This is a toughy. Codes I'm leaning towards are 27071, 20680, 11981 however I just thinkg I could be missing something or could be completely off base. Please help:
PROCEDURE: Takedown of fusion, removal of the femoral head and fusion bone, debridement, create a new acetabulum, removal of one broken screw, and insertion of Prostalac implant to statically used.
DESCRIPTION OF PROCEDURE:. Using the previous surgical wound and veering posteriorly, the skin subQ was divided, the IT band was divided, the skin wound was divided. A probe was placed in the sinus tract and this was followed down to bone. The tissues were mobilized off the gluteus medius. The sciatic nerve was identified. The gluteus maximus was released. The scar tissue posteriorly was excised down to the fusion site. With maximum internal and external rotation, one could see jog of motion at the fusion site consistent with a fibrous union and not solid bony fusion. Further dissection was carried out anteriorly exposing the calcar and the lesser trochanter. The iliopsoas was released from the lesser trochanter. Using then an oscillating saw, the neck was transected. The soft tissues were reflected off the posterior acetabulum, our fusion mass off the superior acetabulum with care being taken to try to not damage the gluteus medius and minimus. The fusion had taken place in 1984 and the abductors were markedly atrophied. There was very little recognizable abductor. Using osteotome and gouges, starting posteriorly, the bone was slowly removed from the old acetabulum. This was made a bit easier because of the fibrous union giving us a clearcut delineation between the head of the femur and the old acetabulum. Once the head of the femur was removed in this fashion, we had developed a neo-acetabulum full of granulation tissue. Using large curettes, the acetabulum was curetted of soft tissue. There was marked bone anteriorly preventing still range of motion of the hip and using again an osteotome and curettes as best possible, the anterior rim of the acetabulum was developed and the femur was slowly mobilized. We were finally able mobilize the femur to where we could internally rotate 90 degrees giving us access to the femoral neck. At this point, I used the reamers to further debride and develop the acetabulum. It was felt that it would be ideal if we could easily remove or we could remove the broken off screws, and using x-ray I was able to identify the site I felt that the screws most likely resided. There was some granulation tissue at the superior aspect of the acetabulum and this is where the sinus tract ended so it was felt that we are dealing with an osteomyelitis involving the bone of the superior acetabulum. Using a burr, we were able to burr down to the most proximal screw and the screw which was not penetrating into the pelvis. Over-reaming the screw, I was able to remove the screw without a great deal of difficulty. Again using the C-arm, I was able to identify a second screw where it should have been. We were able to place a clamp right on what would appeared to be the tip of the 2nd screw and this was in line just distal to the first screw but it was buried in more deeply and about half the broken off screw was in the pelvis. Using a burr and going down on what it was felt to be location of this broken off screw, we encountered brisk arterial bleeding, which was packed off with bone wax. We were not in the pelvis with the burr, but still in the ilium, but I was concerned about this and was very concerned about attempting to remove this broken off screw which was in the pelvis; I was concerned about arterial injury in so doing. It should be noted that there was no infected screw tract or any evidence that there was communication of this broken off screw with the previously-described sinus tract or with the acetabulum. I did not feel that this screw was infected and did not feel that we needed to remove this half screw all the attendant risk in and so doing, and we abandoned this part of the procedure and left the screw, again with bone over the screw and no evidence of communication with the joint. The broaching was then carried out of the proximal femur. My intent was to use an articulated Prostalac designed spacer and we were able, using multiple reamers, I was able to open up the femur so we could get the smallest Prostalac implant seated it in the femur. Unfortunately with this Prostalac implant fully seated, I was still unable to create enough room in the acetabulum to use a head on the trunnion. I did go ahead and deepen the acetabulum further to create more room for an articulated spacer, but once again, I was unable to get enough distraction to use an articulated spacer. It was felt that, I would have to, in order to get distraction I needed, would need to do an extended trochanteric osteotomy with dissection of further anterior bone. At this point in the case, we had already lost probably 1000 mL of blood, and I did not feel that this was warranted, so we went ahead with a static spacer. We first made our femoral cement-coated implant and this was using a Prostalac mold. We used 1 bag of cement with 3 g of vancomycin and 4.2 g of tobramycin. After inserting the femoral implant, we mixed up 2 more bags of cement. These 2 bags of cement had 6 g of vancomycin and 7.2 g of tobramycin. The cement was placed in the acetabulum in a doughy phase. The trunnion reduced into the cement and the cement was allowed to cure around the trunnion. Wound closure was with #1 Vicryl sutures followed by 2-0 Vicryl suture and running 3-0 nylon. The deep tissues were injected with a cocktail of 400 mg of ropivacaine, 30 of Toradol, 10 of morphine, and 0.6 of epinephrine. The subQ was injected with remainder of the above cocktail.
