tendon transfers in the hand


Northampton, PA
Best answers
hello- posting for a co-worker- thoughts on CPT codes?

26946 and 26492 x 2 OR 26483 x 2??? This is the first time I’m seeing an Oppenensplasty procedure and I’m not sure if the 2nd and 3rd Pxs are part of it or not

POSTOPERATIVE DIAGNOSIS: Right hand Charcot-Marie-Tooth disease with
combined low median and ulnar nerve palsies.
  1. Right thumb opponensplasty with extensor indicis proprius tendon
transfer in the hand.
  1. Right index finger abductor plasty with abductor pollicis longus
tendon transfer with graft to the 1st dorsal interosseous.
  1. Right thumb adductor plasty with extensor carpi radialis longus
tendon transfer in the wrist with tendon graft.
  1. Tendon graft harvest from the right leg.

A transverse incision was made over the MP joint of the index finger. The ulnar
deep tendon was identified as the extensor indicis proprius and was
detached at its insertion. Then, a longitudinal incision was made in
the distal forearm and dorsal wrist extending from the ECRL insertion
proximally to the proximal portion of the dorsal wrist retinaculum.
In this wound, I was able to identify the EIP just distal to the
retinaculum. It was identified there and then pulled into the wound,
and then it was identified proximal to the dorsal wrist retinaculum,
where there was a fenestration that I created in the dorsal forearm
fascia. Next, attention was directed to the ECRL, where it was
identified at its insertion and detached for later transfer. An
incision was made over the proximal radial base of the thumb
metacarpal, where the APL was identified and detached.

Next, a 3 cm incision was made over the medial aspect of the distal portion of the
tendo-Achilles. The plantaris tendon was identified and encircled
with a piece of umbilical tape. The umbilical tape was used to strip
the plantaris proximally harvesting approximately 15 to 20 cm of plantaris tendon.

Attention was
redirected back to the forearm. I elected to perform the adductor
plasty for the thumb first. The plantaris was woven as described by
Pulvertaft into the distal end of the ECRL tendon using
Kelly/hemostats. A passage was made in between the interosseous
space of the middle and ring fingers after first making a 2 cm
incision in that area. The counter incision was then made over the
radial aspect of the MP joint. Careful dissection protected the
sensory radial nerve branches. The adductor insertion was
identified. A Kelly retractor was used to make a subcutaneous and
submuscular tunnel between the middle and ring finger metacarpals
progressing radially, hugging the volar aspects of the metacarpals
and ending in the wound on the ulnar side of the thumb MP joint
passing through the 1st web space. The tendon attached to the distal
end of the ECRL was then passed into this wound. A Pulvertaft weave
was placed into the adductor insertion with multiple figure-of-eight
sutures of 3-0 Ethibond. The extra portion of the tendon,
approximately 5 cm long, was harvested from the end of the tendon
where it had been repaired. The adductor plasty was tensioned such
that with the wrist in neutral the thumb was in neutral
abduction/adduction. With the wrist in flexion, the thumb nicely
adducted. Next, attention was directed to the abductor plasty. The
remainder of the tendon graft was repaired with a Pulvertaft weave
using 3-0 Ethibond suture into the distal end of the abductor
pollicis longus. Then, once this was repaired, it was passed in a
subcutaneous tunnel and repaired to the insertion of the 1st dorsal
interosseous on the radial side of the index metacarpal, again using
a Pulvertaft type weave into the tendon, tensioning it such that the
index finger slightly radially deviated. Lastly, the opponensplasty
was performed with the EPL that had been previously harvested. A
subcutaneous tunnel was made from the dorsal wound to the ulnar side
of the hand, where an oblique incision about 3 cm long was made. The
tendon was passed into this incision in the subcutaneous tissue and
then passed around the palmar aspect of the hand near the pisiform
using a Kelly. The Kelly was inserted just proximal to the pisiform
and passed under the subcutaneous tissue to the radial side of the
thumb MP joint. The tendon was passed then through this subcutaneous
tunnel and inserted into the conjoined tendon of the thenar
musculature as well as the EPL. This again was done with a weave
using 3-0 Ethibond. All wounds were irrigated and then closed.
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