Doc did an open immobilization, release and repair of the medial retinacular on a patient with a total knee. My head says 27422 but my gut says "No..not quite." Anything else come to anyone's mind?
Here's the note...
Preoperative Diagnosis: Medial retinacular disruption, left knee, status post complex left total knee arthroplasty revision following previous infection and extensive bone loss.
Postoperative Diagnosis: Medial retinacular disruption, left knee, status post complex left total knee arthroplasty revision following previous infection and extensive bone loss.
Procedures: 1. Medial retinacular immobilization and closure in a pants-over-vest technique. 2. Open left extensive lateral release.
Procedure in Detail: _____ is a patient who had a knee replacement which subsequently came to infection and developed progressive loosening, seen in our office, and extensive two-stage exchange treatment for his infection followed. Initially, there was good success with range of motion in the operating room, once closed for about 80 degrees. Unfortunately, he suffered a fall on the postoperative period very recently and because of this, radiographs were performed, which showed visible dislocation of his patella suggesting medial retinacular disruption and possibly a partial strain of the MCL.
Operative repair was recommended. Extensive risks and benefits were discussed including the risks of stroke, heart attack, death, infection, loosening and wear. He presented to the hospital, was identified appropriately and was involved in surgical site marking in line with the skin incision in the form of the word “yes” and surgeon initials. He was brought to the operating room with procedure verification timeout was completed for appropriate side, site, surgical intervention, positioning, adequate padding of all bony prominences, and verifications of implants, instruments, radiographs as necessary were present and available for surgery. The left leg was isolated with 1010 drapes and nonsterile tourniquet after general anesthesia was induced. Esmarch exsanguination was performed.
The prior skin incision was utilized to gain access to the deep tissues. A medial retinacular flap was fashioned off the anterior surface of the patella. At the complete disruption, the far medial aspect was isolated to the superior tissues. The inferior retinaculum was disrupted, however, only slightly. Extensive lateral release was performed after undermining of the soft tissues. Centralization of the patella was then accomplished. A pants-over-vest closure with Ethibond suture was performed after evacuation of hematoma and extensive irrigation with bacitracin-impregnated solution. Throughout the closure, the knee was assessed through a range of motion. Flexion was tolerated about 70 degrees with the patella centralized. There was a slight medial-lateral laxity, however, it is well balanced. The MCL was palpable and intact and in continuity.
After definitive deep closure with Ethibond suture, subcu closure followed with 2-0 Vicryl, skin was closed with staples. Sterile dressing was applied. Tourniquet deflated. The patient tolerated the procedure well. We placed a knee immobilizer, strictly held a range of motion limited to 0 to 20 degrees, and a plan for a very limited physical therapy except under direct supervision.
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