LScoder2016
Networker
i got 28615 and 28555. Should I be coding 28485 as well?
Postoperative Diagnosis:
1. Fracture of 2nd metatarsal comminuted, right
2. Fracture of 3rd metatarsal comminuted, right
3. Fracture of 4th metatarsal comminuted, right
4. Subluxation of tarsometatarsal joints 2, 3 and 45. Subluxation of inter cuneiform joints, right
Procedure(s) Performed:
1. ORIF 2nd tarsometatarsal joint, right
2. ORIF 3rd tarsometatarsal joint, right
3. ORIF 4th tarsometatarsal joint, right
4. ORIF of intercuneiform joint, righ
Attention was directed to the dorsal aspect of the right foot. The 1st dorsal incision was performed at the interval between the 2nd and 3rd tarsometatarsal joints. This was confirmed via fluoroscopy. The incision was deepened down in the same surgical plane with care taken to retract vital structures and ligate vessels as necessary. Care was taken to avoid all neurovascular and tendinous structures. Blunt dissection was carried down to the deep fascia in interval between the 2nd and 3rd tarsometatarsal joints. A careful soft tissue dissection was performed utilizing a 15 blade and periosteal elevator until adequate exposure to the joints were noted. There was noted to be significant comminution as well as mild displacement of the 2nd metatarsal base fracture. There was significant instability of both the 2nd and 3rd tarsometatarsal joints with dorsal subluxation. This was noted intraoperatively and confirmed via fluoroscopy.
Following adequate exposure, an 8 hole T-plate was placed overlying the 2nd tarsometatarsal joint and bridge plating technique. Fixation was obtained proximally at the level of the intermediate cuneiform with 2.4 mm locking screws. The 2nd TMT joint and comminuted 2nd metatarsal base fracture was then bridged and distally the plate was secured utilizing 2.4 mm locking and nonlocking screws. Excellent stability and reduction were noted and this was confirmed via fluoroscopy.Attention was then directed to the 3rd TMT joint where a similar bridge plating technique was performed. The joint and 3rd metatarsal base fracture site was in a similar fashion stabilized utilizing a 6 hole T-plate and secured with 2.4 mm locking and nonlocking screws. Excellent stability reduction was noted and confirmed via fluoroscopy.
An additional incision was performed overlying the 4th tarsometatarsal joint. This was performed at the lateral aspect of this joint and confirmed the fluoroscopy. Care was taken to maintain at least a 2.5 mm skin bridge from the previous dorsal incision. The incision was deepened down in the same surgical plane with care taken to retract vital structures and ligate vessels as necessary. A blunt dissection was carried down to the level of the extensor digitorum brevis muscle belly. This was carefully elevated and retracted for the remainder of the procedure. Care was taken to protect and retract all neurovascular and tendinous structures. Dissection was then carried out overlying the 4th tarsometatarsal joint and the articular surface of the cuboid and 4th metatarsal base was noted. There was noted to be instability with dorsal subluxation as well as comminution of the 4th metatarsal base fracture. In a similar fashion, a 6 hole T-plate was then applied overlying the dorsal 4th TMT joint. This was secured utilizing 2.4 mm locking and nonlocking screws. Excellent stability and reduction was noted and confirmed via fluoroscopy.
The foot was then stressed with supination, pronation and external rotation. The 1st through 5th tarsometatarsal joints were noted to be stable at this time. There was noted to be instability and gapping at the intercuneiform joint. This was noted on fluoroscopy as well as intraoperatively. A decision was made in order to perform stabilization of the subluxed and unstable intercuneiform joint. A guidewire was then placed under fluoroscopy at the level of the medial cuneiform, across the intercuneiform joint and into the intermediate cuneiform. After placement was confirmed, theguidewire was then drilled and a 4.0 mm fully-threaded headless screw was placed across the intercuneiform joint. Excellent stability was noted and no additional instability was appreciated with repeat stress testing.1 L of iricept was utilized to copiously irrigate the surgical sites. Tourniquet was deflated and incision sites inspected all bleeders cauterized and adequate hemostasis was obtained with electrocautery and Surgicel overlying a small area of the intrinsic muscle belly. Demineralized bone matrix was then packed at the level of the comminuted metatarsal base fractures. Deep layers were reapproximated with 2-0 Vicryl. Subcutaneous layer was reapproximated with 3-0 Monocryl. Skin closure was obtained utilizing 3-0 nylon in horizontal mattress suture technique.
Incision site was dressed with Xeroform, 4x4s, soft roll, ABD and a well-padded posterior splint with Jones cotton and secured with an Ace bandage.
