# CMC with tendon transfer.



## Sage123 (Jan 16, 2015)

Hello to any of could give me help if you have the time.

Here is how I have coded this one.

CPT Codes 25447 and 25310 
ICD 9 Code 716.94

 I'm trying to decide between 25310 or 26480.

CPT code 25310 is more in depth as to how the tendon transfered is done but 26480 has the location down. Please read the op note below and give advice please.

Thank you for any help.



DX. Carpometacarpal joint arthritis, left thumb.

Procedures:Zancolli. 
Trapezium excision. 
Abductor pollicis longus (digastric) tendon transfer/suspension 
arthroplasty, carpometacarpal joint, left thumb

A double-curved incision, beginning over the dorsal radial distal forearm, in line with the abductor pollicis longus and extensor pollicis brevis tendons before they entered  the first dorsal extensor compartment. The incision was carried out 
directly over the abductor pollicis longus to the base of the thumb over 
the radial aspect of the MP joint of the thumb, with the tendon inserting 
into the base of the proximal phalanx of the thumb. Great care was taken to 
protect the superficial branches of the radial nerve, both dorsally and 
palmarly as the dissection was carried down to the abductor pollicis 
longus. The approach to the carpometacarpal joint was just to the dorsal 
side of the abductor pollicis longus and palmar to the extensor pollicis 
brevis. That interval was opened and widened, and Gelpi retractors were 
used to expose the lateral surface of the trapezium and the base of the 
proximal phalanx. 
Dissection was carried down to the capsule overlying the trapezium and a 
Freer elevator was used to define the carpometacarpal joint, as well as the 
scaphotrapezial trapezoid articulations with a retractor maintained and the 
interval between the scaphoid and the trapezium to protect the radial 
artery on its proximal side. 
The capsule was stripped off the trapezium, laterally, dorsally, and 
palmarly as much as possible, and a sagittal saw with a 7 mm blade was used 
to divide the trapezium in several planes to facilitate removal. 
A rongeur was then used to remove all fragments of the trapezium and the 
removal continued in the interval between the first and second metacarpals 
where there was an osteocartilaginous spike coming off the trapezium. When 
the entire trapezium had been excised, the flexor carpi radialis was 
visible in a diagonal path across the palmar aspect of the surgical site 
and arthritic changes were seen at the base of the first metacarpal. 
Copious irrigation was carried out at this point and a 3/32 drill point was 
used on a drill to fashion a hole in the base of the first metacarpal 
approximately 1 cm from its articular surface with the drill point directed 
just distal to the insertion of the abductor pollicis longus in a diagonal 
fashion to exit on the medial surface of the base of the first metacarpal 
for tendon reconstruction and stabilization. At this point the digastric tendon was identified on the palmar side of the abductor pollicis longus and separated from the abductor with the wrist held in radial deviation. The separation was continued back to the distal edge of the first dorsal extensor compartment. 
Attention over the dorsal proximal aspect of the incision was then utilized 
to access the abductor pollicis longus and extensive brevis tendons 
proximal to the proximal edge of the first dorsal extensor compartment, and 
again, great care was taken to protect the superficial branches of the 
radial nerve in the vicinity of the tendons. 
Dissection through the thin fascial layer, over the abductor and extensor 
brevis tendons was then utilized and the small digastric tendon was easily 
identified because it had the first appearing muscle along the course of 
those tendons. The digastric was divided just proximal to its muscle 
surface and could easily be withdrawn to the first dorsal extensor 
compartment. The tendon was then passed underneath the remaining abductor 
pollicis longus, passed through the drill hole from dorsal to the medial 
exit point for the drill hole, and delivered into the wound with a 
hemostat. A right angle clamp was then placed through the flexor carpi 
radialis tendon at the depths of the wound and on its palmar side, through 
which the digastric tendon was withdrawn, using the flexor carpi radialis 
as a 6.4 tendon. 
At this point the digastric tendon was passed through the abductor pollicis 
longus, very close to its insertion site at the base of the first 
metacarpal, and a double weave was utilized, with a second pass more 
proximally. Then, 3-0 Surgilon was then used to anchor the digastric tendon 
into the abductor pollicis longus and this was carried out with traction 
and abduction placed on the thumb, and tension placed on the digastric 
tendon and stump in a manner that produced a tight supporting and 
stabilization effect on the base of the first metacarpal. Then, 3-0 
Surgilon was used to suture the digastric in place, and at this point,


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