mariana30
New
Good morning ortho coders, would you please help me with this rather complex question, a Physician performed a revision of the left hip and open reduction, internal fixation of a left femoral shaft fracture treated with cerclage cables.
PROCEDURE
Revision of the left hip and open reduction, internal fixation of
a left femoral shaft fracture treated with cerclage cables.
FINDINGS
A loose stem and a periprosthetic fracture extending roughly to
the level of the isthmus of her femoral shaft.
IMPLANTS USED
Three Dall-Miles cable and sleeve sets. We used an R3 cross-link
polyethylene liner. We used a Wagner SL Revision stem, 15 x 305.
We used a 36, +3.5 cobalt chrome femoral head. We used a fourth
Dall-Miles cable.
INDICATION
The patient is a 55-year-old female who presented through our
emergency room as a transfer with a fall and a periprosthetic
fracture of her left femur. Based upon her radiographs, it
appeared that her stem may have subsided and was loose and led to
the fracture. Preoperatively, we assessed this and we discussed
risks, benefits, and alternatives of open reduction and internal
fixation versus revision surgery. If the implant was loose, we
would revise it. I discussed that with her in detail
preoperatively. Again, all risks, benefits, and alternatives
were discussed. Informed consent was obtained, as was medical
clearance, and there were no contraindications for the surgery
today.
TECHNIQUE
On March 5, 2013, the patient was identified in the holding area
and taken to the operating room. After perioperative antibiotics
were administered, the patient was given a general anesthetic.
She was then laid supine on the operating room table. We then
placed Foley catheter. She was positioned in lateral decubitus
position with her left hip facing up. All bony prominences on
the right side were well padded. Again, we affixed her pelvis to
the table using our pelvic clamps. We then sterilely prepped and
draped the left lower extremity in standard surgical fashion. At
this point in time, a time-out was called and it was noted that
the left side was the appropriate side for the surgery and we
were allowed to proceed. We then effected an incision over the
previous surgical scar, extending it proximally and distally
using a #10 blade in the dermal and epidermal layers and
subcutaneous tissue. We got to the level of the deep fascia.
The deep fascia was then incised in line with our incision. At
this point time, we then identified the hip capsule. We elevated
this as a single sleeve of tissue with the scar tissue and short
external rotators and reflected it posteriorly. This gave us
good visualization of the hip joint and protection of our sciatic
nerve. We then entered the hip joint and dislocated the hip with
flexion, adduction, and internal rotation. We also elevated the
vastus lateralis off the intermuscular septum so that we could
see our fracture. We then placed the extractor handle on the
femur. With a few taps, the femoral stem came out quite easily.
Once this was done, we then successfully debrided the canal of
the femur using flexible reamers and placed a cable distal to the
fracture site. We obtained good exposure with this. We removed
our polyethylene liner and placed a trial liner. At this point
in time, we then again irrigated the wound with pulsatile lavage
and waited for our cell count to come back, which came back at
950 white blood cells which was negative for infection, less than
10,000 red cells, 5 segs, 14 lymphocytes, and 81 large monocytes.
Again, this was negative for infection. Frozen section was
negative. We went for reimplantation at this time. We then used
our tapered reamers up to a size 15 x 305, which gave us good
purchase into the distal segment. We then trialed with this and
used a +3.5, 36 mm head. We noted we had excellent range of
motion and good stability. At this point in time, we then
removed our trial implants, irrigated the wound with pulsatile
lavage, and placed our 15 x 305 stem into the femoral canal.
Once this was fully seated, just prior to it being fully seated,
we did reduced our fracture and cabled it. We then seated our
implant completely. We then did tighten our cables sequentially
and passed a third cable proximally. We tightened this as well.
Once it was fully tightened, we irrigated the wound with
pulsatile lavage. We trialed with a +3.5 head and noted we had
excellent range of motion and good stability. We then inserted
our final size 36 mm diameter cross-link polyethylene liner for
Smith Nephew R3 shell and placed our 36 head on the end of the
stem. We impacted our 36, +3.5 head once the Morse taper was
engaged. We reduced the hip and noted we had excellent range of
motion, good stability, and no impingement. At this point in
time, we then placed our Grafton putty into the fracture site to
bridge any gaps that we might have had and closed our deep vastus
lateralis with #1 Vicryl in interrupted, figure-of-eight fashion
and then closed our deep fascia with #2 Quill in a running
fashion over a drain. We closed our deep tissues in a couple of
layers using 2-0 Vicryl in interrupted, inverted fashion. Skin
edges approximated using staples and a sterile dressing was
placed. Our drain deep to the fascia was hooked up to suction.
We then, again, placed a sterile dressing. The patient had all
needle and sponge counts correct in the operating room prior to
leaving. The patient was aroused in the operating room and taken
to the recovery room in stable condition.
The codes chosen where: 27138, 27248, Dx 996.41 and 996.44. Is there any articles out there that talks about total arthroplasties and fracture care?
