# coracoclavicular ligament reconstruction w allograft



## peporter (May 27, 2009)

Good morning coders, I need your help with this shoulder surgery. So far I have 23552 and 29826 coded but not sure if the ligament surgery is bundled with the primary procedure or has it's own code. I really need some guidance on this one. Thanks in advance for your help, Paula



-----------------------------------------
PROCEDURE
1. Open reconstruction of acromioclavicular joint with allograft.
2. Left shoulder arthroscopy with coracoclavicular ligament
reconstruction with allograft and Arthrex TightRope.
3. Left shoulder scope with subacromial decompression.


PROCEDURE
 A standard posterior portal was created sharply
through the skin with a scalpel. Blunt trocar and camera was placed
into the glenohumeral joint posteriorly. Upon initial inspection the
biceps tendon was intact. Labrum was intact circumferentially. The
articular cartilage was without any lesions. The glenohumeral pouch was
without any loose bodies. Rotator cuff was intact anterior-posterior.
Subscapularis was intact anteriorly. The glenohumeral joint was normal.
The camera was withdrawn. Subacromial space was entered posteriorly. A
separate lateral incision was made with a scalpel through the skin.
Blunt trocar was placed into the subacromial space. There was a
significant amount of inflammation and bursitis. A shaver was placed
the lateral portal and bursectomy was completed. A thermal wand by
ArthroCare was then taken to release the soft tissue on the undersurface
of the acromion as well as release the coracoacromial ligament
anterolaterally. This revealed a spur on the acromion. This was
removed with the bur. The decompression was completed. Remainder of
the bursa was cleared out with a shaver. The rotator cuff was inspected
and there were no tears. Next the coracoid was identified. The scope
was placed on the lateral portal. A separate anterior portal was
created. This was made over the coracoid process. Thermal wand was
then used to debride the coracoid process space for exposure both top
and bottom. Once this was completed, I withdrew the instruments. I
made a vertical incision over the clavicle 3.5 cm medial to the distal
aspect. This was made with a scalpel. Blunt dissection was taken down
to the deep fascia. Skin was undermined with tenotomy scissors. Blunt
retractor was placed in the wound. All hemostasis obtained throughout
the case with Bovie. The deep fascia was split in line with clavicle
with Bovie. This revealed the clavicle. Again 3.5 cm medial to the
distal end of the clavicle in the center of the clavicle the guide pin
was placed. A 6-mm drill was then used over the pin drilling a hole in
the clavicle. Once this was completed, I placed a scope in the lateral
portal again. I placed the guide by Arthrex through the anterior portal
and also the arm was superiorly in the hole just previously drilled.
distal end of the clavicle in the center of the clavicle the guide pin
was placed. 
The clavicle was reduced. The pin was placed through the hole onto the
clavicle base superiorly. I drilled the pin into the guide in the
center of the clavicle in the center of the coracoid base. The 6-mm
reamer was taken then through the clavicle and through the coracoid.
The guide was removed as well as the guide pin. Nitinol wire was placed
through the drill bit which was grabbed with a grasper through the
anterior portal in the inferior aspect of the coracoid process. The
core reamer was removed. *I did have a posterior tibial tendon allograft
to reconstruct the coracoacromial ligament. This had to be cut down to
a 5 mm graft. This was looped on itself. A #2-FiberWire was taken to
whip stitch both ends. This measured 5 mm through the measuring device.
The center of the graft was then tied on the end of the button by
Arthrex. This was a TightRope Endobutton by Arthrex that was utilized.*
The end of the graft was pulled up through the button proximally. The
white suture was taken through the top of the nitinol wire and loaded,
pulling this through the clavicle through the coracoid base out
anteriorly. The inferior button was taken and pulled through the
clavicle and the coracoid base. This was viewed under the scope. I had
to maneuver the button on the inferior aspect of the coracoid. This
engaged nicely. The clavicle was reduced manually and I could see the
AC joint reduced anatomically. The button was tensioned with the suture
and then tied down. The graft was then tensioned as well. Nitinol wire
was placed between the graft and a 5.5 bioabsorbable anchor by Arthrex
was then placed between the graft in the button securing this into
place. Once this was fully seated, the two ends of the graft were taken
over the AC joint. I took a hemostat through the old AC ligament and
fascia out the lateral side pulling this through the tissue,
reconstructing the acromioclavicular ligament superiorly and
posteriorly. The graft was tied on itself and then with the graft
looped on itself and tied with a #2-FiberWire. Now the ends of the
graft were cut. The clavicle was released and this appeared to be
anatomic. The scope was placed back in the subacromial space. I could
see the clavicle well reduced. Remainder of the subacromial space was
irrigated out with saline and debris was removed with a shaver. The
instruments were withdrawn. The deep fascia was closed with #1 Vicryl.
Vita-Gel soft tissue autograft was injected deeply. Skin was
approximated with 2-0 Vicryl and a running 4-0 Prolene was placed
intradermally. Steri-Strips and Mastisol were applied. Portals were
closed with suture. Local anesthetic was injected. Sterile dressing
was applied. The patient's arm was placed in an immobilizer. The
patient was then awoken from anesthesia without complication and
transferred to the postanesthesia care in stable condition.


----------



## mbort (May 27, 2009)

its going to be unlisted Paula


----------



## peporter (May 27, 2009)

Thanks Mary, so it would be the unlisted 29999 for arthroscopy? Do you have an open procedure that it would be comparable to? Would it be similiar to 23415? Thanks for your help, Paula


----------

