# Radial Head Replacement with Coronoid Fracture Repair



## CHARLENA79 (Jan 10, 2018)

Would this be codes as 24666, alone? Or 24666 and 24685? Is the I&D included for the forearm fracture? 



PROCEDURES PERFORMED:
1.  Left elbow open reduction.
2.  Left elbow radial head prosthetic replacement.
3.  Left elbow coronoid repair.
4.  Left elbow examination under anesthesia with fluoroscopy.
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ANESTHESIA:  General with supraclavicular block.
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TOURNIQUET:  75 minutes.
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ESTIMATED BLOOD LOSS:  Less than 100 mL.
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COMPLICATIONS:  None.
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SPECIMENS:  None.
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IMPLANTS:  Wright medical evolve radial head replacement, size 24 diameter head with +2 stem extension, 7.5 mm diameter stem.
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INDICATIONS:  The patient is a pleasant 67-year-old female who fell sustaining a left elbow fracture/dislocation.  Attempted left elbow closed reduction in the Emergency Department, was unsuccessful.  I was consulted on 12/22/2017 for persistent left elbow dislocation.  X-rays and CT scan demonstrated a posteriorly dislocated ulnar humeral joint with a displaced radial head fracture as well as a coronoid fracture.  We discussed the above stated procedure at length including risks, benefits, potential complications and alternative treatment options.  The patient understood and wished to proceed with surgery.  Informed consent was obtained.
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DESCRIPTION OF PROCEDURE:  The patient was seen in the preoperative holding area and the left elbow was marked.  She was brought back to the operating room and placed in OR table in the supine position.  General anesthesia was obtained and preoperative antibiotics were given.  The left arm was prepped and draped in the usual sterile fashion and formal timeout was taken correctly identifying the patient, surgical site and procedure.  The left elbow was exsanguinated and the tourniquet was inflated.  A lateral approach to the elbow was used.  A standard ECU splitting approach was used.  The incision was carried down sharply through the subcutaneous tissues to the deep fascia.  There was significant edema and hemorrhage within the soft tissues.  Once the deep fascia was exposed, full thickness flaps were elevated anteriorly and posteriorly.  The lateral epicondyle was able to be palpated.  There was a slight amount of avulsion of some, extensor off the lateral condyle.  A split in the extensor tendon was made just anterior to the border of the lateral epicondyle.  This was carried down to the fascia.  Care was taken to protect the lateral ulnar collateral ligament, which appeared to be intact.  The muscle was split bluntly with tenotomy scissors.  At this point, a large hemarthrosis was expressed.  The radial head was dislocate posteriorly behind the capitellum.  With traction applied, the radial head was able to be manipulated into the joint and removed in its entirety.  There was some mild arthritic changes.  The radial head to the most part intact with small comminuted pieces.  This was taken to the back table for measurements.  At this point, the proximal radial neck was able to be exposed and debrided of any comminuted fragments.  No significant dissection into the supinator was required.  Care was taken to protect, the posterior interosseous nerve.  At this point, there were several small fragments of bone within the joint which were removed with a rongeur.  The wound joint was irrigated.  No fractures were identified on the capitellum or the trochlea.  There was noted to be a comminuted fracture of the coronoid.  Small cartilaginous pieces were removed with a rongeur, which were nonreconstructable.  There were some bony fragments remaining attached to the anterior capsule.  These were left intact.  A locking stitch was placed around the bony fragments capturing the anterior capsule as well as using a #2 FiberWire stitch.  This was tagged and later used for repair of the coronoid.  At this point, a posterior incision approximately 3 cm in length over the posterior border of the ulnar was carried down sharply through the subcutaneous tissues to the deep fascia and the bone.  Two 2.0 mm K wires were passed from the posterior ulnar into the fracture bed of the coronoid.  One medial and one lateral drill hole were placed and were able to be seen directly through the incision exiting within the bed of the coronoid fracture.  Again, the coronoid fracture fragments were very comminuted and unable to hold any kind of screw fixation.  Once the K-wire was confirming corrected position.  They were removed one by one and Hewson suture passer was used to pass the #2 FiberWire stitches, which were placed through the anterior capsule and the coronoid fragments.  These were passed through the posterior border of the ulna.  These were tagged and would later be tied down for repair of the coronoid and anterior capsule.  At this point, the proximal radius and neck were exposed.  The canal finder was used.  The hand reaming was taken up to a size 8.5 with good cortical fit.  A size 7.5 stem was selected.  The radial head on the back table was sized at 24 mm in diameter and size +2 neck extension gave appropriate length.  The trial was placed with a 7.5 stem, +2 extension and a 24 diameter head.  This was placed and the elbow joint was reduced.  The elbow was stable with flexion and full extension.  The elbow was also stable without even repair of the coronoid at this point.  The C-arm was brought in confirming appropriate sizing of radial head and length.  The radial head was in line with the lesser sigmoid notch.  This was also seen with direct visualization.  At this point, a satisfactory radial head sizing was confirmed.  The trial was removed and the final implant was selected.  This was prepared and more stable was impacted on the back table.  The final size 24 diameter evolve right medical head with a +2 stem extension and size 7.5 stem was placed in the canal of the radius.  This was then reduced again.  The coronoid and anterior capsule with the elbow joint concentric reduced were then tied securely over the posterior border of the ulna with good bone bridge.  This was securely tied and cut.  At this point, the elbow was taken through full range of motion from 0 degrees to 150 degrees with excellent stability.  This was stable with pronation and supine.  The C-arm was brought in confirming congruent reduction of the ulnohumeral joint and radiocapitellar joint.  The radial head appeared to be satisfactory size and length.  This was in line with the lesser sigmoid notch.  Through the incision the anterior capsule and the coronoid fragments were flushed against the fracture bed on the proximal ulna.  The lateral ulnar collateral ligament proximal origin was also reinspected and intact.  The wound was irrigated with normal saline.  The deep fascia was closed with interrupted 0 Vicryl stitches.  The tourniquet was let down and hemostasis was obtained.  The subcutaneous tissues were closed with 3-0 Vicryl inverted stitches.  The skin incisions were closed with running 3-0 Monocryl stitches.  Dermabond was placed.  Dry sterile dressings were applied.  The patient was placed in a well padded posterior splint with the elbow in 90 degrees flexion and neutral rotation.  The hand was warm and well perfused, at the end of the case with intact radial pulse.
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