ortho1991
Guru
Please help with coding guidance for this op-note. I think it should be coded 27427 for the MPFL 27418 for the TTO and 29877 for the chondroplasty. Is this correct?
RIGHT KNEE DIAGNOSTIC ARTHROSCOPY, EXTENSIVE SYNOVECTOMY AND CHONDROPLASTY: At this
point, a second time-out was performed and the left knee was identified as the correct
operative site. All the antibiotics were infused An anterolateral arthroscopy portal
was then established. The undersurface of the patella had grade 2-3 chondromalacia of
the very medial facet. The trochlear groove was flat and shallow, but not damaged. The
patella was tracking extremely laterally on the trochlea. It was easy to dislocate the
patella. The medial and lateral gutters had no loose bodies. The ACL and PCL were
identified and were found to be intact. The medial and lateral compartments had no
cartilage damage and no meniscal tearing. An anteromedial portal was established and a
gentle chondroplasty was performed of the undersurface of the patella and an extensive
synovectomy was performed. This concluded the arthroscopic portion of the case. All
the arthroscopic equipment was removed.
RIGHT KNEE TIBIAL TUBERCLE OSTEOTOMY: The tourniquet was raised to 250 mmHg after the
leg was exsanguinated with an esmarch bandage. A midline incision was then performed
approximately 8 cm in size and soft tissue flaps were elevated medially and laterally.
At this point, we focused our attention on the tibial tubercle. Christopher Stanton o
was helping me as we internally rotated the knee, made an incision and elevated the
anterior and lateral compartments. We identified the flat edges of the tibia and made
an osteotomy without trying to anteriorize it. We tried to make an osteotomy that was
approximately 10 cm long distally. Once we were able to create a cross cut osteotomy
over the tibial tubercle, we shifted the tibial tubercle while keeping the periosteal
hinge distally and the medial periosteum intact. We shifted the tibial tubercle
medially by 10 mm. A medialization of 10 mm was performed without any anteriorization.
Using 2 large fragment fully threaded cortical screws, one 50 mm and the other one 54 mm
in length and countersinking it, we got an excellent repair of the tibial tubercle back
to its insertion point. Copious irrigation was performed. We now took the knee through
flexion and extension and already the patella was tracking better. Fluoroscopic imaging
showed excellent position of the screws. The tibial tubercle osteotomy extended a few
centimeters below the inferior screw but there was no posterior extension.
RIGHT KNEE MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION: At this point, we focused our
attention on the medial side of the kneecap. We identified the medial facet of the
patella. A 4 cm incision was performed directly over the center of the patella. We
elevated the soft tissue medially and identified the medial patella facet. Using a
sharp blade we incised the medial retinacular and identified the medial patellar border.
A small track was created using a rongeur in the medial patellar facet. I then placed
2 anchors in the medial patella border. The first 1 was placed as proximally as we
could using a 1.8 mm Smith & Nephew Q fix anchor. Excellent purchase was obtained. 18
mm distal we placed a second mini Q fix Smith & Nephew anchor scar with excellent
purchase. On the side table my PA had prepared a semitendinosis allograft that fit
snugly through a 6.5 mm tunnel and had whipstitched the ends. At this point, we then
focused our attention to the rest of the MPFL reconstruction. We identified under
fluoroscopic imaging, the MPFL insertion point on the femur. This was done once we got
the x-ray of the tibia and femoral condyle alignment in a perfect lateral. The
insertion point was identified in line with the posterior cortex just anterior to that
area and anterior to the distal condylar line consistent with Schottles point. Copious
irrigation was performed. A Beath pin was placed into this position and drilled through
the femur proximally and anteriorly. A passing suture was then passed after a 6.5 mm
tunnel was drilled. The MPFL graft was then seated into the tibial tunnel and using a 7
x 25 mm Smith & Nephew bio composite interference screw excellent purchase was obtained.
We then shuttled our MPFL graft in between layer 2 and 3 on the medial side. With the
knee in 30 degrees of flexion the patella was reduced in the groove. Using our Q fix
anchors we then held tension on the MPFL graft and sutured the tails of the MPFL graft
by using the Q fix anchor sutures. The sutures were then reduced and tied down to the
medial patella. Excellent positioning was noted. The knee was taken through 25 cycles
of flexion and extension. At full extension, there was a one quadrant play both
medially and laterally for the patella to move. Copious irrigation was performed.
Fluoroscopic imaging confirmed positioning of both the tibial tubercle osteotomy and the
screws for the tibial tubercle osteotomy as well as the MPFL tunnels. The knee was
irrigated copiously. The medial ligaments were closed with 0 and #1 Vicryl in a figure-
of-eight fashion. The lateral retinaculum was lightly closed over the tibial tubercle
osteotomy with #1 Vicryl. The skin was then closed with 2-0 Vicryl followed by 3-0
Monocryl in a subcuticular fashion. Mastisol, Steri-Strips, Xeroform, and dry sterile
dressings were applied. The patient was placed in a brace locked up in full extension
and was awakened. They were taken to the recovery room in stable condition. They had
tolerated the procedure well.
