Mosaicplasty medial talar dome

klamond

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Please help. I'm assuming I should use unlisted 27899 and compare to 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft). Would I also code the knee arthrotomy, osteochondral graft harvest from left knee? I feel like this is part of the mosaicplasty but the doctor doesn't want to hear that. Any advice would be appreciated.

PROCEDURE: 1. LEFT ANKLE ARTHROSCOPY WITH PARTIAL SYNOVECTOMY.
2. MEDIAL MALLEOLAR OSTEOTOMY LEFT ANKLE.
3. MOSAICPLASTY OF MEDIAL TALAR DOME USING AUTOGENOUS OSTEOCHONDRAL GRAFT.
4. LEFT KNEE ARTHROTOMY.
5. AUTOGENOUS OSTEOCHONDRAL GRAFT HARVEST FROM LATERAL FEMORAL CONDYLE LEFT KNEE.
6. TARSAL TUNNEL RELEASE LEFT KNEE.

INDICATIONS: This is a 24-year-old woman who has longstanding OCD of medial talar dome and failed nonsurgical treatment. Discussed drilling versus mosaicplasty. The patient decided to have a mosaicplasty. Risks, benefits, alternatives and complications of surgery were discussed with the patient. After informed consent was obtained, the patient was brought to the operating room and placed on the operating room table in the supine position. A preoperative dose of antibiotics was given.

The left thigh was placed in a well-padded thigh holder. The left lower extremity was prepped and draped in the usual sterile fashion. The left lower extremity was exsanguinated. Pneumatic tourniquet was inflated to the left thigh. The left ankle was distracted using Smith and Nephew noninvasive ankle distractor and medial and lateral portals were marked and injected with .25% Marcaine. The joint was insufflated with 15 cc of normal saline.

A medial portal was created in standard fashion. 2.3 mm arthroscope was introduced and arthroscopic examination was performed. Some fibrotic tissue was noted laterally. Under arthroscopic guidance a lateral portal was created in standard fashion. On probe examination the medial talar dome OCD was noted. Loose soft articular cartilage with fracturing of the cartilage was noted. Decision was made to perform a mosaicplasty. Partial synovectomy and debrided was performed using motorized shaver. Instruments were withdrawn.

The joint was irrigated with a copious amount of saline. Distraction was released. Thigh support was removed.

A longitudinal incision was made over the medial aspect of the medial malleolus. Superior and inferior Homan retractors were placed. Two drill holes were created from the tip of the medial malleolus going proximally for later fixation. Guidewire was placed vertically from the apex of the medial malleolus towards the shoulder of the joint. Position of the wire was confirmed under fluoroscopy while keeping Homan retractors in placed superiorly and inferiorly. Osteotomy was made using osteotome with frequent irrigation. The osteotomy was completed using osteotome. Medial malleolar piece was retracted distally. The foot was placed in abduction and excellent reduction of the medial malleolar OCD was delivered.

Next, loose articular cartilage was removed. The defect was measured and was approximately 8 x 18 mm. Decision was made to placed three grafts, one 6 mm, one 4 mm and the third one 4 mm. Central portion of the defect was first treated with 6 mm graft. Depuy Mitek system was used. 6 mm drill with guide was used to create the drill hole. Caution was taken to keep the drill vertical perpendicular to the articular surface. 12 mm deep drill hole was created.

Next, a longitudinal incision was made over the lateral aspect of the patellofemoral joint. Arthrotomy was created. Lateral femoral condyle articular surface was exposed. 6 mm harvest was used to harvest the osteochondral plug on the periphery away from the articular portion. Using standard technique 12 mm x 6 mm osteochondral plug was transferred. Next, the plug was transferred to the talar drill hole using standard technique and was press fitted. Caution was not taken to not recess the graft. Excellent position was achieved. The graft was perpendicular and flushed with the articular surface.

Next, two more grafts were placed. One anterior and one posterior to the 6 mm plug. Anterior and posterior grafts were 4 mm each. Using a 4 mm reamer recipient drill hole was created perpendicular to the articular surface. Using the same technique 4 mm x 15 mm plug was harvested from the lateral femoral condyle and transferred and press fitted using the same technique. Again, caution was taken to not shear off the cartilage and keep the graft perpendicular and excellent position was achieved. It was made sure that the graft was not recessed and satisfactory position was achieved.

Using the same technique the third 4 mm plug was placed posterior to the 6 mm plug using the same technique. Again, the plane was kept perpendicular to the articular surface. 4 mm x 15 mm plug was harvested from the lateral femoral condyle edge and transferred using the same technique. Excellent position was achieved. The area was thoroughly irrigated. Intraoperative fluoroscopy showed satisfactory position of the osteochondral plugs and congruency. Arthroscopy pictures were taken using arthroscope. The osteotomy was then repaired using one partially threaded cancellous screw. The second screw was not placed since it was creating impingement over the posterior tibial tendon. One-third tubular plate was placed on the medial side. Two proximal screws were placed proximal to the osteotomy, one distal screw placed, which was unicortical through the metaphyseal portion of the medial malleolus. Excellent fixation was achieved. Intraoperative fluoroscopy showed satisfactory position of the hardware and satisfacotryy alignment.

At this time, the knee was irrigated with copious amount of saline and was closed in layers. Next, posterior to the medial malleolus blunt dissection was performed. Neurovascular bundle was isolated. There was a varicose vein over the tibial nerve noted, which was excised after it was tied off using silk sutures and varicose vein was excised entirely. Prior to doing that, the tibial artery was confirmed by deflating the tourniquet and palpating the pulse and retracting away from the dissection and taking out the vein. The tourniquet was reinflated after 10 minutes for the excision of the vein.

The wound was irrigated and closed in layers. Total tourniquet time was 2 hours and 3 minutes. Tourniquet was deflated after 2 hours and after 10 minutes was reinflated for 3 more minutes and then deflated again. Hemostasis was achieved prior to closure of the wound. The wounds were closed in layers. Sterile dressing was applied. A well-padded posterior coapt splints were applied. The patient tolerated the procedure well. There were no complications. She was brought to the recovery room in satisfactory condition.
 

AlanPechacek

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I agree with you, even though I am an Orthopedic Surgeon (retired). The Descriptor for the Mosaicplasty does include harvesting of the graft. Of course, the code 27416 applies to the procedure being done in the knee joint, and implies that the autograft is being taken from the knee being operated upon, but it does not clearly state that the grafts could not be taken from some other joint, i.e. the other knee for example. Therefore, you are correct in using 27899, Unlisted procedure, leg or ankle, and pairing it with 27416 for comparative value. Furthermore, other than harvesting the graft from the knee joint, he did not do anything else to that knee that would warrant or constitute treatment of any joint pathology.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
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