I am trying to code an op note where the patient had trauma from circular saw, first OP session resulted in repair of vascular system and tendons and bone loss was noted.

The second staged surgery (a few weeks later) was for a bone graft from iliac crest and moved to reconstruct the first metacarpal.

POSTOPERATIVE DIAGNOSIS
Left thumb open fracture with bone loss.

PROCEDURE PERFORMED
Iliac crest bone graft to the left thumb metacarpal (second stage of staged
procedure).

HISTORY
The patient sustained a near amputation of the left thumb approximately 6 weeks ago with a circular saw. He was brought to the operating room the evening of the injury. The wounds were irrigated, tendons were repaired, a plate was placed across the first metacarpal, however, there was noted to be bone loss. The plan at the time was to return in approximately 6 weeks once the wound healed, ensuring there was no sign of any infection and then bone graft at that time. He comes in today for that particular procedure.

DESCRIPTION OF PROCEDURE
After patient identification and marking of the operative limb and site as well as the left iliac crest confirmation, the patient was brought to the operating room, placed on the operating table in supine position. General anesthesia successfully induced. The left upper extremity as well as the left hip prepped and draped in the usual fashion. Half-percent Marcaine with epinephrine, 10 mL, was injected along the left iliac crest. The left iliac crest was then approached sharply. The external oblique taken down
off the iliac crest. Using the Acumen reamer system, two 10-mm plugs were obtained. A small portion of corticocancellous of the crest itself was obtained for use in this as well. This wound was then irrigated with gentamicin spiked normal saline. The bone graft site itself was packed with thrombin-soaked Gelfoam. This was eventually closed in layers with 0 Vicryl, 2-0 Vicryl, 4-0 clear PDS with Mastisol and Steri-Strips.

Attention was turned to the left thumb. The arm was exsanguinated, a
tourniquet inflated to 250 mmHg. Under 4.5 X loupe magnification, the previous longitudinal incision over the first metacarpal was made. Flaps were raised. The first metacarpal was subperiosteally dissected. Care was taken to identify the tendons, which were repaired and reflected these as a unit. The granulation tissue was removed and the bone was taken back to cancellous bone both proximally and distally. The wound was irrigated with
gentamicin spiked normal saline. The cancellous bone graft was then packed in as tightly as possible. The corticocancellous piece was then wedged in as well. This filled the gap quite nicely with a combination of corticocancellous and tightly packed cancellous bone. The final C-arm pictures revealed the gap could be filled quite nicely with bone graft throughout the entire region.