tdesher
Networker
I need any help I can get on this one. Dr performed 3 procedures that I cannot find codes for. The ORIF he is dictating comes back as CPT 27540 but that is an Inpatient only code and we are an ASC.
POSTOPERATIVE DIAGNOSES:
1. Left knee tibial tubercle avulsion fracture.
2. Periosteal sleeve rupture.
3. Medial and lateral retinacular tears.
PROCEDURES PERFORMED:
1. Left knee open reduction and internal fixation of tibial tubercle fracture.
2. Repair of periosteal sleeve avulsion.
3. Repair of medial and lateral retinacular tears.
HARDWARE USING: Synthes and Arthrex system, one 3 x 40 mm screw with a washer, other hardware one BioComposite Triple Play anchor, and two 4.75-mm SwiveLock anchors.
INDICATIONS FOR SURGERY: The patient is 15 years of age. He had injured himself playing basket ball where he came down on a straight leg. He had immediate sudden severe pain and fell on the ground. He had x-rays which initially showed the possibility of a small inferior pole of the patella fracture what felt like a patellar tendon disruption indicating a probable periosteal sleeve avulsion fracture. However, with this injury after discussion with mother because of the severe nature of this problem, they elected to undergo surgery to attempt to resolve this issue.
DESCRIPTION OF PROCEDURE: After the patient was properly identified in the holding area as well as to identifying the proper operative site with his mother present, the patient was then brought into the operating room. At this point, he underwent the induction of a general-type anesthesia and after assurance of proper general anesthesia; the patient was then prepped and draped in an absolute meticulous sterile fashion for left knee surgery. A time-out was then performed to identifying the patient, the operative site, and the surgical procedure with the staff in the room. Preop antibiotics were given at the appropriate time prior to the procedure. At this point now, leg was elevated and Esmarch was applied and the tourniquet was placed to 250 mmHg pressure. The incision was then made from about the superior pole of the patella down to below the tibial tubercle by several centimeters. Soft tissues were incised. Hemostasis was obtained with electrocautery. Gentle dissection was then meticulously carried down to the extensor mechanism. Identification of the quadriceps tendon was easily done which then allowed easy identification of the medial and lateral gutters and identifying the medial and lateral retinacular tearing and then moving down easily identifying at that point deep patellar tendon which was actually intact.
However, on further dissection, the tibial tubercle was avulsed almost completely in toto and was retracted significantly cephalad. In addition, there was a significant amount of periosteum ruptured with small avulsion fracture of the cortical bone anteriorly below the tibial tubercle and that was also retracted cephalad. At this point now, meticulous evaluation of the injury pattern was performed and then thought process given to repair other type of the repair that would provide good overall fixation. The area was then meticulously irrigated with bulb syringe sterile saline and ends of some of the tissue were freshened sharply. The tibial tubercle was able to nicely reduce into its bony bed. In addition, the bone piece of the tibial tubercle as it encompasses essentially the entire tibial tubercle was felt large enough to sustain the placement of the screw. It was felt that a belt-and-suspender type fixation would provide excellent secure stability. For this reason, once the tibial tubercle was reduced anatomically positioned for repair of the periosteal sleeve and cortical bone avulsion was evaluated. A small mark was then placed and it was felt that a cancellous screw with washer would be placed in the tibia and then a Triple Play anchor would be placed below this into the area of cortical avulsion with the periosteal sleeve avulsion. The anchor was placed with initial drilling and then tapping and then placement of the anchor, which showed excellent secure fixation. At this point now, the tibial tubercle was meticulously reduced and held in position. It was drilled centrally with a drill bit and depth gauge in a 40 mm x 3 mm diameter screw was chosen. A washer was applied, and then this was placed without any difficulty giving excellent secure fixation. This very nicely held the tibial tubercle in place. Once this was done, using a free needle and the three limbs of the suture pairs, a central horizontal mattress stitch was placed in the periosteal avulsion encompassing the cortical fracture fragment and then each side stitch medial and lateral were placed in a simple fashion so that there was side edges could be tied down. These were then tied down in standard fashion. At this point now, it was felt that using a weave-type repair similar to what is done with a rotator cuff would be performed which would give a very solid fixation to the periosteal sleeve cortical avulsion fracture. One limb each of these suture pairs was then taken medially and one limb of each of these suture pairs were taken laterally. Proper position on the tibia was then identified and the area was drilled, tapped, and then the suture limbs were placed through a 4.75 mm SwiveLock.
This was preliminarily deployed. Tension placed on the tissues and then the anchor was fully deployed giving excellent secure fixation. These were cut to length. The medial anchor was placed first. The lateral anchor was placed second. This had excellent secure fixation with movement there was no apparent instability at this construct. In addition, the extensive medial and lateral retinacular tears which also went down the medial and lateral aspects of the patellar tendon were repaired in an anatomic meticulous fashion with #2 FiberWire in simple interrupted stitch. Once this entire area was repaired, the area was meticulously irrigated with bulb syringe sterile saline. Gentle motion in the knee showed no instability at all with movement to 90 degrees. The thigh and calf were soft. The area was irrigated in the soft tissues with Exparel for postop pain control. The subcutaneous tissues were closed with 2-0 Vicryl simple interrupted suture and then the skin with a 4-0 Monocryl running subcuticular stitch. The wound was thoroughly cleansed and dried. Benzoin and Steri-Strips were applied. Sterile Adaptic, sterile 4x4's, sterile ABDs and sterile Webril were applied. The tourniquet was then let down for a total tourniquet time of 89 minutes at 250 mmHg pressure. All drips were taken down and then a sterile Ace was applied. Of note, dorsalis pedis pulse intact. Brisk capillary refill on all toes. Thigh and calf were completely soft. The patient was then placed in a brace locked in extension. He was then awakened without difficulty, transferred on to his bed, and taken from the operating room to the recovery room in a stable condition.
