# Open Quadriceps Debridement



## dyoungberg (Mar 28, 2012)

Surgeon performed the following procedure.  Need help coding the Open Quad debridement please...........

POSTOP DIAGNOSIS:  
1. RIGHT KNEE LATERAL MENISCAL TEAR AND QUADRICEPS TENDINOPATHY 
2. RIGHT KNEE CHONDROSIS 

PROCEDURE:
1. RIGHT KNEE ARTHROSCOPIC LATERAL MENISCECTOMY 
2. RIGHT KNEE ARTHROSCOPIC CHONDROPLASTY 
3. RIGHT KNEE ARTHROSCOPIC LIMITED SYNOVECTOMY 
4. RIGHT KNEE OPEN QUADRICEPS DEBRIDEMENT 

ANESTHESIA:  	GENERAL 

TOURNIQUET TIME: 	ZERO (0) 

INTRAOPERATIVE FINDINGS:  
1. Grade II-III changes to the patellofemoral joint and to the medial compartment.
2. Moderate synovitis x three compartments. 
3. White zone tear of the body of the lateral meniscus. 
4. Lateral compartment intact. 
5. ACL-PCL intact. 
6. Moderate heterotopic ossification in the quadriceps tendon with thickening at the 
   quad insertion site on the patella. 

INDICATIONS FOR PROCEDURE: 54 year old male with previous history of open quadriceps debridement by another surgeon many years ago. The patient had new onset pain in the right thigh and knee and was diagnosed with meniscal tear and heterotopic ossification and quadriceps tendinopathy. He had failed all nonoperative treatments. The risks and benefits of surgical management were discussed with the patient and he was given the opportunity to ask questions regarding his treatment plan. When all questions were answered to his satisfaction, he elected to proceed with surgery and signed informed consent. 

PROCEDURE: The patient was greeted in the preoperative holding area where the right knee was correctly identified and initialed as the surgical site. He was then brought back to the operating room for his procedure where he was placed supine on the OR table and  
Appropriate cardiopulmonary monitoring devices were connected. One gram of Ancef was given intravenously and bony prominences were well padded. An SCD was placed on the LLE. He was then administered general anesthesia and intubated. A nonsterile tourniquet was placed on the right thigh. The right knee was examined under anesthesia and found to have a ROM of 0 to 130 degrees, symmetric to the left side with no varus, valgus, anterior or posterior instability. The RLE was then prepped and draped in the standard surgical fashion. An appropriate surgical timeout was performed to confirm the patient as David Foster and the surgical site as the right knee. Bony landmarks and incisions were drawn on the skin and the subcutaneous tissue was infiltrated with approximately 15 cc 0.25% Marcaine w/epinephrine. 

Without inflating the tourniquet, a standard anterolateral portal was used to gain access into the joint and diagnostic arthroscopy began in the suprapatellar pouch which had minimal synovitis to it and no significant patellofemoral plica. Grade II-III diffuse changes were noted on the undersurface of the patella with concurrent disease on the trochlea but no patellar maltracking was noted. The lateral and medial gutters had some mild synovitis but no loose bodies and mild peripheral femoral osteophytes. We next moved into the medial compartment where we established an anterior medial portal under direct visualization and used our arthroscopic shaver to debride the moderate amount of synovitis we found in the anterior medial compartment. We placed our probe into the medial compartment and tested our medial meniscus from posterior to anterior noting no evidence of significant meniscal tearing. Some grade II changes were noted on the lateral tibial plateau and grade II-III changes noted on the medial femoral condyle. With a combination of arthroscopic basket forceps and the shaver we performed an appropriate chondroplasty of the medial femoral condyle and medial tibial plateau to remove the loose fragments of cartilage and leave the remaining cartilage behind. We proceeded into the intercondylar notch where after appropriate synovectomy we were able to evaluate the ACL and PCL and noted these to be intact. Next, we moved into the lateral compartment and again after appropriate synovectomy were able to visualize the chondral surfaces of the lateral femoral condyle and lateral tibial plateau which were intact without any significant changes. The posterior horn of the lateral meniscus was intact and the body at its 9 o'clock position had central meniscal fraying in the white zone. With an arthroscopic basket forceps we removed this frayed meniscus and then used an arthroscopic shaver to contour this back to a stable rim. The anterior horn was unremarkable. Next, we turned our attention back to the patellofemoral compartment. We established a proximal medial portal under direct visualization and inserted our arthroscopic shaver from both superior and inferior to perform appropriate chondroplasty of the patella. We brought the C-arm in to localize our heterotopic lesion but were unable to fully expose and debride this from the undersurface. 

The decision was then made to perform the last step of our procedure open and we removed our instruments from the joint and injected 15 cc 0.25% Marcaine w/epi into the joint. Next, we made a 6.0 cm incision using the patient's previous incision from the superior pole of the patella extending proximally and careful dissection was taken down to the quadriceps tendon and minimal subcutaneous flaps were made. The tendon was then split centrally and we noted thickening of the tendon at the quadriceps attachment to the patella. The heterotopic ossification was skeletonized and the quad tendinitis was noted and debulked and we were able to remove the heterotopic ossification and quad tendinopathy with a combination of Bovie cautery knife and rongeur. We then palpated for any remaining bone and noted none. We brought our C-arm in to confirm that we had removed all radiographic evidence of excess osseous bone formation and when we were happy with this we then irrigated out our deep wound and closed our quadriceps tendon back with #2 FiberWire suture. We then used 2-0 FiberWire suture for the subcutaneous layer and used staples to approximate the skin. We used 4-0 Monocryl suture in the subcuticular layer for our arthroscopic portals and used Dermabond for the skin. We then placed a sterile dressing after washing off the wound and then removed our drapes. The patient was awakened, extubated, and taken to the recovery room in good condition. 

Sponge and instrument counts were correct x two at the end of the case. 

There were no known orthopedic complications for this case. 

Thanks!


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