RIGHT KNEE DIAGNOSTIC ARTHROSCOPY, EXTENSIVE SYNOVECTOMY AND CHONDROPLASTY: At this
point, a second time-out was performed and the left knee was identified as the correct
operative site. All the antibiotics were infused An anterolateral arthroscopy portal
was then established. The undersurface of the patella had grade 2-3 chondromalacia of
the very medial facet. The trochlear groove was flat and shallow, but not damaged. The
patella was tracking extremely laterally on the trochlea. It was easy to dislocate the
patella. The medial and lateral gutters had no loose bodies. The ACL and PCL were
identified and were found to be intact. The medial and lateral compartments had no
cartilage damage and no meniscal tearing. An anteromedial portal was established and a
gentle chondroplasty was performed of the undersurface of the patella and an extensive
synovectomy was performed. This concluded the arthroscopic portion of the case. All
the arthroscopic equipment was removed.
RIGHT KNEE TIBIAL TUBERCLE OSTEOTOMY: The tourniquet was raised to 250 mmHg after the
leg was exsanguinated with an esmarch bandage. A midline incision was then performed
approximately 8 cm in size and soft tissue flaps were elevated medially and laterally.
At this point, we focused our attention on the tibial tubercle. Christopher Stanton o
was helping me as we internally rotated the knee, made an incision and elevated the
anterior and lateral compartments. We identified the flat edges of the tibia and made
an osteotomy without trying to anteriorize it. We tried to make an osteotomy that was
approximately 10 cm long distally. Once we were able to create a cross cut osteotomy
over the tibial tubercle, we shifted the tibial tubercle while keeping the periosteal
hinge distally and the medial periosteum intact. We shifted the tibial tubercle
medially by 10 mm. A medialization of 10 mm was performed without any anteriorization.
Using 2 large fragment fully threaded cortical screws, one 50 mm and the other one 54 mm
in length and countersinking it, we got an excellent repair of the tibial tubercle back
to its insertion point. Copious irrigation was performed. We now took the knee through
flexion and extension and already the patella was tracking better. Fluoroscopic imaging
showed excellent position of the screws. The tibial tubercle osteotomy extended a few
centimeters below the inferior screw but there was no posterior extension.
RIGHT KNEE MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION: At this point, we focused our
attention on the medial side of the kneecap. We identified the medial facet of the
patella. A 4 cm incision was performed directly over the center of the patella. We
elevated the soft tissue medially and identified the medial patella facet. Using a
sharp blade we incised the medial retinacular and identified the medial patellar border.
A small track was created using a rongeur in the medial patellar facet. I then placed
2 anchors in the medial patella border. The first 1 was placed as proximally as we
could using a 1.8 mm Smith & Nephew Q fix anchor. Excellent purchase was obtained. 18
mm distal we placed a second mini Q fix Smith & Nephew anchor scar with excellent
purchase. On the side table my PA had prepared a semitendinosis allograft that fit
snugly through a 6.5 mm tunnel and had whipstitched the ends. At this point, we then
focused our attention to the rest of the MPFL reconstruction. We identified under
fluoroscopic imaging, the MPFL insertion point on the femur. This was done once we got
the x-ray of the tibia and femoral condyle alignment in a perfect lateral. The
insertion point was identified in line with the posterior cortex just anterior to that
area and anterior to the distal condylar line consistent with Schottles point. Copious
irrigation was performed. A Beath pin was placed into this position and drilled through
the femur proximally and anteriorly. A passing suture was then passed after a 6.5 mm
tunnel was drilled. The MPFL graft was then seated into the tibial tunnel and using a 7
x 25 mm Smith & Nephew bio composite interference screw excellent purchase was obtained.
We then shuttled our MPFL graft in between layer 2 and 3 on the medial side. With the
knee in 30 degrees of flexion the patella was reduced in the groove. Using our Q fix
anchors we then held tension on the MPFL graft and sutured the tails of the MPFL graft
by using the Q fix anchor sutures. The sutures were then reduced and tied down to the
medial patella. Excellent positioning was noted. The knee was taken through 25 cycles
of flexion and extension. At full extension, there was a one quadrant play both
medially and laterally for the patella to move. Copious irrigation was performed.
Fluoroscopic imaging confirmed positioning of both the tibial tubercle osteotomy and the
screws for the tibial tubercle osteotomy as well as the MPFL tunnels. The knee was
irrigated copiously. The medial ligaments were closed with 0 and #1 Vicryl in a figure-
of-eight fashion. The lateral retinaculum was lightly closed over the tibial tubercle
osteotomy with #1 Vicryl. The skin was then closed with 2-0 Vicryl followed by 3-0
Monocryl in a subcuticular fashion. Mastisol, Steri-Strips, Xeroform, and dry sterile
dressings were applied. The patient was placed in a brace locked up in full extension
and was awakened. They were taken to the recovery room in stable condition. They had
tolerated the procedure well.