Kelly_Josephine
Networker
dx: Camptodactyly - pediatric, long finger contracture
M24.549 & Q74.0
This deformity operative treatment usually comes with tendon lengthening which was not done. I am overwhelmed trying to break this report into steps - so far I see a trigger finger release and flexor tendon transfer without graft - BUT it also looks like maybe arthrodesis of the PIP joint. It was pinned in hyperextension /flexion so fusion does not fit but I feel like I should be coding the fact that the joint was pinned. Here are the codes I keep coming back to:
26485-F2 - (step 3) for resection and reattachment of FDP
Transfer or transplant of tendon, palmar; without free tendon graft, each tendon
14040 - (step 1) this isn't included in 26485, I don't think, and it is not bundled in CCI edits although surgeon did not measure closure.
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
26860-F2 - (step 4) for pinning of PP to MP
Arthrodesis, interphalangeal joint, with or without internal fixation
26055-F2 - (step 2) for release of pulleys A1 & A3
Tendon sheath incision (eg, for trigger finger)
POSTOPERATIVE DIAGNOSIS: Right long finger camptodactyly
ANESTHESIA: General plus 3 cc of 0.5% plain ropivacaine. PROCEDURES:
1. Release of right long finger PIP contracture.
2. Transfer of right long finger FDS tendon to the dorsal extensor hood
OPERATIVE FINDINGS: Consistent with significant improvement in the degree of contracture.
TOTAL TOURNIQUET TIME: Well under 2 hours.
COMPLICATION: None.
SUMMARY: ?After the induction of general anesthesia by member of the staff and anesthesia team, an appropriate procedural time-out was accomplished. The patient was given a single dose of weight-appropriate Ancef. The right hand was then prepped and draped in the usual sterile fashion over a well-padded upper arm tourniquet. The arm was then exsanguinated with gentle pressure and the tourniquet was inflated to 180 mmHg which 1s approximately 100 points above his systolic pressure at that time.
I began with a limited Bruner-type incision over the PIP flexion crease. The neurovascular bundles were identified and bluntly retracted out of the field the entire time. Dissection proceeded down to the flexor tendon sheath where I then opened the A3 pulley. The FOP tendon was then a traumatically retracted out of the wound and in so doing, I felt a distinct release of proximal tethering followed by significant improvement in the play of the tendon. This suggested a potential adhesion or congenital trigger element proximally. I, therefore, extended the Bruner incision more proximally into the palm and released the entire A 1 pulley.
I then placed a gentle traction on the FDS tendon as well until elastic recoil could be appreciated from the proximal muscle belly. I then proceeded to gently manipulate the PIP and DIP Joints into further extension until I could passively extend the MP, PIP, and DIP Joints simultaneously. I did feel significant tension in the FOP tendon in doing so manifested by flexion of the DIP, however, this was still obtainable. Flexion of the MP allowed for more relaxed extension of the PIP and DIP Joints. The patient preoperatively had approximately 60-degree fixed contracture of the PIP Joint both with the MP flexed and extended, and this could not be improved with manipulation alone. This, therefore, dramatically improved after the mentioned steps. I then located the lumbrical tendon through the volar wound and gently placed this under traction.
This did produce some tensioning of the central slip region as well as extension of the DIP Joint indicating an intact extensor hood. However, I was concerned about relative tendon imbalance given the flexor tendon tightness and the overall strength of the flexors relative to the extensors. I, therefore, released the FDS tendon completely off both insertions on the middle phalanx, delivered this back through the proximal A2 pulley where the chiasm was divided.
I then dissected along the lumbrical t tendon into the dorsal soft tissue where a separate longitudinal incision was made over the mid proximal phalanx. The dorsal extensor hood was then exposed and separated from the periosteum. The FDS was then delivered up the radial side of the digit from volar to dorsal following the path of the lumbrical tendon and woven twice through the extensor hood. This was then secured with multiple interrupted 4-0 Ethibond sutures with the MP in approximately 30 degrees of flexion. With tenodesis of these Joints. this appeared to produce a better balance between the extensors and flexors, however. certainly the FOP at least remained somewhat tight.
Given the small tendon in the other directions, I elected not to step cut lengthen the tendon.
A 0.028 K-w1re was then passed proximally through the intercondylar portion of the proximal phalanx head with the joint hyperextended. The Joint was then placed in slight flexion to prevent induced laxity of the volar plate, and the pin was delivered into the middle phalanx base. The pin was left percutaneously coming through the skin proximally where it was cut short and bent.
The tourniquet was then released and hemostasis was achieved with bipolar electrocautery. The wounds were then irrigated and after adequate hemostasis, they are closed with mattress 5-0 chromic. They were then dressed with...
