jdibble
True Blue
We are having a debate of the correct codes for this procedure. We have come up with 27381 and 27524, however we are not sure if these are the correct codes, or if both would be coded and if only one, which one! Any help for this procedure would be greatly appreciated!
Preoperative Diagnosis
Periprosthetic right patella fracture, chronic
Postoperative Diagnosis
Same
Procedure Performed
Open treatment of periprosthetic right patella fracture with distal pole patella excision, and extensor mechanism reconstruction with hamstrings (gracilis and semitendinosus)
Patient was taken to the operating room where the right lower extremity was prepped and draped in a sterile fashion. Anterior longitudinal incision was reopened and extended somewhat distally. Full-thickness flaps were developed medially and laterally around the extensor mechanism. The central portion of the patellar tendon was thinned and attenuated. The distal pole fragment was identified and excised sharply and removed. The patella was inspected and it was noted that the polyethylene patellar component was still intact and fully covered on the main body of the patellar bone. It was decided to keep the patellar component since it was still intact, but to avoid putting any drill holes or suture holes in the patella itself to avoid further patellar failure. The distal portion of the patellar tendon was still thick and viable. The patella itself could be pulled down to where the distal pole was at the joint line, so the patella Alta in this case was not particularly contracted into a cephalad migrated position. The redundant soft tissue between the main body of the patella and the location of the excised patellar fragment was split midline and the patella was brought distally, and the medial and lateral limbs of all the soft tissue in the thin attenuated portion of the patellar tendon was wrapped medially and laterally around the patella and sutured to the retinacular tissues on the medial and lateral side of the patella. This gave a very good repair. When the knee was allowed to passively flex, and only flexed to about 40°. The decision was made not to rely only on this tentative repair of the soft tissues back to the patella, but to add hamstring grafts to completely reinforce the repair.
The pes anserine tendons were exposed on the proximal medial tibia. Gracilis and semitendinosis tendons were identified. The tendons were left attached distally and resected way up in the thigh. This gave 2 tendons that could be used for reinforcement. The gracilis tendon was sutured to the medial aspect of the patella and the medial retinaculum running up the medial side of the patella past the site of repair using #2 Force fiber suture. The semitendinosis tendon was passed through the distal insertion of the patellar tendon at the tibial tubercle and run up the lateral side of the patella. The tendon was sutured to the soft tissues with #2 Force fiber suture that was sutured to the patella tendon, lateral retinaculum adjacent to the lateral patella, and distal quadriceps tendon. The passive range of motion of the knee was again checked the knee achieved only 40° of flexion. It was felt that this amount of motion would allow the repair to create good full extension with quadriceps contraction. The intent is to immobilize the knee in full extension for several weeks, followed by 0-30 degrees motion, followed by 0-60 degrees motion, followed at 6 weeks by 0-90 degrees motion, so that the patient can slowly regain flexion while maintaining an intact extensor mechanism.
A culture was obtained of the knee joint upon entering the knee and sent to microbiology as a specimen.
Thanks for all the help!!
Preoperative Diagnosis
Periprosthetic right patella fracture, chronic
Postoperative Diagnosis
Same
Procedure Performed
Open treatment of periprosthetic right patella fracture with distal pole patella excision, and extensor mechanism reconstruction with hamstrings (gracilis and semitendinosus)
Patient was taken to the operating room where the right lower extremity was prepped and draped in a sterile fashion. Anterior longitudinal incision was reopened and extended somewhat distally. Full-thickness flaps were developed medially and laterally around the extensor mechanism. The central portion of the patellar tendon was thinned and attenuated. The distal pole fragment was identified and excised sharply and removed. The patella was inspected and it was noted that the polyethylene patellar component was still intact and fully covered on the main body of the patellar bone. It was decided to keep the patellar component since it was still intact, but to avoid putting any drill holes or suture holes in the patella itself to avoid further patellar failure. The distal portion of the patellar tendon was still thick and viable. The patella itself could be pulled down to where the distal pole was at the joint line, so the patella Alta in this case was not particularly contracted into a cephalad migrated position. The redundant soft tissue between the main body of the patella and the location of the excised patellar fragment was split midline and the patella was brought distally, and the medial and lateral limbs of all the soft tissue in the thin attenuated portion of the patellar tendon was wrapped medially and laterally around the patella and sutured to the retinacular tissues on the medial and lateral side of the patella. This gave a very good repair. When the knee was allowed to passively flex, and only flexed to about 40°. The decision was made not to rely only on this tentative repair of the soft tissues back to the patella, but to add hamstring grafts to completely reinforce the repair.
The pes anserine tendons were exposed on the proximal medial tibia. Gracilis and semitendinosis tendons were identified. The tendons were left attached distally and resected way up in the thigh. This gave 2 tendons that could be used for reinforcement. The gracilis tendon was sutured to the medial aspect of the patella and the medial retinaculum running up the medial side of the patella past the site of repair using #2 Force fiber suture. The semitendinosis tendon was passed through the distal insertion of the patellar tendon at the tibial tubercle and run up the lateral side of the patella. The tendon was sutured to the soft tissues with #2 Force fiber suture that was sutured to the patella tendon, lateral retinaculum adjacent to the lateral patella, and distal quadriceps tendon. The passive range of motion of the knee was again checked the knee achieved only 40° of flexion. It was felt that this amount of motion would allow the repair to create good full extension with quadriceps contraction. The intent is to immobilize the knee in full extension for several weeks, followed by 0-30 degrees motion, followed by 0-60 degrees motion, followed at 6 weeks by 0-90 degrees motion, so that the patient can slowly regain flexion while maintaining an intact extensor mechanism.
A culture was obtained of the knee joint upon entering the knee and sent to microbiology as a specimen.
Thanks for all the help!!