Need help with this one please

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54
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loma linda
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Preoperative diagnoses:
1. Impending pathological fracture left proimxal tibia
2. Bone tumor left proimal tibia, unspecified

Postoperative diagnoses:
1. Impending pathological fracture left proimxal tibia
2. Bone tumor left proimal tibia, unspecified

Procedure(s) performed:
1. Biopsy left tibia bone tumor with frozen section
2. Excision, curettage of left proximal tibia bone tumor
3. Cemenation and internal fixation of left proximal tibia bone cavity and impending pathological fracture
4. Cryotherpay left tibia bone cavity

Anesthesia: Genral and regional block

Brief history and indications: The patient is a 27 yr old man with a several month history of pain in the left proximal tibia with large destructive lytic lesion in the metaphseal/epiphyseal region with extension through the anterior medial cortex into the soft tissues. This was suspicious for giant cell tumor of bone based on the radiology and clinical features. Alternatives, risks, and benefits were discussed with the patient and he wished to proceed with surgery.

Description of procedure: The patient was brought to the operating room and placed in the supine postion on the operating table. General anesthesia was induced by Dr. The patient was given prophylactic IV antibiotics. The left hind quater was prepped with chloraprep and draped in the usual sterile fasion.

We first proceeded with biopsy of the left tibial lesion. I used a C-arm image to help localized the area of this large lytic lesion in the proximal tibia. I made a 2 cm longitudinal incision over the anteromedial aspect of the proximal tibia centered over the prominent soft tissue portion that had extended through the tibial cortex. The dissection was carried down through subcutaneous tissues and the PEs anserinus tendons and periosteum were divided to expose the soft tissue tumor that had destroyed the cortex. This was bloody and orangish in mature consistent with giant cell tumor of bone. I took a sample of this and sent it for frozen section pathology review.

The pathologist reported that this could be consistent with giant cell tumor. There was no evidence of malignancy. Based on there reading and the clinical and radiographic appearance. I proceeded with the remainder of the surgery.

A sterile tourniquet was placed on the thigh. The leg was elevated and tourniquet raised to 250 mmHg pressure. I extended the incision approximately 15 to 18 cm along the anterior medial tibia. Dissection was carried down to the periosteum. The pes anserinus tendons were dividied and the periosteum elevated. The patient had a defect that was about 3 x 3 cm oval with tumor protruding through the anterior medial cortex. I performed a complete curettage of the tumor with curettes and rongeurs. The patient also had some defects in the lateral aspect of the metaphyseal cortex. The subchondral bone on the tibial plateau was intact. I used a high speed bur to bur to all the edges of the tumor cavity.

We then used cryotherapy, liquid nitrogen freeze and thaw in 3 cycles. We used the spray as adjuvant to help reduce the recurrence rate for giant cell tumor we. We trial Biomet proximal tibial plate. I had to contour this plate to fit the diaphyseal/metaphyseal region. I placed 5 locking screws proximally and then 2 temporary screws in the diaphysis to ensure the fit. I removed the plate. We then packed the entire bone cavity with methylmetacrylate bone cement with antibotic. While the cement was still wet, I then inserted the plate with locking screws proximally into the cement and we placed the 2 distal cortical screws into the diaphysis. Cement was allowed to dry. I placed 2 additional screws in the diap;hyseal region. C arm image was used to confirmed good position and fill with cement. We then relaeased the tourniquet. Hemostasis was achieved with the Aquamntys, electrocauter, and bone wax. The periosteum and pes anserinus tendons were repaired ove the hardware. Subcutaneous layers were irrigated and closed over a drain with 0 vicryl, 3-0 vicryl, and the skin was closed with staples. A sterile compression dressing was applied.
 

iowagirl77

Guru
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138
Location
Cedar Rapids, IA
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I'd look at 27745 for the cementation and fixation. The excision and biopsy will bundle into this so they cannot be billed. I couldn't find a code for the cryotherapy, but perhaps someone else is familiar with this?
 
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