PROCEDURE: Takedown of fusion, removal of the femoral head and fusion bone, debridement, create a new acetabulum, removal of one broken screw, and insertion of Prostalac implant to statically used.
DESCRIPTION OF PROCEDURE:. Using the previous surgical wound and veering posteriorly, the skin subQ was divided, the IT band was divided, the skin wound was divided. A probe was placed in the sinus tract and this was followed down to bone. The tissues were mobilized off the gluteus medius. The sciatic nerve was identified. The gluteus maximus was released. The scar tissue posteriorly was excised down to the fusion site. With maximum internal and external rotation, one could see jog of motion at the fusion site consistent with a fibrous union and not solid bony fusion. Further dissection was carried out anteriorly exposing the calcar and the lesser trochanter. The iliopsoas was released from the lesser trochanter. Using then an oscillating saw, the neck was transected. The soft tissues were reflected off the posterior acetabulum, our fusion mass off the superior acetabulum with care being taken to try to not damage the gluteus medius and minimus. The fusion had taken place in 1984 and the abductors were markedly atrophied. There was very little recognizable abductor. Using osteotome and gouges, starting posteriorly, the bone was slowly removed from the old acetabulum. This was made a bit easier because of the fibrous union giving us a clearcut delineation between the head of the femur and the old acetabulum. Once the head of the femur was removed in this fashion, we had developed a neo-acetabulum full of granulation tissue. Using large curettes, the acetabulum was curetted of soft tissue. There was marked bone anteriorly preventing still range of motion of the hip and using again an osteotome and curettes as best possible, the anterior rim of the acetabulum was developed and the femur was slowly mobilized. We were finally able mobilize the femur to where we could internally rotate 90 degrees giving us access to the femoral neck. At this point, I used the reamers to further debride and develop the acetabulum. It was felt that it would be ideal if we could easily remove or we could remove the broken off screws, and using x-ray I was able to identify the site I felt that the screws most likely resided. There was some granulation tissue at the superior aspect of the acetabulum and this is where the sinus tract ended so it was felt that we are dealing with an osteomyelitis involving the bone of the superior acetabulum. Using a burr, we were able to burr down to the most proximal screw and the screw which was not penetrating into the pelvis. Over-reaming the screw, I was able to remove the screw without a great deal of difficulty. Again using the C-arm, I was able to identify a second screw where it should have been. We were able to place a clamp right on what would appeared to be the tip of the 2nd screw and this was in line just distal to the first screw but it was buried in more deeply and about half the broken off screw was in the pelvis. Using a burr and going down on what it was felt to be location of this broken off screw, we encountered brisk arterial bleeding, which was packed off with bone wax. We were not in the pelvis with the burr, but still in the ilium, but I was concerned about this and was very concerned about attempting to remove this broken off screw which was in the pelvis; I was concerned about arterial injury in so doing. It should be noted that there was no infected screw tract or any evidence that there was communication of this broken off screw with the previously-described sinus tract or with the acetabulum. I did not feel that this screw was infected and did not feel that we needed to remove this half screw all the attendant risk in and so doing, and we abandoned this part of the procedure and left the screw, again with bone over the screw and no evidence of communication with the joint. The broaching was then carried out of the proximal femur. My intent was to use an articulated Prostalac designed spacer and we were able, using multiple reamers, I was able to open up the femur so we could get the smallest Prostalac implant seated it in the femur. Unfortunately with this Prostalac implant fully seated, I was still unable to create enough room in the acetabulum to use a head on the trunnion. I did go ahead and deepen the acetabulum further to create more room for an articulated spacer, but once again, I was unable to get enough distraction to use an articulated spacer. It was felt that, I would have to, in order to get distraction I needed, would need to do an extended trochanteric osteotomy with dissection of further anterior bone. At this point in the case, we had already lost probably 1000 mL of blood, and I did not feel that this was warranted, so we went ahead with a static spacer. We first made our femoral cement-coated implant and this was using a Prostalac mold. We used 1 bag of cement with 3 g of vancomycin and 4.2 g of tobramycin. After inserting the femoral implant, we mixed up 2 more bags of cement. These 2 bags of cement had 6 g of vancomycin and 7.2 g of tobramycin. The cement was placed in the acetabulum in a doughy phase. The trunnion reduced into the cement and the cement was allowed to cure around the trunnion. Wound closure was with #1 Vicryl sutures followed by 2-0 Vicryl suture and running 3-0 nylon. The deep tissues were injected with a cocktail of 400 mg of ropivacaine, 30 of Toradol, 10 of morphine, and 0.6 of epinephrine. The subQ was injected with remainder of the above cocktail.