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Thread: Surgery Help Distal Femoral

  1. #1

    Default Surgery Help Distal Femoral

    AAPC: Back to School
    I was lookign at CPT 27514, but Im just not sure. Does anyone have any suggestions on how this surgery should be coded?

    Distal femoral fracture, comminuted, osteopenic.

    1. Open reduction and internal fixation of distal femoral
    fragment pieces.
    2. Distal femoral replacing hinged knee replacement.

    1. DePuy LPS distal femoral replacing hinged knee replacement,
    left-sided, extra small, with a 31 mm sleeve and a 16 x 75 mm
    2. DePuy MBT size 3 revision tibial component with a 29 mm
    sleeve and a 13 x 30 mm stem.
    3. Extra small 12 mm thick LPS hinged polyethylene insert.
    4. A 35 mm oval dome patella.

    The extensor mechanism was opened through a standard medial
    parapatellar approach. A large hemarthrosis was evacuated.
    Additional exposure was gained by elevating the tissue off the
    proximal medial tibia around to the midline. We split the
    suprapatellar pouch which was already split and edematous. The
    fracture hematoma was evacuated. She had significant
    comminution. There was a sagittal split right down to the
    condyles. There was a transverse fracture at the metaphyseal
    flare on the medial side. There were 2 large fragments going up
    the medial and lateral side. We spent painstaking effort and
    time shelling out the portions of the distal femur, removing the
    anterior cruciate ligament, posterior cruciate ligament, and
    meniscus. We were able to reduce the fracture fragments on the
    medial side and placed a cerclage cable, both to release hoop
    stresses as well as to retain some of the medial side of the
    bone. With the fracture more reduced, we were able to bring the
    leg out to length. We measured from the joint line 100 mm up the
    femur, which encompassed most of the fracture pieces. The
    femoral shaft was marked here. We reduced the trochlea as best
    as was possible and assessed our overall rotation off the tibial
    tubercle and the patella and marked our trochlear groove,
    Whiteside's line on this proximal portion of the femur as well.
    We were then able to shell out most of the femur and ultimately
    cut what remained of the shaft at 100 mm. The cerclage wire was
    tightened but not crimped, and it kept all the pieces together.
    We then turned our attention to the tibia. The tibia was
    exposed. The meniscal remnants were removed. The proximal tibia
    was cut using an extramedullary guide. These bony surfaces were
    obviously pristine as the primary area. We prepared it for size
    3 MBT tibia and a 29 mm sleeve. Trial was inserted. We turned
    our attention back to the femur. The femoral shaft was reamed to
    accept a 16 mm stem. The small 31 mm broach was seated nicely at
    the 100 mm cut. It was quite tight and rotationally solid here.
    We went back and forth with multiple trials. It appeared that
    we needed 100 mm of distal length with plus or minus 0 or 5
    adapter. For that reason, we dropped down to a 35 mm segment to
    give us 95 mm of implant and we could use the 0, 5, or 10 mm
    adapter. It appeared that we had good rotation, good femoral and
    tibial tracking, and not over lengthening as we could still
    separate the 12 mm polyethylene tibial tray. At this time, we
    prepared the patella as well. It was measured and cut to accept
    a 35 mm patella. We then cemented the tibial component in place
    and the patella component in place. The tourniquet was
    ultimately deflated, and hemostasis was achieved. We assembled
    the femoral component on the back table. We chose a 5 mm adapter
    with 95 mm of length to get us back on 100. We were able to
    impact this into place. It was extremely tight. The sleeve was
    extremely solid. It actually countersunk 1 mm or 2 mm, and it
    clearly stopped and would not go any further. We undertook
    multiple trials of polyethylene and settled on a 12. The 14 just
    seemed a little bit tight.

  2. #2
    Join Date
    Apr 2007
    Piedmont Area Coders, VA


    Hi there!
    I think you are right on with the 27514 for the femur work. Since you replaced the tibial plateaus, would 27442-59 fit for the tibial work?

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