# Hammertoe surgery-AAPC CODE A ROUND



## lizmariecat@yahoo.com (May 23, 2012)

Hi-I'm brand new CPC-A and don't mind telling everyone I'm stuck, ha ha.  Doing Code A Round Round 1 Ambulatory Surgery...here is what I have: ICD 9 735.4    and 239.2
CPT 28285-50
76000-26
28043 RT-51.......not trying to cheat my way to 1 CEU but I can use a hint--thanks
OPERATIVE REPORT

INJECTABLES: A  total  of 36  cc  of 0.5%  Marcaine  plain preoperatively.

COMPLICATIONS:None.

FINDINGS:Unknown  soft tissue  mass  second  interspace right foot during dissection.
SPECIMENS:Soft tissue mass from the right foot , and bones from bilateral feet sent to Pathology.

DESCRIPTION OF THE PROCEDURE: 
The patient was brought into the operative room and placed on the operating table in the supine position. Local anesthesia consisting of 0.5% Marcaine plain, a total of 36 cc was injected into the right and left foot in an infiltrated manner near the surgical site. Next, bilateral feet and ankles were scrubbed, prepped, and draped in the usual aseptic technique. Then, using an Esmarch bandage, the right foot was exsanguinated and the pneumatic ankle tourniquet was elevated to 250 mmHg through the duration of the case.
Next, attention was directed to the right second digit where hammer digit deformity was noted and exostosis was noted to the second metatarsal head, which was confirmed on x-ray. An approximately 5 cm curvilinear incision was made on the dorsal aspect of the second metatarsophalangeal joint extending distally onto the digit. This incision was deepened using #15 blade down to subcutaneous tissue exposing the extensor tendon and the capsular structures in the process. Blunt dissection ensued with good exposure obtained to the second metatarsophalangeal joint where there was noted to be exostosis. Following removal of the capsule, using an osteotome and mallet, the dorsal exostosis was removed from the second metatarsal head of the right foot along with medial and lateral exostosis as well.The bone was then sent to Pathology for microevaluation. 
Next, the area was checked for any sharp edges, which were denuded using a power bur and area was copiously flushed with 0.9% normal saline. 
Next, attention was directed to the adjacent third metatarsal head where there was noted also to be an exostosis that was causing pain. At this time using power equipment, the exostosis was removed in toto and sent to Pathology for evaluation. 
Once again all sharp edges were denuded using a power bur. The area was flushed copiously with 0.9% normal saline solution. 
Next, attention was directed further distally over the second digit where there was noted to be hammer digit deformity. Using a #15 blade, the extensor tendon was transected transversally and the proximal interphalangeal joint was incised and reflected exposing the head of the proximal phalanx. Using the #64 blade, adequate exposure was achieved and using power equipment, a cut was made from dorsal to plantar removing the entire head of the proximal phalanx. 
Next, 0.045 K-wire was inserted in a standard retrograde manner and position was checked using C-arm fluoroscopy. The position was adequate and pin was inserted just distal to the metatarsophalangeal joint. 
It should be noted that while blunt dissection occurred around the second interspace of the right foot between the second and third metatarsal head, there appeared to be a soft tissue mass that appeared to be consistent with a diagnosis of a ganglion cyst. The soft tissue mass was dissected sharply and bluntly away from the interspace. It was removed from the surgical site and was sent to Pathology for evaluation.
Also the second and third metatarsal head appeared yellow. The cartilage appeared yellowed and showed evidence of degenerative joint disease with generous amount of osteophyte present. Following removal of the soft tissue mass and fixation of the second digit, the extensor tendon was repaired using 3-0 Vicryl suture and the capsular structures were also repaired using 3-0 Vicryl suture at the second metatarsophalangeal joint. Next, 4-0 Vicryl subcutaneous sutures were used for reapproximation followed by 5-0 Prolene used in a simple interrupted technique for skin closure.
Attention was then directed to the left foot where there was noted to be hammer digit deformity of digits two, three, and four and exostosis of the left second metatarsal head. An incision was made on the dorsal aspect of the second digit using a #15 blade and extending the incision over the metatarsophalangeal joint.
Next, incisions were also marked out and made on the dorsal aspect of the third and fourth digits of the left foot as well. These incisions did not extend past the metatarsophalangeal joints. Following this, sharp dissection occurred followed by blunt dissection down to the second metatarsophalangeal joint. 
There noted be an exostosis protruding from the surface of the bone. Again, using an osteotome, mallet and power equipment, the exostosis was removed from the surgical site and sent to Pathology for evaluation. Once again all sharp edges were denuded using a power bur and rasp until all smooth edges
were noted. C-arm fluoroscopy was used to confirm the removal of the exostosis. 
Following this, copious amount of normal saline was used to flush the area and attention was then directed this way to the second digit where hammer digit deformity was noted. Prior surgery was also performed on second digit where proximal interphalangeal joint was surgically fused. So, decision was made to do arthroplasty of the middle phalanx in order to allow for adequate pin fixation and correction of the second digit. 
Using power equipment, the head of middle phalanx was removed entirely from the surgical field and sent to Pathology. Once again 0.045 K-wire was inserted in a retrograde fashion and proper alignment was confirmed using C-arm fluoroscopy.
Next, attention was directed to the third digit of the left foot where hammer digit deformity was noted. Using sharp and blunt technique, dissection was achieved on exposing the head of the proximal phalanx using a #64 blade and #15 blade to transect the extensor tendon. Once the head of the proximal phalanx was exposed, using power equipment, the head was resected and sent to Pathology for evaluation. Once again a 0.45 K-wire was inserted in retrograde fashion and placement was confirmed using C-arm
fluoroscopy. 
Next, attention was directed to the fourth digit where again a dorsal incision was made. Using sharp and blunt dissection, the head of the proximal phalanx was exposed after transection of the extensor tendon. Again, using power equipment, the head of the proximal phalanx was removed and sent to Pathology for evaluation. Following this, a 0.45 K-wire was inserted in retrograde fashion to maintain n a rectus alignment and proper placement was confirmed using C-arm fluoroscopy.
Next, attention was directed to the head of the proximal phalanx of the second digit where there was noted to be an exostosis causing rubbing to the first digit. This exostosis was removed using a combination of rongeur and a power bur until it was removed entirely and the surfaces were smoothed.
Next, all three incision sites were copiously flushed with 0.9% normal saline and the extensor tendon digits two, three, and four were repaired using 3-0 Vicryl suture followed by 4-0 Vicryl suture used to repair the pre-approximate incision sites using subcutaneous sutures. Then, 5-0 Prolene suture was used to repair the skin using simple interrupted technique.
Specimens that were sent to Pathology were as follows: The soft tissue mass of the right second nterspace and bone from bilateral osteotomies. Following closure, both feet had Owen silk applied to them along with dressing consisting of 4 x 4's, Kling, and Coban in a mildly compressive manner. Both tourniquets were released and warmth and perfusion returned to all digits of both feet. Capillary refill time was less than two seconds to all digits. The wires were bent using a Kocher and Jurgan balls were placed on the tips in order to protect them and followed by the wires being cut with a wire cutter. 
The patient tolerated the anesthesia and  procedure well and was transported to the PACU with vital signs stable and vascular status intact. The patient will follow up in the office as previously scheduled. The patient was given postoperative instructions and adequate pain management.


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