# Knee surgery-Please help me



## DRWINGCHUN (Aug 10, 2011)

Please help me code the following procedure from the op-note below.
We have a difference of opinions.

 IMPLANTS USED:	STRYKER SCORPIO NRG CRUCIATE RETAINING FEMORAL SYSTEM, WITH #1 LEFT FEMORAL COMPONENT, 32 MM RECESSED POLYETHYLENE PATELLA, #7 STANDARD TIBIAL TRAY, AND A #7 CRUCIATE RETAINING 8 MM TIBIA BEARING INSERT.

DISPOSITION:	STABLE AND EXTUBATED TO THE RECOVERY ROOM.

FINDINGS:  Significant tricompartmental osteoarthritis with complete denuding of cartilage on the medial compartment of both the femur and the tibia.

INDICATIONS:  The patient is a 65-year-old female who was in the early 1980 sustained significant injury to the left tibia, resulting in residual deformity of the left lower extremity.  The left lower extremity was in varus by about 5 degrees however, the patient has developed significant tricompartmental arthritis of the left knee.  Her range of motion preoperatively is from approximately 5 degrees of flexion to 45 degrees of flexion.  The patient has failed nonoperative management and was indicated for left total knee arthroplasty.  Preoperatively, an extensive discussion was held with the patient regarding her ultimate goal of this procedure and the patient understands this procedure as primarily for pain relief.  We will attempt to restore motion however the patient full understands that this procedure was for pain relief.  All risks, benefits, and alternatives were explained to the patient and the patient understands.  Informed consent was signed preoperatively.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and general anesthesia was induced.  The tourniquet was applied high on the left thigh.  All bony prominences were well-padded.  The patient received perioperative antibiotics in the operating room in the form of Ancef.  Foley catheter was placed.  The patient's left lower extremity was then prepped and draped in the sterile fashion.  The tourniquet was inflated.

We began the procedure by making approximately 15 cm incision over the exact course of her prior anterior knee scar, in longitudinal fashion.  Hemostasis was well maintained.  Medial and lateral skin flaps were elevated sharply.  We then performed a medial parapatellar arthrotomy in the standard fashion.  Significant medial tibial release was performed, including the deep medial collateral ligament as well as portion of the pes anserine insertion.  The very proximal aspect of the patellar tendon insertion was released subperiosteally.  The lateral tibial plateau was also visualized by removing the infrapatellar fat pad and exposing to the lateral joint line.  We then attempted to evert the patella however, this could not be done.  We then turned our attention superiorly and performed an erected snip in approximately 45 degrees of obliquity and following the vastus fibers.  We then recessed the ACL with the knee in extension.  We released part of the medial meniscus as well as lateral meniscus.  We were then able to evert the patella and flex the knee up to 90 degrees.  There were no complications doing so.

We then turned our attention to completing the resection of the ACL.  PCL was spared.  Medial and lateral meniscus, that were visualized and removed with electrocautery.  We released medial and lateral capsular femoral bands that were evident.  We then turned our attention to the tibia.  Using the extramedullary tibial guide, in the appropriate posterior slope and varus-valgus alignment, we made an approximate 1 cm cut off the proximal tibia using the lateral tibial plateau as a guide.  We then finished our osteotomy using an osteotome and removed the cut bone.  We then turned our attention posteriorly and removed any medial and lateral posterior horns of the meniscus that were maintained.  Any visual posterior osteophytes were removed.  We then turned our attention to the distal femur and using our NRG tensioning device at approximately 3.5 marked on the medial and lateral components, we tensioned our soft tissues of the knee and inserted two pins anteriorly on the distal femur.  We applied our distal femoral cutting guide, and resected the appropriate amount of bone from the distal femur.  The knee was appropriately re-tensioned in flexion.  After this cut was made using approximately 3.5 numbers on the medial and lateral side of the jig.  We then used our posterior referencing guide to measure the size of the femoral component.  This was measured with #9 cruciate retaining Scorpio NRG component.  We then draped to the lugholes and applied the four-in-one cutting guide.  Taking great care to protect the medial and lateral soft tissue structures, we resected the anterior and posterior portions of distal femur and made our anterior and posterior chamfer cuts accordingly.  We then trialed with a #7 tibia and a #9 femur using 8 mm poly and the knee was seemed to obtain full extension and at least 90 degrees of flexion.  The knee was stable in varus and valgus and anteroposterior stress.  We then assessed the patellar tracking and it was seen that the patellar tendon subluxed laterally when we flexed up the knee.  We performed a lateral retinacular release from inside-out taking great care to not enter through the entire retinaculum.  We then reassessed our patellar tracking and in flexion, it was seen that the patellar tracking was acceptable.  We then removed our components and realigned the tibial tray at the medial one-third of the tibial tubercle.  There was an acceptable amount of overhanging bone on the tibia and the keel was then punched out.

We then returned our attention to the patella and measured its thickness to the approximately 23.5 mm.  We then recessed 10 mm of bone from the patella using the patellar reamer and the lugholes were drilled.  Any remaining overlying osteophytes were removed with the bone cutter.  We then re-trialed our all components and the patellar tracking was determine to be acceptable.  The knee was stable to varus-valgus in the anteroposterior stress.  We then removed all the trial components and flexed the knee in 90 degrees thoroughly irrigated the tibia, femur, and patella in preparation for cement.  We then proceeded to cement the components and placed the polyethylene liner in the usual standard fashion.  We then reassessed our stability and motion as well as patellar tracking and all were deemed to be acceptable.

We copiously irrigated the wound and deflated the tourniquet after approximately 137 minutes.  Hemostasis was well maintained.  There was no significant bleeding.  We the closed the erected snip with #1 Vicryl in interrupted figure-of-eight sutures and closed the arthrotomy with #1 PDS interrupted suture.  We closed the subcutaneous tissue with #2-0 interrupted Vicryl sutures and the skin with staples.  Prior to closing all remaining cement that was visible was removed from the knee and all significant osteophytes were also removed.  A sterile dressing was applied and final x-rays were taken and determined to be acceptable.  The patient was then awoken from anesthesia and transferred to the recovery room in stable fashion.


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## swillard (Aug 11, 2011)

this is a total knee replacement, 27447


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## DCoburn (Aug 11, 2011)

I agree with swillard.  Looking at the components used; this is a total knee arthroplasty (27447.  Even though it is mentioned that the  patient had an previous injury; it did not state in the documentation that any fixations was removed nor the location of the injury to the tibia therefore, you cannot use a conversion or revision CPT code for the repair.

Just my 1 1/2 cent


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## DRWINGCHUN (Aug 15, 2011)

Thank you, we were having a difference of opinion.


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