# Carpometacarpal Resection Arthroplasty



## coderguy1939 (Oct 20, 2008)

Doctor is doing a "Carpometacarpal Resection ARthroplasty w/pinning".  He does a capsulotomy and excises the trapezium but does not insert a prosthesis or perform a tendon transfer.  The thumb metacarpal is fixed to the adjacent second metacarpal using a percutaneously placed k-wire.  Would this be a reduced service 25447 or just a carpectomy with pinning?  Thanks.


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## mbort (Oct 20, 2008)

Look at 25332 to see if that works...also see below...it may be of help in making your decision as well.

Year: 2005 

Issue: January 

Pages: 7-13 

Title: Coding Communication: Wrist Arthroplasty Coding 

Body: Wrist arthroplasty is one of several types of reconstructive procedures performed primarily to relieve wrist pain and provide some degree of functionality without loss of stability for patients who have failed conservative treatment for conditions such as rheumatoid arthritis, osteoarthritis, or damage following trauma. These and other conditions can occur alone or in combination and can involve individual or multiple bones, joints, and ligaments of the wrist. In each case, therefore, wrist arthroplasty is tailored to treat the specific condition(s) and disabilities affecting each individual wrist.

Wrist Anatomy

Knowledge of fundamental wrist anatomy is an important prerequisite for understanding wrist arthroplasty. The wrist, also called the carpus, is the region between the distal forearm and the hand. It consists of the distal radius and ulna (bones of the forearm), eight small carpal bones arranged in two rows (proximal and distal), and the proximal metacarpal bones of the hand, which radiate out from the wrist. The bones are connected to each other by a complex series of ligaments. It is important to note that the anatomy of the important ligaments and joints of the wrist can vary from person to person and that these differences can influence various conditions affecting the wrist.

The proximal row of carpal bones consists of the scaphoid, lunate, and triquetral bones, which articulate with the radius and the articular disk of the ulna. The articulation of the distal radius with the scaphoid and lunate is the radiocarpal joint. These bones also articulate with each other and with the bones of the distal row. The pisiform bone is part of the proximal row but lies on the anterior surface of the triquetral bone, with which it articulates exclusively. The distal row of carpal bones is made up of the trapezium, trapezoid, capitate, and hamate bones.

The triangular fibrocartilage complex (TFCC) covers the distal end of the ulna (the head) and separates the ulna from the wrist joint. The TFCC is the major stabilizer of the distal radioulnar joint and acts as a shock absorber between the distal ulna and the lunate and triquetrum. The space between the TFCC and lunate and triquetrum is the ulnocarpal joint.

A thick layer of fascia, known as the extensor reti naculum, overlies the distal radius like a bracelet on its posterior or dorsal aspect. This structure sends extensions (septa) downward to the radius to form separate compartments through which run the extensor tendons of the wrist and fingers. The six dorsal compartments are numbered 1 through 6, with the numbering beginning on the radial side of the wrist.

On the anterior or volar (palmar) side of the wrist, a layer of fascia called the flexor retinaculum, forms the palmar roof of the carpal tunnel through which the median nerve and finger and thumb flexor tendons pass.

Coding Wrist Arthroplasty

Codes 25441-25446 describe procedures that include excision of the bone(s) named in the code descriptor and their replacement with a prosthetic device. For wrist arthroplasty without replacement with a prosthetic device, code 25332 should be referenced.

Code 25322 may involved different techniques depending on the nature of the presenting problem(s), the patient's requirements for activities of daily living, and the surgeon's preference. Intercarpal fusion is not included in this procedure and may be reported separately. When performed, harvest of fascia from the patient may be reported separately using either code 20920 or 20922 as appropriate. Internal or external fixation is included, but not both.

Code 25447 describes interposition arthroplasties performed in either the intercarpal or carpometacarpal joings.

Code 25332

Code 25332, Arthroplasty, wrist, with or without interposition, with or without external or internal fixation, describes arthroplasty of the wrist joint as opposed to arthroplasty of the intercarpal or carpometacarpal joints described in code 25447. Each wrist arthroplasty procedure can differ in technique and component parts, depending on the nature of the presenting problem(s), the patient's requirements for activities of daily living, and the surgeon's preference. The following two examples illustrate this fact. For instance, an arthroplasty may include synovectomy and restoration of the alignment of the radius and carpal bones with temporary internal fixation in order to create a fibrous ankylosis of the joint. Interposition may or may not be utilized. If performed, interposition is used to maintain the radiocarpal space (the space between the distal radius and the carpal bones) by insertion of native tissues (such as tendon, perichondrium, dorsal retinaculum, fascia lata) or silastic material. In contrast, palmar shelf arthroplasty includes resection of the cartilage and subchondral bone (the bone just beneath the cartilage). The radius is contoured to provide a “shelf” into which the proximal carpal row can fit. The wrist is reduced on the radius and is temporarily immobilized with a Kirschner wire. The internal fixation is removed and joint motion is started once soft

tissue healing is complete.