M24.549 & Q74.0
This deformity operative treatment usually comes with tendon lengthening which was not done. I am overwhelmed trying to break this report into steps - so far I see a trigger finger release and flexor tendon transfer without graft - BUT it also looks like maybe arthrodesis of the PIP joint. It was pinned in hyperextension /flexion so fusion does not fit but I feel like I should be coding the fact that the joint was pinned. Here are the codes I keep coming back to:
26485-F2 - (step 3) for resection and reattachment of FDP
Transfer or transplant of tendon, palmar; without free tendon graft, each tendon
14040 - (step 1) this isn't included in 26485, I don't think, and it is not bundled in CCI edits although surgeon did not measure closure.
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
26860-F2 - (step 4) for pinning of PP to MP
Arthrodesis, interphalangeal joint, with or without internal fixation
26055-F2 - (step 2) for release of pulleys A1 & A3
Tendon sheath incision (eg, for trigger finger)
POSTOPERATIVE DIAGNOSIS: Right long finger camptodactyly
ANESTHESIA: General plus 3 cc of 0.5% plain ropivacaine. PROCEDURES:
1. Release of right long finger PIP contracture.
2. Transfer of right long finger FDS tendon to the dorsal extensor hood
OPERATIVE FINDINGS: Consistent with significant improvement in the degree of contracture.
TOTAL TOURNIQUET TIME: Well under 2 hours.
COMPLICATION: None.
SUMMARY: ?After the induction of general anesthesia by member of the staff and anesthesia team, an appropriate procedural time-out was accomplished. The patient was given a single dose of weight-appropriate Ancef. The right hand was then prepped and draped in the usual sterile fashion over a well-padded upper arm tourniquet. The arm was then exsanguinated with gentle pressure and the tourniquet was inflated to 180 mmHg which 1s approximately 100 points above his systolic pressure at that time.
I began with a limited Bruner-type incision over the PIP flexion crease. The neurovascular bundles were identified and bluntly retracted out of the field the entire time. Dissection proceeded down to the flexor tendon sheath where I then opened the A3 pulley. The FOP tendon was then a traumatically retracted out of the wound and in so doing, I felt a distinct release of proximal tethering followed by significant improvement in the play of the tendon. This suggested a potential adhesion or congenital trigger element proximally. I, therefore, extended the Bruner incision more proximally into the palm and released the entire A 1 pulley.
I then placed a gentle traction on the FDS tendon as well until elastic recoil could be appreciated from the proximal muscle belly. I then proceeded to gently manipulate the PIP and DIP Joints into further extension until I could passively extend the MP, PIP, and DIP Joints simultaneously. I did feel significant tension in the FOP tendon in doing so manifested by flexion of the DIP, however, this was still obtainable. Flexion of the MP allowed for more relaxed extension of the PIP and DIP Joints. The patient preoperatively had approximately 60-degree fixed contracture of the PIP Joint both with the MP flexed and extended, and this could not be improved with manipulation alone. This, therefore, dramatically improved after the mentioned steps. I then located the lumbrical tendon through the volar wound and gently placed this under traction.
This did produce some tensioning of the central slip region as well as extension of the DIP Joint indicating an intact extensor hood. However, I was concerned about relative tendon imbalance given the flexor tendon tightness and the overall strength of the flexors relative to the extensors. I, therefore, released the FDS tendon completely off both insertions on the middle phalanx, delivered this back through the proximal A2 pulley where the chiasm was divided.
I then dissected along the lumbrical t tendon into the dorsal soft tissue where a separate longitudinal incision was made over the mid proximal phalanx. The dorsal extensor hood was then exposed and separated from the periosteum. The FDS was then delivered up the radial side of the digit from volar to dorsal following the path of the lumbrical tendon and woven twice through the extensor hood. This was then secured with multiple interrupted 4-0 Ethibond sutures with the MP in approximately 30 degrees of flexion. With tenodesis of these Joints. this appeared to produce a better balance between the extensors and flexors, however. certainly the FOP at least remained somewhat tight.
Given the small tendon in the other directions, I elected not to step cut lengthen the tendon.
A 0.028 K-w1re was then passed proximally through the intercondylar portion of the proximal phalanx head with the joint hyperextended. The Joint was then placed in slight flexion to prevent induced laxity of the volar plate, and the pin was delivered into the middle phalanx base. The pin was left percutaneously coming through the skin proximally where it was cut short and bent.
The tourniquet was then released and hemostasis was achieved with bipolar electrocautery. The wounds were then irrigated and after adequate hemostasis, they are closed with mattress 5-0 chromic. They were then dressed with...