Thanks a million
Mariana
PROCEDURE
Revision of the left hip and open reduction, internal fixation of
a left femoral shaft fracture treated with cerclage cables.
FINDINGS
A loose stem and a periprosthetic fracture extending roughly to
the level of the isthmus of her femoral shaft.
IMPLANTS USED
Three Dall-Miles cable and sleeve sets. We used an R3 cross-link
polyethylene liner. We used a Wagner SL Revision stem, 15 x 305.
We used a 36, +3.5 cobalt chrome femoral head. We used a fourth
Dall-Miles cable.
INDICATION
The patient is a 55-year-old female who presented through our
emergency room as a transfer with a fall and a periprosthetic
fracture of her left femur. Based upon her radiographs, it
appeared that her stem may have subsided and was loose and led to
the fracture. Preoperatively, we assessed this and we discussed
risks, benefits, and alternatives of open reduction and internal
fixation versus revision surgery. If the implant was loose, we
would revise it. I discussed that with her in detail
preoperatively. Again, all risks, benefits, and alternatives
were discussed. Informed consent was obtained, as was medical
clearance, and there were no contraindications for the surgery
today.
TECHNIQUE
On March 5, 2013, the patient was identified in the holding area
and taken to the operating room. After perioperative antibiotics
were administered, the patient was given a general anesthetic.
She was then laid supine on the operating room table. We then
placed Foley catheter. She was positioned in lateral decubitus
position with her left hip facing up. All bony prominences on
the right side were well padded. Again, we affixed her pelvis to
the table using our pelvic clamps. We then sterilely prepped and
draped the left lower extremity in standard surgical fashion. At
this point in time, a time-out was called and it was noted that
the left side was the appropriate side for the surgery and we
were allowed to proceed. We then effected an incision over the
previous surgical scar, extending it proximally and distally
using a #10 blade in the dermal and epidermal layers and
subcutaneous tissue. We got to the level of the deep fascia.
The deep fascia was then incised in line with our incision. At
this point time, we then identified the hip capsule. We elevated
this as a single sleeve of tissue with the scar tissue and short
external rotators and reflected it posteriorly. This gave us
good visualization of the hip joint and protection of our sciatic
nerve. We then entered the hip joint and dislocated the hip with
flexion, adduction, and internal rotation. We also elevated the
vastus lateralis off the intermuscular septum so that we could
see our fracture. We then placed the extractor handle on the
femur. With a few taps, the femoral stem came out quite easily.
Once this was done, we then successfully debrided the canal of
the femur using flexible reamers and placed a cable distal to the
fracture site. We obtained good exposure with this. We removed
our polyethylene liner and placed a trial liner. At this point
in time, we then again irrigated the wound with pulsatile lavage
and waited for our cell count to come back, which came back at
950 white blood cells which was negative for infection, less than
10,000 red cells, 5 segs, 14 lymphocytes, and 81 large monocytes.
Again, this was negative for infection. Frozen section was
negative. We went for reimplantation at this time. We then used
our tapered reamers up to a size 15 x 305, which gave us good
purchase into the distal segment. We then trialed with this and
used a +3.5, 36 mm head. We noted we had excellent range of
motion and good stability. At this point in time, we then
removed our trial implants, irrigated the wound with pulsatile
lavage, and placed our 15 x 305 stem into the femoral canal.
Once this was fully seated, just prior to it being fully seated,
we did reduced our fracture and cabled it. We then seated our
implant completely. We then did tighten our cables sequentially
and passed a third cable proximally. We tightened this as well.
Once it was fully tightened, we irrigated the wound with
pulsatile lavage. We trialed with a +3.5 head and noted we had
excellent range of motion and good stability. We then inserted
our final size 36 mm diameter cross-link polyethylene liner for
Smith Nephew R3 shell and placed our 36 head on the end of the
stem. We impacted our 36, +3.5 head once the Morse taper was
engaged. We reduced the hip and noted we had excellent range of
motion, good stability, and no impingement. At this point in
time, we then placed our Grafton putty into the fracture site to
bridge any gaps that we might have had and closed our deep vastus
lateralis with #1 Vicryl in interrupted, figure-of-eight fashion
and then closed our deep fascia with #2 Quill in a running
fashion over a drain. We closed our deep tissues in a couple of
layers using 2-0 Vicryl in interrupted, inverted fashion. Skin
edges approximated using staples and a sterile dressing was
placed. Our drain deep to the fascia was hooked up to suction.
We then, again, placed a sterile dressing. The patient had all
needle and sponge counts correct in the operating room prior to
leaving. The patient was aroused in the operating room and taken
to the recovery room in stable condition.
The codes chosen where: 27138, 27248, Dx 996.41 and 996.44. Is there any articles out there that talks about total arthroplasties and fracture care?
Thanks a million
Mariana