I could use some help coding this case. I know what to do for teh removal retained implants, but not sure about the allograft.

1. Removal of retained deep surgical implants, partially resorb biocomposite screw, left tibia.
2. Cancellous allograft bone grafting tibial defect.


SURGICAL INDICATIONS: The patient is a 45-year-old white female with a history of a left knee ACL reconstruction done number of years ago with good results, but has now developed severe degenerative joint disease about the medial compartment, but also pain directly along the tibial insertion site for interference screw. She has a biocomposite absorbable Arthrex screw that appears to potentially be loosening with resorption, giving her symptoms. She is brought to surgery at this time for removal of the screw and bone grafting of the defect. The patient and family understand the possible risks and complications of the surgery to include, but not be limited to neurovascular compromise, infection, pain, stiffness, instability, arthritis, thrombophlebitis, weakness, continued problems, recurrence, death, and sepsis.

PROCEDURE: The patient was brought to the operating room in a premedicated state and placed on the operating room table in a supine position. Following induction of adequate general LMA anesthesia, the left leg was then prepped and draped in the usual sterile fashion and the patient was given prophylactic antibiotics. A surgical time-out was then initiated with all personnel in the room, verifying the patient’s identification as well as the operative site. The pneumatic tourniquet was then Esmarch inflated to 275 mmHg, following which a 3-cm longitudinal incision was made in the previous scar and carried down through the subcutaneous tissues.

Adequate hemostasis was obtained using electrocauterization. Sharp and blunt dissection down to the tibial cortex was performed, and there was noted to be a cheesy type substance noninfected, which represents the screw resorption and dissolution that was removed. There were fragments of the screw that were likewise removed as well. The defect site was then curetted back to a cancellous and cortical bone, and the wound was then copiously irrigated with normal saline. Allograft cancellous bone grafting was then brought forward and impacted into the defect. The knee was noted to have no crepitance, full motion, no instability, and no drawer, Lachman, or pivot-shift signs for being present. The periosteum and soft tissues were then repaired over top of the tibial defect, holding the graft in place. The wounds were again electrocauterized for hemostasis, following which the subcutaneous tissues were repaired with interrupted 2-0 Vicryl sutures. The skin was closed with interrupted everting 4-0 nylon sutures. The wounds were covered with Adaptic, 4 x 4s, sterile cast padding, and an Ace wrap for gentle compression. 0.25% Marcaine without epinephrine was infiltrated about the soft tissues. The patient was sent to the recovery room in a stable condition, will be maintained on full-weightbearing ambulation as tolerated, elevation, ice, and restriction of activities, and was given Percocet and Phenergan for medications.