EHFcoding
New
Hello everyone, we will appreciate a second opinion for the following op report. 27138-22, but not sure about additional codes.
Postoperative Diagnoses:
1. Left periprosthetic fracture involving the left femur with previous left total hip arthroplasty in place with subsidence of the femoral stem, status post previous fixation of the femur for periprosthetic distal femur fracture with total knee arthroplasty in place with separate fracture extending within the periprosthetic fixation of the previous distal femur.
2. History of left hip arthroplasty and possible revision left hip arthroplasty at outside hospital.
3. History of left total knee arthroplasty.
4. History of periprosthetic fracture of the distal femur with open reduction and internal fixation of the distal femur.
5. Nonunion with fibrous union of portions of the greater trochanter , intertrochanteric femur and malunion of the lesser trochanter region
Indications for Procedure: The patient, female presenting with extremely complex presentation of the left femur. She has undergone multiple surgeries including left total hip arthroplasty, possible revision of left total hip arthroplasty, left total knee arthroplasty, periprosthetic of the distal femur, and open reduction and internal fixation of the distal femur using plate and screw fixation, now presenting with likely subsidence of the femoral stem and multiple fractures of the proximal femur and fractures extending into the femoral shaft along portions of the previous fixation. The risks, benefits, and alternatives were discussed with the patient and she would like to proceed with surgery again understanding risks and benefits.
Procedure In Detail: The patient was identified in the preoperative holding area. The operative site was marked by the surgical team. The patient was then brought to the operating room, where general endotracheal anesthesia was induced. The left lower extremity was prepped and draped in the usual sterile fashion after the patient was positioned laterally. At this time, an incision was made along the proximal left femur extending to the skin and fat down to the level of the fascia and extensive amount of scarring and true planes were difficult to establish, but after the fasciotomy, posterior femur was identified proximally and incision was taken along the posterior femur. Distally the vastus lateralis was dissected anteriorly revealing the femoral shaft more distally. The previous plate was visualized from the previous fixation. Cerclage cables were placed proximal to the plate to prevent any subsidence of the proximal fractures. Given possibly use of a long stem, prophylactic fixation of the distal femur was then performed with separate incision along the mid, distal portion of the femur. This was taken through the skin and fat down to the fascia and against the vastus lateralis, the femoral bone was exposed and cerclage cables were placed for distal prophylactic fixation. Attention was then turned back to the femur proximally. There was severe anatomy disruptance; proximally the lesser trochanter was healed in malunited position posteriorly and the greater trochanter was nearly nonexistent posteriorly. There was some fibrous union of anterior greater trochanter likely from previous chronic fractures of the greater trochanter from her previous revision surgery. Regardless, the stem was visualized and found to be subsided. The timing of the subsidence was suspect given that the stem was well healed to the lateral trochanteric bone. Bur was taken to loosen the attachments and the stem then removed. At this time, the anatomy of the proximal femur was noted to be quite disrupted given large loss of proximal bone. The lesser trochanter, healed in a malunited position, was a reference point. Regardless, reaming began in the femur after removal of multiple screws in the proximal plate that was previously placed. After appropriate reaming, the appropriate size stem was impacted into the distal femur. We then trialed a proximal body that was appropriate and then removed the body and turned attention to the acetabulum. Retractors were placed and appropriate soft tissue releases were performed. Previous acetabular system had an incompatible head with the new system and no liners were made for the type of cup which was in place, which is a Solitaire cup, therefore, the previous liner was removed using osteotomes. The cup was found to be well fixed in an acceptable position. Therefore, we chose to retain the previous well-fixed cup. Appropriate-size acetabular liner was fashioned where the previous cut and modulated in the back table for cementing. The liner was then cemented within the femoral cup with increased version, then previously placed after the new acetabular position was solidified. Attention was then turned back to the femur. Proximal body was placed using a +10 body and trialing began. Trialing was found to be appropriate in terms of leg length and stability. Therefore, the final proximal body was packed into place and a +2.5 head was placed and the hip was reduced once more. Hip was found to be stable throughout range of motion and therefore, the wound was thoroughly irrigated and at this time, the posterior capsular tissues were closed with 0 Vicryl. The previous fibrotic union of greater trochanter was evaluated and malunion of the greater trochanter while intact may prove future issue, therefore, we decided to address the malunion. The fibrous tissue was taken down at the malunion site and bone graft was placed from previously obtained reamers. FiberTape was used to fix the nonunited fracture and drilled through the lesser trochanter to wrap it in position. This would hopefully lead to better union and prevention of any complications down the line. At this time, the wounds were then further closed with 0 Vicryl, 2-0 Monocryl, 3-0 Monocryl, and sterile dressings were applied. The patient was awoken from anesthesia and transferred to the recovery room in stable condition.
For coding purposes, this case warrants the use of 22 modifier. The patient presents with multiply revised field in the left femur. There was extensive amount of scar tissue and range of motion was quite difficult to obtain due to the severe contractures with increased time, effort, surgical skill, surgical technique of greater than 100%.
