer of toes 2–4
3. Right extensor hallucis longus tendon Z-lengthening
4. Pinning of right toes 1–2
5. Extensor and flexor tenotomies of right fifth toe
6. Right extensor tendon tenolysis of the extensor hallucis longus tendon.
Description of procedure
Patient was met in the preoperative holding area and his operative extremity was marked by the surgical team. He was
then taken to the operating room and placed on the operating table in the supine position. Preoperative antibiotics
and anesthesia were administered by the anesthesia team. A thigh tourniquet was placed on the operative
extremity. The operative extremity was prepped and draped in standard sterile fashion. A final timeout was then
performed identifying the correct patient, operative extremity. An operative procedure. The Esmarch bandage was
used to exsanguinate the limb and the thigh tourniquet was elevated to 300 mmHg. We first made a longitudinal
dorsal incision centered over the great toe extending into his existing surgical scar. However at this point he began
to bleed through his tourniquet therefore at that time we decided to let the thigh tourniquet down and switch to a calf
tourniquet set at 250 mmHg. Once we inflated the Tourniquet we then proceeded with our dissection down to the
extensor hallucis longus tendon. We found that it was significantly scarred down and we performed a tenolysis
freeing up all the scar tissue so that there was good excursion. We found that the great toe MTP joint was dorsally
dislocated therefore we took down the dorsal metatarsophalangeal joint and excised a significant amount of scar
tissue. Once all the scar tissue was taken down we attempted to reduce the MTP joint however 1 were unable to
due to the EHL tendon. Therefore at this time we performed a Z-lengthening tenotomy of the EHL tendon. We were
then able to reduce the MTP joint. However we decided not to pain at this point as we wanted to proceed with the
other toes first.
Next we then moved to the second toe. We were able to access the second toe MTP joint through our existing
incision. Once again we found that the second MTP joint was completely dorsally dislocated and we had to take
down the dorsal capsule of the second MTP joint excising a severe amount of tissue and taken down the collateral
ligaments. The extensor tendon of the second toe was then identified and was also found to be significantly scarred
down. Rather than attempt to perform a tenolysis we performed a tenotomy as part of our flexor to extensor tendon
transfer anyway. With this we then used McGlamry in order to reduce the second toe. We made a separate medial
incision on the second toe at the level of the proximal phalanx. The brevis flexor tendons were transected and
excised. A slit was made in the distal stump of the extensor tendon and the FHL tendon of the second toe was then
transferred to the dorsum of the second toe and tenodesed using a 3-0 Vicryl to the extensor tendon.
We then moved onto the third fourth and fifth toes. For the third and fourth toes we made a curvilinear incision which
started approximately over the MTP joint and curved to the lateral aspects of the toes to the level of the proximal
phalanx. The third and fourth MTP joints were also dorsally subluxed. Dorsal capsulotomies were performed of the
MTP joints and significant scar tissue was excised and the collateral ligaments were taken down. Extensor
tenotomies were performed at the level of the MTP joint as well. A McGlamery tool was used to reduce the MTP
joints. On the lateral incisions at the level of the proximal phalanges, we excised the FDB tendon slips of each and
transected the FDL tendons and similar to the second toe we transfer them through a slit in the extensor tendon
distal stump and tenodesed them using 3-0 Vicryl.
For the fifth toe once again a curvilinear incision was made approximately starting at the MTP joint curving to the lateral
aspect of the proximal phalanx. Rather than performing a tendon transfer we simply performed a dorsal MTP joint
capsulotomy excising scar tissue and taken down the collateral ligaments and performing an extensor tenotomy as
well as tenotomy of the FDB and FDL tendons. A McGlamery toe was used to reduce the MTP joint. An iatrogenic
OCD lesion about 1 x 2 mm was made while using the McClamary and a 0.045 K wire was used to perform a
microfracture of the fifth metatarsal head.
Once all the MTP joints were reduced and the flexor and extensor tenotomy's or transfers were completed we then at
this point pin the first and second toes as they were the most deviated and would not stay reduced by itself. A
0.062 K wire was inserted at the tip of the great toe and fired into the first metatarsal this held the reduction well.
Similarly 0.062 K wire was introduced into the tip of the second toe and fired into the second metatarsal head as
well. At this point we then repaired our EHL Z-lengthening using 2-0 FiberWire. Final three-view x-ray of the right
foot was taken in order to confirm appropriate reduction and placement of our pins.
At this point the 2 K wires were cut and bent and wire caps were placed. Tourniquet was let down and all the toes
were observed to pink up appropriately. The second toe took some time as it was the most dislocated however once
we let the foot down to gravity and poured warm saline over the foot the toe pinked up. The incisions were copiously
irrigated and we closed in a layered fashion using 3-0 Vicryl and 3-0 nylon and staples. He was placed into a soft
dressing. All counts were correct at the end the case. Local anesthetic was injected for pain control. He was
awoke from anesthesia and taken to the PACU in stable condition..
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