Need help with failed ACL repair surgery

driley6@hvc.rr.com

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This is an APV can you please help me with the correct CPT and DX coding. I came up with so far 27457, 29867 but I'm second guessing myself.

Postoperative Diagnosis: Failed right ACL graft. Right knee varus deformity. Subtotal right medial meniscectomy with a severed root attachment posteriorly with significant mid-body loss. Medial femoral condyle grade 3-4 lesion measuring 2cm mediolateral by 2.5 cm anterior to posterior.

Material Forwarded to Lab: None

Operation Performed:
1. Exam under anesthesia, right knee.
2. Diagnostic knee arthroscopy.
3. Arthroscopically assisted femoral hardware removal with femoral and tibial tunnel bone grafting using allograft, stimublast putty and cortical cancellous chips.
4. High Tibial Osteotomy (HTO) with an Arthrex locking titanium Puddu plate with MTF tri-cortical wedges.

Op Date: 23 June 2016

EBL: Minimal
Fluids: Lactated Ringer’s
Complications: None
Tourniquet Time: None
Implants: None

Findings: Exam under anesthesia of the right knee showed range of motion 0/3/135. The patella was stable to medial and lateral translation. There was a negative J-sign. He had a 2B Lachman’s exam. He had a positive shift. He had a pivot glide. He had a negative posterior drawer. He had a 2+ anterior drawer. He was stable to varus and valgus stress at 0 and 30 degrees, distally neurovascularly intact.

Indications: The patient is a 24 y/o Active Duty 1st LT Engineer who sustained his first ACL rupture while a Cadet during his Plebe year in 2012. He underwent an autograft bone-tendon-bone ACL reconstruction which he subsequently healed without difficulty. However, he re-injured his knee while in Cadet athletic activities. He underwent a revision allograft ACL reconstruction and again did well with this. He was able to graduate and has been commissioned as an Engineer Officer and has even gone to Cyber School. He notes that since finishing Cyber School, his knee has been significantly more unstable. He notes that his symptoms are nearly 100% instability. He denies any activity related pain. He is able to do ruck marches up to 12 miles with his unit without any limitation other than his new onset instability.

He was seen at Fort Campbell and subsequently referred to West Point. On evaluation he was found to have an unstable ACL examination and also noted to have a varus alignment of his knee asymmetric to his contralateral side.

We obtained long standing films and a CT scan of his knee in addition to the MRI and plain films that he had prior to coming here. He was found to have some tunnel widening on his tibial side. His femoral side showed no significant tunnel widening. His varus knee mapped out to a correction of 10mm plate to correct him to the lateral aspect of the lateral tibial spine given his chondromalacia of his medial femoral condyle that appeared to be at least a grade-3 on his MRI.

We discussed with him a staged approach with the first stage being tunnel bone grafting with hardware removal and HTO. Likely with his ACL reconstruction revision, a medial meniscus transplant. We discussed the possibility of cartilage surgery based on the findings of this diagnostic arthroscopy

Risks, benefits, expected outcomes, particularly risk of allograft were discussed with the patient. Informed consent was obtained and placed on the chart.


Procedure: After identifying the patient in the preoperative holding area and identifying the operative extremity in accordance with the hospital policy by signing the surgical site, he had a saphenous nerve block administered by the anesthesia service. He was taken by gurney to the operative suite. He was placed supine on the operating room table. Adequate general endotracheal anesthesia was administered.

Exam under anesthesia of the right knee was performed confirming the above findings. Next, we placed a non-sterile tourniquet, lateral post, and two sheet bump. We dropped the foot of the table and prepped and draped the right lower extremity. We placed the left leg to the well-leg holder padding all bony prominences.

We then performed a timeout was performed initiated by the surgeon confirming the surgical site, the procedure, special equipment, allergies and antibiotics.

With this completed, we started our diagnostic arthroscopy. Using the previously landmarks, we placed the inferolateral portal and the superomedial portal. We inserted the scope into the joint and insufflated the arthroscopic fluid and placed the outflow portal in the superomedial site. We then hooked this to the outflow. Under direct visualization with an 18 gauge spinal needle we placed the inferomedial portal. We then placed the probe into the joint and performed diagnostic arthroscopy confirming the above findings.