Postoperative Diagnoses:
1. Left periprosthetic fracture involving the left femur with previous left total hip arthroplasty in place with subsidence of the femoral stem, status post previous fixation of the femur for periprosthetic distal femur fracture with total knee arthroplasty in place with separate fracture extending within the periprosthetic fixation of the previous distal femur.
2. History of left hip arthroplasty and possible revision left hip arthroplasty at outside hospital.
3. History of left total knee arthroplasty.
4. History of periprosthetic fracture of the distal femur with open reduction and internal fixation of the distal femur.
5. Nonunion with fibrous union of portions of the greater trochanter , intertrochanteric femur and malunion of the lesser trochanter region
Indications for Procedure: The patient, female presenting with extremely complex presentation of the left femur. She has undergone multiple surgeries including left total hip arthroplasty, possible revision of left total hip arthroplasty, left total knee arthroplasty, periprosthetic of the distal femur, and open reduction and internal fixation of the distal femur using plate and screw fixation, now presenting with likely subsidence of the femoral stem and multiple fractures of the proximal femur and fractures extending into the femoral shaft along portions of the previous fixation. The risks, benefits, and alternatives were discussed with the patient and she would like to proceed with surgery again understanding risks and benefits.
Procedure In Detail: The patient was identified in the preoperative holding area. The operative site was marked by the surgical team. The patient was then brought to the operating room, where general endotracheal anesthesia was induced. The left lower extremity was prepped and draped in the usual sterile fashion after the patient was positioned laterally. At this time, an incision was made along the proximal left femur extending to the skin and fat down to the level of the fascia and extensive amount of scarring and true planes were difficult to establish, but after the fasciotomy, posterior femur was identified proximally and incision was taken along the posterior femur. Distally the vastus lateralis was dissected anteriorly revealing the femoral shaft more distally. The previous plate was visualized from the previous fixation. Cerclage cables were placed proximal to the plate to prevent any subsidence of the proximal fractures. Given possibly use of a long stem, prophylactic fixation of the distal femur was then performed with separate incision along the mid, distal portion of the femur. This was taken through the skin and fat down to the fascia and against the vastus lateralis, the femoral bone was exposed and cerclage cables were placed for distal prophylactic fixation. Attention was then turned back to the femur proximally. There was severe anatomy disruptance; proximally the lesser trochanter was healed in malunited position posteriorly and the greater trochanter was nearly nonexistent posteriorly. There was some fibrous union of anterior greater trochanter likely from previous chronic fractures of the greater trochanter from her previous revision surgery. Regardless, the stem was visualized and found to be subsided. The timing of the subsidence was suspect given that the stem was well healed to the lateral trochanteric bone. Bur was taken to loosen the attachments and the stem then removed. At this time, the anatomy of the proximal femur was noted to be quite disrupted given large loss of proximal bone. The lesser trochanter, healed in a malunited position, was a reference point. Regardless, reaming began in the femur after removal of multiple screws in the proximal plate that was previously placed. After appropriate reaming, the appropriate size stem was impacted into the distal femur. We then trialed a proximal body that was appropriate and then removed the body and turned attention to the acetabulum. Retractors were placed and appropriate soft tissue releases were performed. Previous acetabular system had an incompatible head with the new system and no liners were made for the type of cup which was in place, which is a Solitaire cup, therefore, the previous liner was removed using osteotomes. The cup was found to be well fixed in an acceptable position. Therefore, we chose to retain the previous well-fixed cup. Appropriate-size acetabular liner was fashioned where the previous cut and modulated in the back table for cementing. The liner was then cemented within the femoral cup with increased version, then previously placed after the new acetabular position was solidified. Attention was then turned back to the femur. Proximal body was placed using a +10 body and trialing began. Trialing was found to be appropriate in terms of leg length and stability. Therefore, the final proximal body was packed into place and a +2.5 head was placed and the hip was reduced once more. Hip was found to be stable throughout range of motion and therefore, the wound was thoroughly irrigated and at this time, the posterior capsular tissues were closed with 0 Vicryl. The previous fibrotic union of greater trochanter was evaluated and malunion of the greater trochanter while intact may prove future issue, therefore, we decided to address the malunion. The fibrous tissue was taken down at the malunion site and bone graft was placed from previously obtained reamers. FiberTape was used to fix the nonunited fracture and drilled through the lesser trochanter to wrap it in position. This would hopefully lead to better union and prevention of any complications down the line. At this time, the wounds were then further closed with 0 Vicryl, 2-0 Monocryl, 3-0 Monocryl, and sterile dressings were applied. The patient was awoken from anesthesia and transferred to the recovery room in stable condition.
For coding purposes, this case warrants the use of 22 modifier. The patient presents with multiply revised field in the left femur. There was extensive amount of scar tissue and range of motion was quite difficult to obtain due to the severe contractures with increased time, effort, surgical skill, surgical technique of greater than 100%.