Intercarpal fusion is not included in this procedure and may be reported separately. When performed, harvest of fascia from the patient may be reported separately using either code 20922 or 20922, as appropriate. Either internal or external fixation is included, but never both.

Code 25441

Code 25441, Arthroplasty with prosthetic replacement; distal radius, involves excision of the distal radius and replacement with a spacer such as a silicon implant (Swanson). The following describes a Swanson silicone implant arthroplasty in which the distal end of the radius and the proximal carpal bones are fashioned to receive the silicone implant.

A longitudinal dorsal midline incision is made over the radiocarpal joint. The skin and subcutaneous tissues are retracted and the extensor retinaculum is incised and reflected radially. Extensor tendons are mobilized and retracted. The wrist capsule is opened and part of the proximal portion of the carpal bones is removed to create a flat surface. The opposing, distal end of the radius is removed to provide a flat surface parallel to the carpal surface. The intramedullary canal of the radius is reamed to receive the radial implant. The capitate bone and the third metacarpal distal to it are reamed for the metacarpal component of the implant. Following satisfactory testing of trial implant sizes, the final implant components are inserted. A portion of the distal ulna may be resected. The wrist capsule is securely closed around the implant to provide support and stabilization. The extensor retinaculum is reapproximated with sutures and the wound is closed in layers over small subcutaneous drains.

Code 25442

Code 25442, Arthroplasty with prosthetic replacement; distal ulna, is a procedure in which the distal end of the ulna is removed and replaced with a prosthesis. The ulna may be approached through a skin incision over the distal ulna or through a dorsal incision over the radioulnar joint. The extensor retinaculum is incised and the distal ulna is exposed. After using a template to mark the line for resection, the distal ulna is removed with an oscillating saw. A hole is reamed in the ulnar intramedullary canal following satisfactory testing using a trial prosthesis. The final stem of the prosthesis is inserted (with or without bone cement) and tapped into place. A separate ulnar head prosthesis is sutured to the soft tissues that previously held the native ulnar head. The prosthesis is seated firmly on the stem component. Soft tissues followed by the remaining articular capsule are sutured over the prosthesis. The extensor retinaculum is closed followed by layer closure of the subcutaneous tissue and skin. The wound is dressed and the forearm is immobilized in a long arm splint.

Code 25443

Code 25443, Arthroplasty with prosthetic replacement; scaphoid carpal (navicular), describes removal of the scaphoid bone and its replacement with a prosthesis. The incision is placed over the dorsal radiocarpal joint. After incisions into the skin, subcutaneous tissue, the underlying extensor retinaculum, and the dorsoradial capsule of the wrist joint, the scaphoid bone is exposed and removed piecemeal. A thin piece of bone is left in place, attached to the radiocarpal ligaments to support and stabilize the implant. Sutures are inserted in the lunate bone and distal end of the implant and then the prosthesis is seated in place. The wound is closed in layers with small drains inserted into the subcutan-eous tissue. The wound is dressed and the wrist is splinted.

Code 25444

Code 25444, Arthroplasty with prosthetic replacement; lunate, describes excision of the lunate bone followed by its replacement with a prosthesis, usually through a dorsal longitudinal incision in the radiocarpal area. Following incisions into the skin, subcutaneous tissue, the underlying extensor retinaculum, and the dorsocarpal ligament, the lunate bone is exposed and all but a small slice of bone is removed. A small slice of bone is allowed to remain attached to the palmar ligaments for support. The remaining bone, with its attached intact palmar ligaments, is used to provide support and stabilize the implant. Sutures are placed in both ends of the prosthesis and into the bones (scaphoid and triquetral bones) at either end. The sutures are tightened to seat the prosthesis in place between them. The dorsocarpal ligament is closed with sutures and the wound is closed in layers. The wound is dressed and a splint is applied.

Code 25445

Code 25445, Arthroplasty with prosthetic replacement; trapezium, describes excision of the trapezium and its replacement with a prosthesis. The following description includes utilization of a separate slip of tendon to provide supplementary support for the implant. Depending on the type of implant used and the surgeon's preference, that process may be omitted.