Postoperative Diagnosis:
1. Fracture of 2nd metatarsal comminuted, right
2. Fracture of 3rd metatarsal comminuted, right
3. Fracture of 4th metatarsal comminuted, right
4. Subluxation of tarsometatarsal joints 2, 3 and 45. Subluxation of inter cuneiform joints, right
Procedure(s) Performed:
1. ORIF 2nd tarsometatarsal joint, right
2. ORIF 3rd tarsometatarsal joint, right
3. ORIF 4th tarsometatarsal joint, right
4. ORIF of intercuneiform joint, righ
Attention was directed to the dorsal aspect of the right foot. The 1st dorsal incision was performed at the interval between the 2nd and 3rd tarsometatarsal joints. This was confirmed via fluoroscopy. The incision was deepened down in the same surgical plane with care taken to retract vital structures and ligate vessels as necessary. Care was taken to avoid all neurovascular and tendinous structures. Blunt dissection was carried down to the deep fascia in interval between the 2nd and 3rd tarsometatarsal joints. A careful soft tissue dissection was performed utilizing a 15 blade and periosteal elevator until adequate exposure to the joints were noted. There was noted to be significant comminution as well as mild displacement of the 2nd metatarsal base fracture. There was significant instability of both the 2nd and 3rd tarsometatarsal joints with dorsal subluxation. This was noted intraoperatively and confirmed via fluoroscopy.
Following adequate exposure, an 8 hole T-plate was placed overlying the 2nd tarsometatarsal joint and bridge plating technique. Fixation was obtained proximally at the level of the intermediate cuneiform with 2.4 mm locking screws. The 2nd TMT joint and comminuted 2nd metatarsal base fracture was then bridged and distally the plate was secured utilizing 2.4 mm locking and nonlocking screws. Excellent stability and reduction were noted and this was confirmed via fluoroscopy.Attention was then directed to the 3rd TMT joint where a similar bridge plating technique was performed. The joint and 3rd metatarsal base fracture site was in a similar fashion stabilized utilizing a 6 hole T-plate and secured with 2.4 mm locking and nonlocking screws. Excellent stability reduction was noted and confirmed via fluoroscopy.
An additional incision was performed overlying the 4th tarsometatarsal joint. This was performed at the lateral aspect of this joint and confirmed the fluoroscopy. Care was taken to maintain at least a 2.5 mm skin bridge from the previous dorsal incision. The incision was deepened down in the same surgical plane with care taken to retract vital structures and ligate vessels as necessary. A blunt dissection was carried down to the level of the extensor digitorum brevis muscle belly. This was carefully elevated and retracted for the remainder of the procedure. Care was taken to protect and retract all neurovascular and tendinous structures. Dissection was then carried out overlying the 4th tarsometatarsal joint and the articular surface of the cuboid and 4th metatarsal base was noted. There was noted to be instability with dorsal subluxation as well as comminution of the 4th metatarsal base fracture. In a similar fashion, a 6 hole T-plate was then applied overlying the dorsal 4th TMT joint. This was secured utilizing 2.4 mm locking and nonlocking screws. Excellent stability and reduction was noted and confirmed via fluoroscopy.
The foot was then stressed with supination, pronation and external rotation. The 1st through 5th tarsometatarsal joints were noted to be stable at this time. There was noted to be instability and gapping at the intercuneiform joint. This was noted on fluoroscopy as well as intraoperatively. A decision was made in order to perform stabilization of the subluxed and unstable intercuneiform joint. A guidewire was then placed under fluoroscopy at the level of the medial cuneiform, across the intercuneiform joint and into the intermediate cuneiform. After placement was confirmed, theguidewire was then drilled and a 4.0 mm fully-threaded headless screw was placed across the intercuneiform joint. Excellent stability was noted and no additional instability was appreciated with repeat stress testing.1 L of iricept was utilized to copiously irrigate the surgical sites. Tourniquet was deflated and incision sites inspected all bleeders cauterized and adequate hemostasis was obtained with electrocautery and Surgicel overlying a small area of the intrinsic muscle belly. Demineralized bone matrix was then packed at the level of the comminuted metatarsal base fractures. Deep layers were reapproximated with 2-0 Vicryl. Subcutaneous layer was reapproximated with 3-0 Monocryl. Skin closure was obtained utilizing 3-0 nylon in horizontal mattress suture technique.
Incision site was dressed with Xeroform, 4x4s, soft roll, ABD and a well-padded posterior splint with Jones cotton and secured with an Ace bandage.
