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Thread: Arthoscopic turned Open Osteochondral Defect repair talus

  1. #1
    Join Date
    Apr 2007
    Duluth, MN

    Exclamation Arthoscopic turned Open Osteochondral Defect repair talus

    AAPC: Back to School
    I need help coding this--I cannot for the life of me figure it out.
    Here is the operative report. Please Please help!!!

    Osteochondral fracture anterolateral right talus.

    Osteochondral fracture anterolateral right talus.

    1. Diagnostic right ankle arthroscopy with removal of loose osteochondral fragments and synovectomy/debridement.
    2. Open attempted osteochondral defect repair with microfracture.

    ---- MD

    ------, PA-C, MD


    Dr. -------.

    1900 cc crystalloid.


    54 minutes at 300 mmHg.


    PT is a 25-year-old female who sustained an inversion injury to her right ankle 07/22/2011. She had immediate onset of pain and inability bearing weight. She was initially seen by Dr. ---- in place of her primary care physician, Dr. -----, with negative x-rays. She was subsequently seen in the orthopedic office and although there was no obvious malleolar fracture, she did have a defect in the talar dome. The MRI confirmed osteochondral fracture of the anterolateral talus with mild displacement. Recommendations to proceed with diagnostic arthroscopy of the right ankle for evaluation of the congruity of the articular surface with possible removal of osteochondral fracture versus repair either arthroscopically or open were discussed in detail. The risks and benefits were discussed and these included but were not limited to, bleeding, infection, damage to vessels, damage to nerves, loss of ankle range of motion, post-traumatic ankle arthritis and need for further surgery in the future. After hearing this and answering all of her questions, she did elect to proceed with surgery. Informed written consent was obtained prior to the procedure.

    PT was prophylaxed against infection with 900 mg of IV clindamycin. She was then brought to the operating room with confirmation of appropriate patient, appropriate site surgery and appropriate procedure. She underwent excellent general anesthesia. A well-padded pneumatic tourniquet was placed in the proximal aspect of the right thigh and the extremity was prepped and draped in the usual fashion. Initially, the tourniquet was not inflated. An anterolateral portal was made just lateral to the tertius and just distal to the palpable joint line. There was still some moderate swelling so anatomical landmarks were slightly difficult, but I was able to identify the peroneus tertius from anterolateral approach the ankle joint was infiltrated with 20 cc of saline. An 11 blade was used to make a skin incision only then blunt dissection was taken down into the capsule, releasing fluid to confirm appropriate intra-articular position. Swelling made anatomic landmarks slightly more difficult to palpate. The knife blade was used through the skin only and then bluntly dissected down with a hemostat into the ankle joint itself with release of intraarticular fluid confirming intra-articular position. A standard 4 mm arthroscope was then placed into the anterior aspect of the joint. Transillumination was used in the outside in technique for the anteromedial portal, which was made just lateral to the tibialis anterior tendon. Transillumination was used to avoid the saphenous neurovascular structures. Small joint shaver was used to debride a moderate amount of synovitis in the anterior aspect of the ankle joint. There was some scar tissue in both the medial and lateral gutters, which was debrided using a shaver. Osteochondral fracture of the lateral talar dome was immediately evident. This did show some articular incongruity 2 to 3 mm. Probing showed that these were completely unstable fragments completely delaminated. Once they were disrupted from their tissue bed arthroscopic examination showed that they appeared to be sheared off right at the subchondral plate with very minimal bone attached and some areas with no bone. There was one larger fragment and then a lateral left shoulder fragment with a little more bone which was much smaller and fragmented. Manipulation of the fragments were used to see if attempted reduction could be performed, although this was difficult and the overall quality of the chondral surface was in question, it did appear that we may have a chance to repair this. Unfortunately, it was slightly behind the inferior lip of the tibia and despite the ankle distractor, I did not feel that we could get appropriate alignment of the pins arthroscopically. Thus, a grasper was used to remove the two osteochondral fragments which were placed in sterile saline.

    The arthroscopic portion was then completed. The extremity was exsanguinated using Esmarch wrap and tourniquet was inflated to 300 mmHg. Anterolateral portal was extended, once again opening the skin only with a 15 blade. A combination of blunt dissection and sharp dissection scissors was used down to the anterolateral joint line. Manual distraction and a freer elevator used as a joystick we were able to evaluate the osteochondral defect. Evaluation of the chondral fragments on the back table was performed and the larger of the two fragments was approximately 7 mm x 4 mm, the smaller fragment was 8 mm x 3 mm. The smaller fragment was comminuted and had significant disruption of the articular cartilage so I did not feel that this was repairable. The larger fragment had less bone attached but did feel we should attempt to fix this. A curette was used to debride fibrinous tissue and clot from the repair bed. The osteochondral fragment was then placed in the defect bed. Temporary stabilization was attempted with a 0.35 K-wire, but unfortunately due to lack of bony support the articular cartilage is plastically deformed and despite multiple attempts left significant articular step offs. Once again, cartilage was beginning to fragment so, unfortunately just felt there was not enough subchondral bone attached to support the cartilage and allow for predictable osseous healing and thus it was elected to abort the OCD repair. The surrounding chondral shoulders were stable, so a microfracture awl was used to perform multiple perforations in the subchondral bone. There was some delaminating cartilage off the anterior aspect of the distal tibia and this was trimmed back with a rongeur to a stable margin.

    The OCD bed and ankle itself was copiously irrigated with normal saline. The incision was closed in layers of 2-0 Vicryl subcutaneously, followed by horizontal mattress 3-0 nylon sutures for the skin. Anteromedial arthroscopic portal was reapproximated with a 3-0 nylon suture. Ankle and the area of the surgical incision was infiltrated with a total of 20 cc of 0.25% Marcaine plain. Postop dressing consisted of Adaptic 4 x 4s, ABDs, cast padding and a well padded short leg posterior splint. There were no complications. PT tolerated the procedure well, was awakened in the operating room and taken to the PACU in stable condition.

    Thank you thank you.
    Tina Wosmek CPC, COSC

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


    I'll take a stab at this one, Tina!
    Because your "dx" scope changed to a debride/synovectomy, then you had to abort the scope to do an open procedure, you lose it altogether to the open code.

    Now, for the open OCD. drum roll please.......

    I have a few thoughts on it.
    #1 28445. Controversial, yes, but since there was a piece of OC surface avulsed off with bone attached, technically that is a fracture. And, there does NOT have to be fixation used to report. (AND open OCD w/ grafting is right below..so it is in the same series (FX) of codes...)
    #2 28100. I attended AAPC National 2009, in which a foot MD spoke on this. He said the definition & explanation of the code matches what was done to the talus.

    Thoughts from anyone else?

  3. #3
    Join Date
    Apr 2007
    Duluth, MN


    The only thing the MD is going to object to is the Microfracture performed. this would be similar to what is done in 29879 for the knee.

    I thought of the FX care code two but again I get stuck at the microfracture because there is so much more work that goes into that.
    Tina Wosmek CPC, COSC

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