Needing help with operative note - orthopedic

SMoose

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Procedures performed: Left subtalar joint arthrodesis with an iliac crest bone graft

Implants: Paragon 28, 7.0mm cannulated screws and Trinity bone graft substitute

Indication:
Pt has a history of two surgical interventions on the hindfoot and had persistent swelling, pain, and CT evidence of profound arthrosis in the subtalar joint.

Description of Procedure:
A sinus tarsi approach was used to access the subtalar joint. An incision was made starting at the tip of the fibula extending distally toward the fourth toe. Sin and subcutaneous tissue were sharply incised. The peroneal tendon was found dislocated away from its typical position. It was protected. The extensor digitorum brevis muscle belly was split in the subtalar joint was exposed. It was opened with a lamina spreader without teeth and then with a k-wiredistractor. The subtalar joint revealed abundant subchondral cyst formation as well as sclerotic hard bone and really rather profound changes. A chisel, osteotome, curette, and burr were used to debride the joint back to cancellous appearing services. The entire joint was repaired until the flexor halluces tlongus was visualized moving deep across the subtalar joint. Numerous channels were drilled in the bone in order to facilitate bony fusion. Once the joint had been adequately prepared, incision was then made along the anterior iliac crest starting at the anterior superior iliac spine. The skin and subcutaneous tissue were sharply incised. The crest was exposed and then a bone graft core harvester reamer was used to take two cores of autograft followed by a curette used to take additional autograft. The area between the tables was then filled up with cancellous chips as well as thrombin Gelfoam and then the fascia was closed followed by meticulous closure of subcutaneous tissue and skin. Sterile dressing was applied. Attention was then directed back toward the subtalar joint where the autograft as well as Trinity bone graft substitute was placed in the subtalar joint. Using intraoperative mini c-arm, a guidewire was then placed in the heel across the subtalar joint into the talus. Lateral views as well as Harris heel view and AP ankle was used in order to assess positioning of the screw. Two screws were placed in order to secure solid fixation of the subtalar joint. Both these screws had excellent purchase and then assessed the subtalar joint, it was nice and clinicall stable; however, there was room for additional bone graft substitute, therefore we placed another millitliter of Trinity followed by cancellous chips in order to close down all the dead space. We then meticulously closed the incision in layers. Sterile dressings and a splint were applied. The patient tolerated the procedure well ....

When it comes to feet - I find this is difficult! I realize the 28725 for subtalar arthrodesis, but am having trouble with the iliac crest autograft and bone substitute how to code or if included? The physician's nurse put down 20970, but I think that is over and beyond what he did.

Could you please review and give me your opinions? I really appreciate your time!
 
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