With the diagnostic arthroscopy confirmed, we placed the knee into enough hyperflexion that we could localize the screwdriver into the femoral interference screw taking care to protect the medial femoral condyle. Using the standard ACL screwdriver, we removed the screw. We then debrided the tunnel walls back to a bleeding edge using guidewire and the 8mm low profile reamer in standard fashion.

With this completed, we took our measurement of the medial femoral condyle articular cartilage lesion. With that completed, we turned our attention back to the femoral tunnel on the ACL. We also confirmed that the tibial tunnel did not communicate significantly with the joint. The most recent tunnel appeared to be just posterior to the inner meniscal ligament.

At this time, we used tuberculin syringes to deliver stimublast and cortical cancellous chips that were crushed together in a slurry. We injected these into the femoral tunnel. We tamped this into placed with a bone tamp and mallet. We took care to remove any loose pieces of bone from within the joint. We removed the scope and instruments from the joint. at this time, we removed all arthroscopic fluid from the joint through the cannula.

We then turned our attention to the High Tibial Osteotomy (HTO) and bone grafting of the tibial tunnel. We used the previous existing tibial incision extending it slightly proximal and distal to measure approximately 7cm. We dissected down to the skin and subcutaneous tissue after putting the tourniquet up at 250 mmHg. We then dissected down to the pes anserine tendon. We then made a sharp tenotomy with the Bovie at the insertion of the pes tendon in line with the crest of the tibia extending from the superior margin distally. We extended this posteriorly along its superior margin reflecting the pes subperiosteally thus including the superficial MCL into out flaps. We carried this around the posteromedial border of the tibia.

At this time, we placed a traction stitch into the pes tendon and then identified the tibial screw. We removed this without difficulty. We then debrided the tibial tunnel. Using the same cortical cancellous chip and Stimublast slurry, we bone grafted the tibial tunnel.

Next, we identified the medial edge of the patellar tendon. We dissected deep to it and placed a retractor between the patellar tendon and tibial tubercle. We elevated the most proximal attachment of the deep patellar tendon and placed the patellar tendon retractor deep to the patellar tendon. We placed the radiolucent retractor at the proposed site of the osteotomy, subperiosteally, posterior around to the proximal tib/fib joint in standard fashion using fluoroscopy to confirm the site.

Next, we placed two guide pins in line with each other, parallel to the tibial plateau. We then placed the cutting jig over this using break away pins and reusable pin that we mallet into place. Next, we used the oscillating saw to initiate our proximal tibial osteotomy. We then completed it anteriorly and posteriorly using osteotomes taking care to stay within the limits of the posterior tibial retractor. We noticed that valgus force at the osteotomy site allowed the osteotomy to just creep open. We then placed the osteotomy jack into the joint and impacted this into place using the wedges to just 10mm width taking care to allow the bone to plastically deform.

We confirmed that we did not breach the lateral cortex. We then placed a 10mm trapezoidal plate with the wider part of the trapezoid posteriorly along the posterior border of the tibia. Using standard AO technique, we placed two 6.5 x 50 screws in the proximal locking holes towards the tibial spine. In the two distal holes, we placed 4.5mm cortical screws, the most anterior being 40mm and the more posterior one being 52mm. We got excellent purchase. The osteotomy site was stable to stress.

We then irrigated the wound copiously with normal saline lavage. We then placed the cortical cancellous chips and Stimublast slurry into the wound. We then placed two tri-cortical wedges from MTF that were 10mm thick, anterior and posterior to the plate, impacting them into place with the bone tamp and placed additional Stimublast around these edges.

Next, we gently irrigated the wound one more time. At this time, we used #2 Ethibond in an interrupted figure-of-eight fashion to repair the flap back to its L shape donor site. We were able to cover the plate in its entirety. We then closed the skin in layers with 0-Vicryl, 2-0 Vicryl and used staples for the portal sites and the incision. We took the tourniquet down after having achieved hemostasis. We then put Xeroform dressings with 4x8, ABD and over this we placed cotton Webril and an ace wrap followed by a TED hose. We placed the right lower extremity into a knee immobilizer, awakened the patient from general endotracheal anesthesia. He tolerated the procedure well with no complications and transferred to the PACU.




Postoperative Plan: He will be admitted overnight for acute pain management and physical therapy to begin the morning. He will rehab according the standard ACL protocol.

We will bring him back some period after 3 months for his revision ACL reconstruction likely with contralateral BTB graft as well as a medial meniscus transplant and possibly a medial femoral condyle OC allograft.
 
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