LScoder2016
Networker
Im hoping someone can help me out. The patient injured their foot last summer. patient seen in February and MRI results "The ligament appears thin and stretched out and not the thick radio dense structure it typically is when uninjured."
Provider stated they would move forward with a repair of Lisfranc ligament with Stress imaging of Lisfranc interval. I was thinking CPT 28615-Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed, due to suture button technique as the internal fixature of a lisfranc injury, but I'm thrown off with tarsometatarsal joint dislocation. Any feedback would be great! Thanks in advance.
Preoperative Diagnosis & Postoperative Diagnosis:
Lisfranc sprain, right
Midfoot instability, right
Implants:
Flex band twist, artelon 0.12
Flex band twist, artelon 0.3
G lock implant Stryker
PRP injection
Attention was then directed to the midfoot region of the right lower extremity. X-ray was utilized to mark out base and lateral border of 2nd metatarsal as well as cuneiform medially and intermediate cuneiform dorsally.
Incision was made with sterile 15 blade through skin directly over lateral distal aspect of base of 2nd metatarsal.
K-wire was then obtained and utilized to guide fixation from lateral aspect of 2nd metatarsal base obliquely and proximally oriented towards the medial wall of the medial cuneiform.
Appropriate trajectory across Lisfranc interval was confirmed via fluoroscopy. Over drilling was performed for Artelon ligament repair. Free long straight needle was then utilized to pull flex band through drilled hole from lateral to medial. Suture button was applied to lateral aspect of implant and situated on lateral base of 2nd metatarsal appropriately.
Appropriate tension was applied to flex band and G lock implant was utilized to secure flex band within osseous tunnel of medial cuneiform. Appropriate tension was noted with reduction of Lisfranc interval on x-ray. Attention was then directed to the dorsal aspect of the midfoot where a fresh sterile 15 blade was utilized to incise directly over intermediate cuneiform.
Care was taken to retract and protect neurovascular bundle. K-wire was provisionally placed dorsally perpendicular to cuneiform and drilling was performed. Soft tissue envelope was freed dorsally over midfoot and medial arm of flex band was crossed under soft tissue envelope and secured per manufacture instructions with G lock in dorsal intermediate cuneiform drill hole.
Appropriate reduction was confirmed with fluoroscopy. Stress imaging xray obtained by stressing the 1st and 2nd metatarsal and no laxity was noted across the lisfranc interval. No excessive movement was noted across the Lisfranc interval through stress.
Tourniquet was deflated and surgical site irrigated with copious amounts of normal saline. Adequate hemostasis was achieved prior to closure.PRP injected to surgical site. Local block performed with one-to-one mixture 20 cc Exparel (133mg) and 0.5% Marcaine in sterile manner.Deep closure performed with 2-0 Vicryl and skin reapproximated with 2-0 nylon.Dressing of Xeroform, 4x4s, Kling, Ace applied to lower extremity secured in Cam boot.Patient tolerated the procedure and anesthesia well. The patient was transferred to the PACU with stable vital signs. After a period of postoperative monitoring, the patient will be discharged home. The patient will be heel touch weightbearing to the right foot.
Provider stated they would move forward with a repair of Lisfranc ligament with Stress imaging of Lisfranc interval. I was thinking CPT 28615-Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed, due to suture button technique as the internal fixature of a lisfranc injury, but I'm thrown off with tarsometatarsal joint dislocation. Any feedback would be great! Thanks in advance.
Preoperative Diagnosis & Postoperative Diagnosis:
Lisfranc sprain, right
Midfoot instability, right
Implants:
Flex band twist, artelon 0.12
Flex band twist, artelon 0.3
G lock implant Stryker
PRP injection
Attention was then directed to the midfoot region of the right lower extremity. X-ray was utilized to mark out base and lateral border of 2nd metatarsal as well as cuneiform medially and intermediate cuneiform dorsally.
Incision was made with sterile 15 blade through skin directly over lateral distal aspect of base of 2nd metatarsal.
K-wire was then obtained and utilized to guide fixation from lateral aspect of 2nd metatarsal base obliquely and proximally oriented towards the medial wall of the medial cuneiform.
Appropriate trajectory across Lisfranc interval was confirmed via fluoroscopy. Over drilling was performed for Artelon ligament repair. Free long straight needle was then utilized to pull flex band through drilled hole from lateral to medial. Suture button was applied to lateral aspect of implant and situated on lateral base of 2nd metatarsal appropriately.
Appropriate tension was applied to flex band and G lock implant was utilized to secure flex band within osseous tunnel of medial cuneiform. Appropriate tension was noted with reduction of Lisfranc interval on x-ray. Attention was then directed to the dorsal aspect of the midfoot where a fresh sterile 15 blade was utilized to incise directly over intermediate cuneiform.
Care was taken to retract and protect neurovascular bundle. K-wire was provisionally placed dorsally perpendicular to cuneiform and drilling was performed. Soft tissue envelope was freed dorsally over midfoot and medial arm of flex band was crossed under soft tissue envelope and secured per manufacture instructions with G lock in dorsal intermediate cuneiform drill hole.
Appropriate reduction was confirmed with fluoroscopy. Stress imaging xray obtained by stressing the 1st and 2nd metatarsal and no laxity was noted across the lisfranc interval. No excessive movement was noted across the Lisfranc interval through stress.
Tourniquet was deflated and surgical site irrigated with copious amounts of normal saline. Adequate hemostasis was achieved prior to closure.PRP injected to surgical site. Local block performed with one-to-one mixture 20 cc Exparel (133mg) and 0.5% Marcaine in sterile manner.Deep closure performed with 2-0 Vicryl and skin reapproximated with 2-0 nylon.Dressing of Xeroform, 4x4s, Kling, Ace applied to lower extremity secured in Cam boot.Patient tolerated the procedure and anesthesia well. The patient was transferred to the PACU with stable vital signs. After a period of postoperative monitoring, the patient will be discharged home. The patient will be heel touch weightbearing to the right foot.
