The operative report was "coded" as CPT 20670, 20690, 27216, 27217, 27536.
I am grateful for any assistance.
The patient was taken to the operating room suite, where - was intubated and sedated on the hospital bed by anesthesia staff without complication. - was transferred to the operating room table. All bony prominences were well padded. Sequential compressive device on the right lower extremity. Foley catheter in place. Bilateral upper extremities on foam padding, well padded. The left lower extremity also well padded with foam padding in long leg splint to be removed for second portion of the surgical procedure. Right distal femoral skeletal traction remained in place to allow for deformity correction during fixation of pelvic ring. Approximately 15 pounds distal femoral skeletal traction were maintained. Appropriate prophylactic
antibiotics were administered by anesthesia staff. The pelvic region was then prepped and draped in sterile fashion. A surgical pause was performed. All members of the surgical team were present. No objections to proceeding.
Attention was turned to the anterior aspect of the pelvic ring. A uniplanar external fixator was applied to correct internal rotation, flexion deformity of the right hemipelvis. Attention was turned to the anterior aspect of the right hemipelvis, where a 1.6 mm Kirschner wire was inserted to appropriate start site and trajectory for insertion of a supraacetabular Schanz pin. A small stab incision was made after the wire was inserted unicortically and a 4.5 mm cannulated drill and soft tissue sleeve were inserted several centimeters using multiplanar fluoroscopic imaging to ensure safe passage of the drill in the osseous corridor. A 5 mm Schanz pin was subsequently inserted and seated just above the greater sciatic notch. This procedure was
repeated on the left hemipelvis for insertion of an additional supraacetabular Schanz pin. An oblique distraction vector, left cranial to right caudal was then applied through an anterior uniplanar external fixator pin-to-bar frame with additional traction being applied to the right lower extremity to correct the flexion deformity, after which time a near anatomic restoration of overall pelvic alignment was achieved.
Attention was then turned to the posterior pelvic ring. A 1.6 mm Kirschner wire was inserted to the appropriate start site and trajectory for insertion of an iliosacral screw at the first sacral segment. The wire was inserted percutaneously and unicortically after which time a small stab incision was made and 4.5 mm drill with soft tissue sleeve was inserted. The drill was then passed using multiplanar fluoroscopic imaging to confirm safe placement throughout, followed by exchange for a 3.2 mm wire after which a scratch technique was performed without evidence of cortical perforation throughout the osseous pathway. A partial thread through 7.0 mm cannulated screw with washer of appropriate length was subsequently inserted, achieving compression across the posterior aspect of the crescent fragment as confirmed using multiplanar fluoroscopic imaging.
The procedure was then repeated at the second sacral segment for insertion of a transiliac transsacral screw. A 1.6 mm Kirschner wire was inserted unicortically followed by a small stab incision after which a 4.5 mm cannulated drill and soft tissue sleeve were inserted. The drill was passed to the level of the mid sacral body. Again, using multiplanar fluoroscopic imaging including AP, inlet, outlet lateral sacral views. This was exchanged for a 3.2 mm threaded wire to perform a scratch technique without evidence of cortical perforation. The drill was then reinserted and continued across the midline of the sacrum; however, with limited resistance at this time. Due to the tortuous nature and degree of sacral dysmorphism present, the decision was made to obtain a 3D fluoroscopic image with the drill in place. This demonstrated that the osseous pathway may not be viable extending anteriorly to this degree and thus, the drill was pulled back and redirected posteriorly, after which time a greater degree of cortical resistance was noted. A scratch technique was again performed without evidence of cortical perforation anteriorly in the left hemipelvis and the wire was inserted across the contralateral sacroiliac joint and outer table of the ilium. A depth gauge was used to measure for screw of appropriate length and subsequent insertion of a 7.0 mm cannulated screw fully threaded in nature performed.
Attention was then turned to the anterior pelvic ring where a 1.5 mm Kirschner wire was inserted percutaneously at the appropriate start site trajectory for subsequent insertion of an antegrade 4.5 mm cannulated superior ramus screw. Multiplanar fluoroscopic imaging including obturator outlet and inlet views were used. The wire was inserted approximately 1 cm. A small stab incision was made, followed by insertion of a 4.5 mm cannulated drill. This was inserted to the supraacetabular region under fluoroscopic guidance, followed by insertion of a 2.0 mm blunt-tipped wire, which was tapped to the level of the pubic body. Subtraction measure wire technique was subsequently utilized and the 4.5 mm cannulated screw was inserted. Provisional fixation was removed at that time including anterior pelvic external fixator pin-to-bar frame in skeletal traction. Final fluoroscopic imaging obtained, confirming restoration of alignment with stable fixation and safe placement of all implants. Wounds were copiously irrigated with normal saline and sequential layered closure was performed beginning with 2-0 PDS for deep dermal tissue and 3-0 nylon for the skin in vertical mattress suture pattern. Sterile dressings were applied and drapes were
removed.
Attention was then turned to the left lower extremity. The patient was repositioned, sacral bump was removed and left lower extremity was placed on a bone foam ramp. The left lower extremity was then prepped and draped in sterile fashion. Repeat surgical pause was performed. All members of the surgical team were present. No objections to proceeding.
Attention was turned to the proximal femur. Fluoroscopic guidance was used to localize the appropriate position for placement of a 5 mm Schanz pin distal to the lesser trochanter. Skin was incised sharply with knife and a 3.2 mm drill was inserted bicortically through a soft tissue sleeve, through after which a 5 mm Schanz pin was inserted by hand under irrigation. The procedure was repeated at the distal tibia for insertion of a second 5 mm Schanz pin and a pin-to-bar frame was constructed. A gentle distraction vector was then applied to the pin-to-bar frame which was locked into place. A 1.6 mm Kirschner wire was then inserted percutaneously under fluoroscopic guidance from lateral to medial in the subchondral region, traversing a minimally displaced intraarticular proximal tibia split. The wire was passed and out the medial aspect and a small stab incision was made, allowing for insertion of a depth gauge to measure for subsequent screw insertion of appropriate length. Prior to screw insertion, a periarticular clamp was applied to achieve compression across the articular surface and a fully threaded 3.5 mm cortical screw of appropriate length was inserted in a medial to lateral fashion. Kirschner wire was subsequently removed.
Additional Schanz pins were applied, 1 in the distal femur and 1 in the proximal tibia and the overall alignment of the fracture was adjusted, confirmed to be acceptable to allow for soft tissue decompression. A significantly displaced tibial tubercle segment was then indirectly manipulated with gentle palpation and repositioning of the leg and provisionally stabilized with 2 percutaneous 1.6 mm Kirschner wires, which were cut short and buried underneath the skin. Final fluoroscopic imaging obtained, confirming acceptable alignment, stable fixation and safe placement of all implants. Wounds were irrigated with normal saline. Percutaneous wounds were closed using 3-0 nylon in a vertical mattress suture pattern. Sterile Kerlix bolsters were applied. Drapes were removed and final plain film radiographs obtained confirming intraoperative fluoroscopic findings of restoration of alignment with stable fixation and safe placement of implants.
The patient was subsequently awakened from anesthesia, extubated, and transferred to the hospital bed, and taken to PACU for recovery in stable condition.
ATTESTATION: I was present and scrubbed for the entire case.
Postoperative protocol as noted above.