A longitudinal incision is made through the skin and subcutaneous tissues over the trapezium. A second incision is made on the forearm to expose the flexor carpi radialis (FCR) tendon. Attention is turned to the initial incision where the extensor retinaculum of the first compartment is incised followed by exposure and incision of the joint capsule. The joints on either side of the trapezium, including its joint with the

meta-carpal bone of the thumb, are exposed. The trapezium is removed piecemeal, leaving a thin slice of bone attached to the ligaments for support and stabilization of the prosthesis. Part of the adjacent trapezoid bone may be removed if necessary. The proximal end of the metacarpal bone is removed and an opening is made in its shaft to receive the stem of the prosthesis.

The previously exposed FCR is dissected to prepare a slip of tendon, which is then pulled up into the trapezium excision site. Its distal end remains attached to the second metacarpal. In a series of steps, the tendon slip is woven through the tissues in the operative field and across the trapezoidectomy site to act as a support and anchoring mechanism for the implant.

Sutures are placed across the reflected flaps of the capsule in preparation for closure. The prosthesis is inserted and the FCR tendon slip is placed under the dorsal joint capsule and looped through the adductor pollicis longus tendon and sutured in place. The capsule and then the first dorsal compartment are closed with sutures. The wound is closed and dressed. Anterior and posterior splints are applied.

Code 25446

Code 25446, Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist), describes the essential principles of total wrist arthroplasty, which are basically the same regardless of the device used. The following is a description of the technique for the universal total wrist prosthesis.

A dorsal longitudinal skin incision is made in line with the third metacarpal. The skin and subcutaneous tissues are retracted, and the extensor retinaculum is incised and reflected radially. Extensor tenosynovectomy is performed. The joint capsule over the distal ulna is opened and reflected distally, and 1 cm of the distal ulna is removed. The radiocarpal joint is opened, the wrist is flexed, and the end of the radius is exposed. Using a template as a guide, a saw is used to remove the dorsal lip and articular surface of the radius. This step exposes the proximal row of carpal bones, which are then removed using an oscillating saw cut that is placed across the scaphoid and triquetral bones perpendicular to the capitate and third metacarpal bones. In the process, the lunate bone is completely removed while a small distal portion of the scaphoid and triquetral bones remains. Intercarpal fusion among the capitate, scaphoid, triquetrum, and hamate bones is carried out by removing their articular cartilages.

A drill hole is placed in the capitate and extended into the adjoining third metacarpal bone. Next, the medullary canal of the radius is reamed and the end of the radius is cut to match the contour of the radial end of the prosthesis. Following satisfactory testing of trial components, a small amount of cement is introduced into the capitate hole and the stem of the carpal component is inserted and tapped in. Screws are inserted through the holes on either side of the carpal component and tightened. Bone grafts, reserved from the previously removed bones, are packed into the remaining carpal bones to achieve fusion.

Bone cement is introduced into the medullary canal of the radius, and the radial component is inserted. A polyethylene interface is placed over the carpal component plate. The carpal and radial components are reduced in place and the joint tested for stability. The ulnar joint capsule is closed tightly to stabilize the distal ulna. Next, the capsule of the radiocarpal joint is reattached to the distal radius with sutures. If the capsule is deficient, half of the extensor retinaculum is used to cover the prostheses. It is closed meticulously. The remaining half of the retinaculum is closed followed by layer closure of the skin and subcutaneous tissues. The wound is dressed and the wrist is immobilized in neutral position with a splint.

Code 25447

Code 25447, Arthroplasty, interposition, intercarpal or carpometacarpal joints, represents an interposition arthroplasty of either intercarpal or carpometacarpal joints. It is performed by excising part of one or more of the respective bones and then inserting soft tissue, such as an “anchovy” of tendon or a piece of fascia, between them. The interposition tissue acts as a spacer to maintain the space between the bones and create a fibrous ankylosis between them. The following two examples provide descriptions of (1) carpometacarpal (CMC) arthroplasty of a nonthumb joint followed by (2) a CMC joint arthroplasty of the thumb.

CMC Excluding Thumb

Through a linear skin incision, the carpometa-carpal joint capsule is exposed and then incised transversely. Either the distal surface of the carpal bone or the proximal surface of the metacarpal bone is removed. The donor tendon or fascia is rolled and placed between the two bones. A Kirschner wire is inserted through the metacarpal and the adjacent metacarpal for fixation. The joint capsule is closed with sutures. The hand and wrist are immobilized in a splint.

