# achilles tendon question



## BFAITHFUL (Apr 21, 2009)

dx:  exostosis posterior calcaneus 726.91 
       Achilles tendon enlargement & calcium depositis w/in tendon

Findings:
Gross findings at the time of surgery, an exostosis was noted on the posterior aspect of right calcaneus.  There is a slight enlargement of the posterior, dorsal, and superior surface of the bone.  The Achilles tendon as it reached its insertion was extremely hypertrophied and there were calcium deposits w/in the tendon.

Description of procedure:

attention was first drawn to the posterior aspect of the right heel, where a serpentine incision beginning medial to the Achilles tendon approximately 4cm distal from the incision and then was carried down transversed over the posterior calcaneous and ended is laterally.  suq tissue was then meticulously dissected  via blunt dissection exposing the Achilles tendon.  Two flaps were created, one in a dorsal lateral direction and the other in a distal medial direction creating adequate exposure.  particular attention was paid to take the skin and subq tissue in one layer.  at this point a linear incision was made in the vertical direction through the midline of the achilles tendon, the thickening of the tendon was better appreciated and as were some of the intratendinous calcium deposits.  The tendon was dissected distally down towards the insertion exposing the calcaneal posterior exostosis.  As much of the endon was left intact while still gaining adequate exposure of the exostosis.  The exostosis was then removed using an osteotome and mallet.  The area was rasped smooth using a power burr.  Now the posterior superior, and dorsal wedge of the calcaneous was removed using a combination of bone rongue and a osteotome.  the contour of normal anatomy was followed.  all edges were rasped smooth.  distal tendon wasevaluated near its insertion at the calcaneous and calcium deposits were meticulously dissected out in their entirety.  A portion of the tendon was debulked.  more than adequate amount of tendon was always left to ensure proper healing & function

the operative area was surgically lavaged several time throughout procedure.  Then, just prior to reattachment of the achilles tendon and closure of the wound was copiously flushed and drained.  Now two suture anchors were placed into the posterior aspect of the calcaneous one on the medial side and one on the lateral side.  The Achilles tendon was placed back in proper positioning and with the use of aBunnel suture both halves of the tendon was reattached to the calcaneous.  Now the midline tendon was cut and it was reattached using a running stitch of 2-0 Vicryl.  The subq tissue was reapposed using 3-0 Vicryl and the skin was eapposed using 4-0 Prolene with a subcuticular stitch.  A short leg fiberglass cast was then applied with the foot in a plantar flexed position to ensure tension off the tendon.  


im thinking 28118 but not sure about billing separately for 27650/27654, i know most of the time to get to the exostosis there has to be a reattachment of achilles tendon but not sure since there were calcific deposits and tendon was hypertrophied if i can bill w/mod 59

Your help with this one is appreciated!!!


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