POSTOPERATIVE DIAGNOSES:
1. Left knee tibial tubercle avulsion fracture.
2. Periosteal sleeve rupture.
3. Medial and lateral retinacular tears.
PROCEDURES PERFORMED:
1. Left knee open reduction and internal fixation of tibial tubercle fracture.
2. Repair of periosteal sleeve avulsion.
3. Repair of medial and lateral retinacular tears.
HARDWARE USING: Synthes and Arthrex system, one 3 x 40 mm screw with a washer, other hardware one BioComposite Triple Play anchor, and two 4.75-mm SwiveLock anchors.
INDICATIONS FOR SURGERY: The patient is 15 years of age. He had injured himself playing basket ball where he came down on a straight leg. He had immediate sudden severe pain and fell on the ground. He had x-rays which initially showed the possibility of a small inferior pole of the patella fracture what felt like a patellar tendon disruption indicating a probable periosteal sleeve avulsion fracture. However, with this injury after discussion with mother because of the severe nature of this problem, they elected to undergo surgery to attempt to resolve this issue.
DESCRIPTION OF PROCEDURE: After the patient was properly identified in the holding area as well as to identifying the proper operative site with his mother present, the patient was then brought into the operating room. At this point, he underwent the induction of a general-type anesthesia and after assurance of proper general anesthesia; the patient was then prepped and draped in an absolute meticulous sterile fashion for left knee surgery. A time-out was then performed to identifying the patient, the operative site, and the surgical procedure with the staff in the room. Preop antibiotics were given at the appropriate time prior to the procedure. At this point now, leg was elevated and Esmarch was applied and the tourniquet was placed to 250 mmHg pressure. The incision was then made from about the superior pole of the patella down to below the tibial tubercle by several centimeters. Soft tissues were incised. Hemostasis was obtained with electrocautery. Gentle dissection was then meticulously carried down to the extensor mechanism. Identification of the quadriceps tendon was easily done which then allowed easy identification of the medial and lateral gutters and identifying the medial and lateral retinacular tearing and then moving down easily identifying at that point deep patellar tendon which was actually intact.
However, on further dissection, the tibial tubercle was avulsed almost completely in toto and was retracted significantly cephalad. In addition, there was a significant amount of periosteum ruptured with small avulsion fracture of the cortical bone anteriorly below the tibial tubercle and that was also retracted cephalad. At this point now, meticulous evaluation of the injury pattern was performed and then thought process given to repair other type of the repair that would provide good overall fixation. The area was then meticulously irrigated with bulb syringe sterile saline and ends of some of the tissue were freshened sharply. The tibial tubercle was able to nicely reduce into its bony bed. In addition, the bone piece of the tibial tubercle as it encompasses essentially the entire tibial tubercle was felt large enough to sustain the placement of the screw. It was felt that a belt-and-suspender type fixation would provide excellent secure stability. For this reason, once the tibial tubercle was reduced anatomically positioned for repair of the periosteal sleeve and cortical bone avulsion was evaluated. A small mark was then placed and it was felt that a cancellous screw with washer would be placed in the tibia and then a Triple Play anchor would be placed below this into the area of cortical avulsion with the periosteal sleeve avulsion. The anchor was placed with initial drilling and then tapping and then placement of the anchor, which showed excellent secure fixation. At this point now, the tibial tubercle was meticulously reduced and held in position. It was drilled centrally with a drill bit and depth gauge in a 40 mm x 3 mm diameter screw was chosen. A washer was applied, and then this was placed without any difficulty giving excellent secure fixation. This very nicely held the tibial tubercle in place. Once this was done, using a free needle and the three limbs of the suture pairs, a central horizontal mattress stitch was placed in the periosteal avulsion encompassing the cortical fracture fragment and then each side stitch medial and lateral were placed in a simple fashion so that there was side edges could be tied down. These were then tied down in standard fashion. At this point now, it was felt that using a weave-type repair similar to what is done with a rotator cuff would be performed which would give a very solid fixation to the periosteal sleeve cortical avulsion fracture. One limb each of these suture pairs was then taken medially and one limb of each of these suture pairs were taken laterally. Proper position on the tibia was then identified and the area was drilled, tapped, and then the suture limbs were placed through a 4.75 mm SwiveLock.
This was preliminarily deployed. Tension placed on the tissues and then the anchor was fully deployed giving excellent secure fixation. These were cut to length. The medial anchor was placed first. The lateral anchor was placed second. This had excellent secure fixation with movement there was no apparent instability at this construct. In addition, the extensive medial and lateral retinacular tears which also went down the medial and lateral aspects of the patellar tendon were repaired in an anatomic meticulous fashion with #2 FiberWire in simple interrupted stitch. Once this entire area was repaired, the area was meticulously irrigated with bulb syringe sterile saline. Gentle motion in the knee showed no instability at all with movement to 90 degrees. The thigh and calf were soft. The area was irrigated in the soft tissues with Exparel for postop pain control. The subcutaneous tissues were closed with 2-0 Vicryl simple interrupted suture and then the skin with a 4-0 Monocryl running subcuticular stitch. The wound was thoroughly cleansed and dried. Benzoin and Steri-Strips were applied. Sterile Adaptic, sterile 4x4's, sterile ABDs and sterile Webril were applied. The tourniquet was then let down for a total tourniquet time of 89 minutes at 250 mmHg pressure. All drips were taken down and then a sterile Ace was applied. Of note, dorsalis pedis pulse intact. Brisk capillary refill on all toes. Thigh and calf were completely soft. The patient was then placed in a brace locked in extension. He was then awakened without difficulty, transferred on to his bed, and taken from the operating room to the recovery room in a stable condition.