Hello,
I rarely code feet and I am a little confused with the op report with muscle belly repair, etc. Can anyone help me code this?
Thanks in advance.
Dx: Torn extensor digitorum longus tendons, extensor, and peroneus tertius tendon.
Operations:
1.) Exploration of wound.
2.) Exploration of anterior tibial tendon.
3.) Exploration of extensor hallucius longus tendon.
4.) Exploration of long toe extensors and peroneus tertius, left leg with repair of torn extensor digitorum longus tendons.
5.) Repair of torn peroneus tertius tendon.
We removed the sutures that have been originally inserted and is done by another hospital. We were able to explore the wound superficially and specifically I found no evidence of any of the branches of the superficial peroneal visible and the extent of the wound superiorly, inferiorly, medially, or laterally. I felt that therefore they must have already pierced, so it must be under the deep fascia. The curural fascia was opened to expose the anterior ulna on the most medial side of his leg and reflected laterally to expose the tibialis and Achilles muscle and tendon, which appeared to be intact as did the extensor to the big toe. We slowly worked our way distally and proximally looking for evidence of the laceration of these 2 medial tendons and I was unable to demonstrate that. I was able to get the hemostat underneath the tibialis and Achilles tendon, and I actually picked his leg up with that. This brought the foot into a little supination and dorsiflection. Likewise with the big toe extensor, we were able to lift his leg and extend his big toe. Both these tendons seemed to have continuity with dorsiflexion of the toe and dorsiflection of the foot. We continued to explore more laterally and we did find some disruption. There were what appeared to be 3 tendons laterally, although 2 of them were very close together and then much far distally we were able to isolate 3 separate tendons. The most lateral of these appeared to be the peroneus tertius, because it did not seem to have continuity with all the other toes with plantar flexion of the 4th, 5th, 2nd, and 3rd toes at all. I pulled these tendons back down distally. There was quite a gap between these tendons distally and the more proximal tendons, but as we pulled on the proximal tendons they did come down in close continuity. We finally decided that we were dealing with 2 branches of the extensor digitorum longus and the peroneus tertius tendon. In addition, there was significant tear of the muscle belly of the extensor digitorum longus. We then worked on repairing the tendons with #2-0 nonabsorbent nylon suture. These were woven sutures back-and-fourth (a Kessler-type suture) and after this was done first on the tertius and then on the extensor digitorum longus, the repairs were supplemented with interrupted #2-0 Vycrol; figure-of-eight in the peroneus tertius and 3 in the combined repair of the bundle of the extensor digitorum longus. Since these 2 tendons were so close in proximity and seemed to all functioning as a unit, we repaired them as a unit. Again, another Kessler suture had been inserted first in this and then the reinforcements. This brought about what appeared to be a much more digitorum that was also appeared to be torn was sutured with 4 figure-of-eight 3-0 Vicryl sutures.
We then explored and looked for branches of the superficial peroneal nerve and I cound not identify any branches in any part of the wound that was exposed. I was very confident that I was unable to identify any other branches and therefore I hope that there was maybe an aberrant anatomy of these branches or that they were just down deeper in the fascia they I had contemplated, but I decided that it was time to just close the crural fascia with interrupted #2-0 Vicryl sutures as best we cound. The extensor retinaculum had been opened partially just ablove the ankle and this was repaired with interrupted #2 Vicryl figure-of-eight sutrues as well. Then subcutaneous sutures were placed in the lart skin flap. We had to extend the original transverse traumatic laceration distally along the tendons and this extended the wound proximally 3 inches. The wound was closed with the deep subcutaneous sutures and then interrupted nylong sutures were used in the skin. The foot was maintained in the dorsiflexed position throughout this part of the procedure. Once the skin was closed, sterile dressings were applied and a short-leg case was applied. Agood part of our time was spent looking for the peroneal tendon that we never found.
I rarely code feet and I am a little confused with the op report with muscle belly repair, etc. Can anyone help me code this?
Thanks in advance.
Dx: Torn extensor digitorum longus tendons, extensor, and peroneus tertius tendon.
Operations:
1.) Exploration of wound.
2.) Exploration of anterior tibial tendon.
3.) Exploration of extensor hallucius longus tendon.
4.) Exploration of long toe extensors and peroneus tertius, left leg with repair of torn extensor digitorum longus tendons.
5.) Repair of torn peroneus tertius tendon.
We removed the sutures that have been originally inserted and is done by another hospital. We were able to explore the wound superficially and specifically I found no evidence of any of the branches of the superficial peroneal visible and the extent of the wound superiorly, inferiorly, medially, or laterally. I felt that therefore they must have already pierced, so it must be under the deep fascia. The curural fascia was opened to expose the anterior ulna on the most medial side of his leg and reflected laterally to expose the tibialis and Achilles muscle and tendon, which appeared to be intact as did the extensor to the big toe. We slowly worked our way distally and proximally looking for evidence of the laceration of these 2 medial tendons and I was unable to demonstrate that. I was able to get the hemostat underneath the tibialis and Achilles tendon, and I actually picked his leg up with that. This brought the foot into a little supination and dorsiflection. Likewise with the big toe extensor, we were able to lift his leg and extend his big toe. Both these tendons seemed to have continuity with dorsiflexion of the toe and dorsiflection of the foot. We continued to explore more laterally and we did find some disruption. There were what appeared to be 3 tendons laterally, although 2 of them were very close together and then much far distally we were able to isolate 3 separate tendons. The most lateral of these appeared to be the peroneus tertius, because it did not seem to have continuity with all the other toes with plantar flexion of the 4th, 5th, 2nd, and 3rd toes at all. I pulled these tendons back down distally. There was quite a gap between these tendons distally and the more proximal tendons, but as we pulled on the proximal tendons they did come down in close continuity. We finally decided that we were dealing with 2 branches of the extensor digitorum longus and the peroneus tertius tendon. In addition, there was significant tear of the muscle belly of the extensor digitorum longus. We then worked on repairing the tendons with #2-0 nonabsorbent nylon suture. These were woven sutures back-and-fourth (a Kessler-type suture) and after this was done first on the tertius and then on the extensor digitorum longus, the repairs were supplemented with interrupted #2-0 Vycrol; figure-of-eight in the peroneus tertius and 3 in the combined repair of the bundle of the extensor digitorum longus. Since these 2 tendons were so close in proximity and seemed to all functioning as a unit, we repaired them as a unit. Again, another Kessler suture had been inserted first in this and then the reinforcements. This brought about what appeared to be a much more digitorum that was also appeared to be torn was sutured with 4 figure-of-eight 3-0 Vicryl sutures.
We then explored and looked for branches of the superficial peroneal nerve and I cound not identify any branches in any part of the wound that was exposed. I was very confident that I was unable to identify any other branches and therefore I hope that there was maybe an aberrant anatomy of these branches or that they were just down deeper in the fascia they I had contemplated, but I decided that it was time to just close the crural fascia with interrupted #2-0 Vicryl sutures as best we cound. The extensor retinaculum had been opened partially just ablove the ankle and this was repaired with interrupted #2 Vicryl figure-of-eight sutrues as well. Then subcutaneous sutures were placed in the lart skin flap. We had to extend the original transverse traumatic laceration distally along the tendons and this extended the wound proximally 3 inches. The wound was closed with the deep subcutaneous sutures and then interrupted nylong sutures were used in the skin. The foot was maintained in the dorsiflexed position throughout this part of the procedure. Once the skin was closed, sterile dressings were applied and a short-leg case was applied. Agood part of our time was spent looking for the peroneal tendon that we never found.