# Help on knee arthroscopy - Right anterior cruciate ligament



## smcbroom (Aug 7, 2008)

PREOPERATIVE DIAGNOSES:

1.  Right anterior cruciate ligament graft failure with retained hardware.

2.  Medial meniscal tear.



POSTOPERATIVE DIAGNOSES:

1.  Right anterior cruciate ligament graft failure.

2.  Medial meniscal tear.

3.  Retained tibial and femoral hardware.



PROCEDURES PERFORMED:

1.  Right knee arthroscopy with medial meniscal repair.

2.  Distal femoral BioScrew removal.

3.  Proximal tibial BioScrew removal.

4.  Reaming, curettage, and allografting of distal femoral tunnel.

5.  Reaming, curettage, and allografting of proximal tibial tunnel.


Arthroscopic examination of the suprapatellar pouch and medial and lateral gutters revealed a large medial plica that did not appear particularly pathologic.  The patella and trochlea were unremarkable.  Examination of the notch revealed disruption of the ACL graft from its tibial attachment.  The PCL was intact.  Examination of the lateral compartment was unremarkable.  Examination of the medial compartment revealed posterior horn bucket-handle tear at the red on white junction.



PROCEDURE IN DETAIL:

Following induction of general anesthesia, the right thigh tourniquet and thigh holder were applied.  The left leg was placed in a well-leg holder.  Under sterile conditions, the right knee was injected with 30 cc of 0.25% Marcaine with epinephrine in a standard fashion.  The right lower extremity was then prepped and draped in the usual fashion.



Standard anterolateral and anteromedial portals were established and diagnostic arthroscopy was performed with the findings as above.  A shaver and rasp were used to widely debride and freshen the tear site.  Loose flaps were removed.  Posteromedial portal was also established and used to prepare the posteromedial synovium and to freshen the tear from the posterior aspect.  Next, the repair was performed using the FasT‑Fix implants.  Two implants were used and provided for good reduction and repair of the meniscus.



Next, the tourniquet was inflated.  A 3-cm longitudinal incision over the distal pes and tibial tunnel site was made.  The tibial tunnel was identified and a screwdriver was used to remove the BioScrew without difficulty.  This track was hand reamed with the 11-mm reamer.  This was used to centralize and place the guidepin.  The 14-mm trephine was then used over the appropriate guidepin to adequately remove the sclerotic tunnel edges and remaining graft.  The shaver and curette were used to clean the inside of the tunnel and visualization with the arthroscope confirmed appropriate reaming of the tunnel.



Next, the remainder of the ACL graft was resected from its femoral attachment.  An attempt was made to remove the femoral screw with the screwdriver and with the easy out that this was not possible because the direction of the femoral screw diverged from the tibial tunnel.  For this reason, the guidepin was drilled in appropriate position through the femoral screw and the screw was removed by sequentially reaming it out.  Sequential reaming was done with 8-mm, 9-mm, and 10-mm reamers.  The 10-mm provided for adequate debridement of the tunnel with removal of the sclerotic tunnel edges and the remaining graft and screw.  The reaming was done to a depth of 30 mm.



Next, the femoral tunnel was grafted.  Demineralized bone matrix was impacted into the depth of the femoral tunnel.  Using the collard pin from the trephine set.  Next, a 2-mm long x 10-mm in diameter allograft bone plug was impacted to be flush with the edge of the notch.



Next, the tibial allograft bone plug was fashioned.  It was cut into two 10-mm plugs, 14 mm in diameter.  The first was impacted up to place to the level of the tibial spines.  Next, the Allofit demineralized bone matrix was impacted behind this and finally the second plug was placed in to sandwich beneath the demineralized bone matrix.  The remaining distal defect was filled with demineralized bone matrix.  The graft was then seen to be in appropriate position.



The knee was thoroughly irrigated and remaining debris was removed.  The arthroscope was removed.  The fascia was closed over the distal tibial tunnel and the skin was closed with 2-0 Vicryl subcutaneous and staples on skin and portals.  Then, 30 cc of 0.25% Marcaine with epinephrine was instilled into the joint.  A sterile dressing was applied followed by a TED hose and the brace locked in extension.  The patient was awakened and extubated in the operating room and transferred to the recovery room in stable condition.


This is a new ballgame for me....what is he talking about with the reaming, curettage and allografting?  Can someone assist me with CPT codes for the procedures listed and ICD-9 codes?  I would greatly appreciate it!!!


----------



## mbort (Aug 7, 2008)

before I respond...Who are you coding for surgeon or facility?


----------



## smcbroom (Aug 7, 2008)

oh so sorry....an ASC


----------



## smcbroom (Aug 7, 2008)

also, non-Medicare patient...commercial payer


----------



## mbort (Aug 7, 2008)

29882-rt (meniscal repair)     836.0    727.83
29888-rt (revision-failed ACL)  844.2   996.78
20680-rt (removal hardware)  996.78
L8699 (bone matrix/plug/allograft)  844.2  996.78
C1713 (fast-fix anchors for meniscal repair) 836.0

The above is not in any specific order. I did not check CCI edits. It is based on ASC coding--not surgeon.


----------



## smcbroom (Aug 8, 2008)

so what he means by the reaming, curettage and allografting of distal femoral & proximal tibial tunnel is the 29888?  I would have never thought that, so now I know.  I appreciate your input very much!


----------



## mbort (Aug 8, 2008)

yes he was reaming out the previous ACL repair preparing for re-repair.  He used the allograft to assist in this repair.


----------



## smcbroom (Aug 8, 2008)

thanks again MBort...as always you are a wealth of information


----------