CMC Including Thumb

A CMC joint arthroplasty of the thumb is a commonly performed procedure. The base procedure described by 26447 is as follows. A curvilinear incision is made over the radial aspect of the proximal first metacarpal extending proximally over the trapezium and trapezio-scaphoid joint. The interval between the slips of the abductor pollicis longus is developed and the periosteum over the base of the first metacarpal and trapezium is elevated along with dorsal and palmar flaps of the first CMC and scaphotrapezial capsules. The trapezium is carefully removed, taking care not to injure the adjacent radial artery and flexor carpi radialis. (Some surgeons will remove the base of the first metacarpal.) The interposition material chosen by the surgeon is placed in the defect created by removal of the trapezium. Usually an autologous tendon is used though other tissues such as fascial lata and allografts have been used. The interposition material is secured in the trapezial defect. A temporary Kirschner wire is often used to stabilize the arthroplasty. The capsule is closed and a splint applied.

If the surgeon chooses a tendon graft as the interposition material, and if the tendon is harvested at a different site through a separate incision(s), the harvesting of the tendon graft should be coded separately with 20924, Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris). If, on the other hand, the surgeon harvests a local tendon (ie, flexor carpi radialis or abductor pollicis longus) through the same incision as that used for the arthroplasty, it is included in the basic procedure and is not reported separately. While the harvesting of local tendons can require counter-incisions to free the tendon graft proximally, such accessory incisions would not be coded in addition to the arthroplasty.

Variation: Suspension Arthroplasty

Dr Richard Burton popularized a variation of the basic CMC joint arthroplasty of the thumb procedure in which the first metacarpal is suspended to the second metacarpal to inhibit the proximal migration of the first metacarpal that often occurs after simple excisional arthroplasty of the first CMC joint. This “suspension arthroplasty” requires additional surgical maneuvers. Typically, one half (or all) of the FCR is used to create the new intercarpal ligament between the first and second metacarpals. To accomplish this, the FCR is exposed through a series of transverse forearm incisions. One half of the tendon is detached from the muscle belly proximally and brought into the distal trapeziectomy wound. The tendon is dissected to its insertion on the base of the second metacarpal. A hole is drilled in the radial aspect of the base of the first metacarpal and the liberated half of the FCR is passed through this hole and secured to the lateral aspect of the first metacarpal with a suture. The remaining free FCR is woven around the intact FCR (still attached to the muscle belly proximally and second metacarpal distally) and/or abductor pollicis longus and sutured into the trapeziectomy defect. A Kirschner wire can be used for temporary stabilization.

The transfer of the FCR to the base of the first metacarpal is not a part of the basic first CMC arthroplasty procedure and must be coded in addition to 25447 with either 26480, Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon, or 25310, Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon, as appropriate. Modifier 51 would be appended to the secondary procedure in either the 2544 7 + 26480 or 25310 code pairs.

The work involved with the suspension arthroplasty is similar to that of a tendon transfer. In both the tendon transfer and suspension, a tendon is harvested and transferred to a different site. In addition, both procedures require exact tensioning of the tendon transfer. In an active tendon transfer, the proper tension is needed to provide motion; in the suspension, the proper tension is needed to permit motion of the first ray (thumb) but inhibit proximal migration of the first metacarpal.

References

Arnold-Peter CW, Hastings H, eds. Surgery of the Arthritic Hand and Wrist. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002.

Blair WF, ed. Techniques in Hand Surgery. Baltimore, Md: Williams & Wilkins; 1996.

Eaton RG, Akelman E, Eaton BH. Fascial implant arthroplasty for treatment of radioscaphoid degenerative disease. J Hand Surg. 1989;14A:766-774.

Green DP, Hotchkiss RN, Pederson WC. Green's Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999.

Lichtman DM, Alexander AH. The Wrist and Its Disorders. 2nd ed. Philadelphia, Pa: WB Saunders Company; 1997.

Millender LH, Nalebuff EA. Preventive surgery, tenosynovectomy and synovectomy. Orthop Clin North Am. 1975;6:765.

Saffar P, Amadio PC, Foucher G, eds. Current Practice in Hand Surgery. St Louis, Mo: Mosby; 1997.

Taleisnik J: Rheumatoid arthritis of the wrist. Hand Clin. 1989;5:257.

Watson HK, Weinzweig J, eds. The Wrist. Philadel-phia, Pa: Lippincott Williams & Wilkins; 2001.


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## coderguy1939 (Oct 20, 2008)

I reviewed that 2005 info but went right by 25332.  I'll take a look at it in detail.  Thanks.


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