Hello! I am having trouble with an coding an op report. Hoping someone will please give advice!!
Pre Dx: End-stage osteoarthritis, first metatarsophalangeal joint of left foot
Post Dx: same
Procedure: Arthroplasty of the first metatarsophalangeal joint, left foot
An incision was created over the dorsal medial aspect of the first metatarsophalangeal joint and was carried down through subcutaneous tissues bluntly. A medial capsulotomy was created exposing the proximal aspect of the proximal phalanx of the left great toe and the distal aspect of the first metatarsal on the left foot. A ball and cup arthroplasty was created. Significant joint crepitus was encountered prior to spur removal and joint reshaping. Significant decrease in regards to the patient's crepitance with passive range of motion of the first metatarsophalangeal joint of the left foot was encountered. The wound was copiously irrigated. Bone wax was placed over the exposed cancellous bone surfaces. The wound was copiously irrigated. Medical capsulotomy was reapproximated with 2-0 running Vicryl sutures. Skin was reapproximated with 5-0 nylon suture in a running horizontal mattress fashion. Sterile dressing was applied. The patient was transported to the recovery room in stable condition. Local anesthetic was injected into the incision site prior to dressing application for postoperative pain management. Sponge and needle counts remained correct throughout the case. Estimated blood loss was minimal.
I keep questioning myself on this case. I truly appreciate all help. THANKS!
Pre Dx: End-stage osteoarthritis, first metatarsophalangeal joint of left foot
Post Dx: same
Procedure: Arthroplasty of the first metatarsophalangeal joint, left foot
An incision was created over the dorsal medial aspect of the first metatarsophalangeal joint and was carried down through subcutaneous tissues bluntly. A medial capsulotomy was created exposing the proximal aspect of the proximal phalanx of the left great toe and the distal aspect of the first metatarsal on the left foot. A ball and cup arthroplasty was created. Significant joint crepitus was encountered prior to spur removal and joint reshaping. Significant decrease in regards to the patient's crepitance with passive range of motion of the first metatarsophalangeal joint of the left foot was encountered. The wound was copiously irrigated. Bone wax was placed over the exposed cancellous bone surfaces. The wound was copiously irrigated. Medical capsulotomy was reapproximated with 2-0 running Vicryl sutures. Skin was reapproximated with 5-0 nylon suture in a running horizontal mattress fashion. Sterile dressing was applied. The patient was transported to the recovery room in stable condition. Local anesthetic was injected into the incision site prior to dressing application for postoperative pain management. Sponge and needle counts remained correct throughout the case. Estimated blood loss was minimal.
I keep questioning myself on this case. I truly appreciate all help. THANKS!