dsibley67
Networker
I have coded this op note as 29999 and will compare it to 23412. I just wanted a second opinion and to make sure I am not missing anything. Any help will be greatly appreciated! Thanks!
PREOPERATIVE DIAGNOSIS: Left gluteal tear
POSTOPERATIVE DIAGNOSES: Full-thickness anterior gluteal minimus tear with partial thickness
gluteal medius tear
PROCEDURES PERFORMED: Endoscopic iliotibial band lengthening, trochanteric bursectomy,
gluteus medius debridement and gluteus minimus repair.
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area and I went
through the risks and benefits of operation. The operative hip was marked and the patient was taken back
to the operating room, underwent general endotracheal anesthesia, went into lateral decubitus position.
The left hip was sterilely prepped and draped in a standard orthopedic fashion. A time-out was called
confirming the patient laterality and planned for administration of antibiotics. Once everyone agreed to
proceed, using a spinal needle I triangulated the more superficial aspect of the patellar facet and then hand
breadth both proximal and distal to that location, made 1 cm incision. I went into the trocar and palpated
the spinal needle to clear some of the soft tissue and inserted a shaver and debrided the soft tissue just off
of the IT band, obtained hemostasis with electrocautery. I then placed the patient's hip in abduction and
then ultimately released the IT band and underneath went down to the vastus lateralis with my landmark
and went proximally and the patient had a full-thickness gluteus minimus tear as well as partial thickness
gluteus medius. The gluteus medius was a small flap of tissue that I gently debrided. As for the gluteus
minimus, it was a bare spot, I shaved off some of the superficial bone of the shaver and then had to make
two more accessory portals to used a tissue grasper to make sure that I was able to reduce the tissue over
to the trochanter which I was able to. So I then malleted in a FiberTak rotator cuff suture. I removed the
knotless mechanism. I then passed two mini tapes as well as one FiberWire, so three in total, I passed
them and I pulled on to bring them down to the bone and then I brought them into all one into a lateral
slightly more distal SwiveLock. Everything was moving as a unit. I then removed the trochanter bursa
with a shaver and obtained hemostasis with electrocautery. Following this I let the water out and injected
local anesthetic. The incisions were then closed with 3-0 nylon, Xeroform, 4x4, ABD, Medipore tape.
The patient was then successfully awoken up from anesthesia and taken to PACU in stable condition.
The patient will be 50% weightbearing and if unable to tolerate full weightbearing with the hip abduction
brace in 0 to 90 degrees, she should wear that for six weeks in total. All questions and concerns were
answered. The patient will be given a collagen dressing, she can change those on post day #3.
PREOPERATIVE DIAGNOSIS: Left gluteal tear
POSTOPERATIVE DIAGNOSES: Full-thickness anterior gluteal minimus tear with partial thickness
gluteal medius tear
PROCEDURES PERFORMED: Endoscopic iliotibial band lengthening, trochanteric bursectomy,
gluteus medius debridement and gluteus minimus repair.
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area and I went
through the risks and benefits of operation. The operative hip was marked and the patient was taken back
to the operating room, underwent general endotracheal anesthesia, went into lateral decubitus position.
The left hip was sterilely prepped and draped in a standard orthopedic fashion. A time-out was called
confirming the patient laterality and planned for administration of antibiotics. Once everyone agreed to
proceed, using a spinal needle I triangulated the more superficial aspect of the patellar facet and then hand
breadth both proximal and distal to that location, made 1 cm incision. I went into the trocar and palpated
the spinal needle to clear some of the soft tissue and inserted a shaver and debrided the soft tissue just off
of the IT band, obtained hemostasis with electrocautery. I then placed the patient's hip in abduction and
then ultimately released the IT band and underneath went down to the vastus lateralis with my landmark
and went proximally and the patient had a full-thickness gluteus minimus tear as well as partial thickness
gluteus medius. The gluteus medius was a small flap of tissue that I gently debrided. As for the gluteus
minimus, it was a bare spot, I shaved off some of the superficial bone of the shaver and then had to make
two more accessory portals to used a tissue grasper to make sure that I was able to reduce the tissue over
to the trochanter which I was able to. So I then malleted in a FiberTak rotator cuff suture. I removed the
knotless mechanism. I then passed two mini tapes as well as one FiberWire, so three in total, I passed
them and I pulled on to bring them down to the bone and then I brought them into all one into a lateral
slightly more distal SwiveLock. Everything was moving as a unit. I then removed the trochanter bursa
with a shaver and obtained hemostasis with electrocautery. Following this I let the water out and injected
local anesthetic. The incisions were then closed with 3-0 nylon, Xeroform, 4x4, ABD, Medipore tape.
The patient was then successfully awoken up from anesthesia and taken to PACU in stable condition.
The patient will be 50% weightbearing and if unable to tolerate full weightbearing with the hip abduction
brace in 0 to 90 degrees, she should wear that for six weeks in total. All questions and concerns were
answered. The patient will be given a collagen dressing, she can change those on post day #3.