# Excision vicker's ligament wrist



## seslinger (Jun 7, 2011)

I have an op note that I could use some help on:
Dx. is madelung's deformity wrist 
Procedure: 1. Excision anomalous vickers ligment volar wrist 
                 2. Epiphysiolysis of distal radius epiphysis with interpositional of free fat graft

... incision made in the distal forearm centered over the ulnar aspect of the distal radius.  The median nerve was identified, there was a large persistent median artery present and the median nerve began to bifurcate in the distal forearm at the edge of the entrance of the carpal canal.  The nerve was retracted.  The pronator quadratus was identified & was detached from its radial aspect leaving a cuff of tissue for later repair. The pronator quadratus was then mobilized ulnarward & the distal radius well exposed.  The thickened Vickers ligament was easily identified.  This was dissected off the distal radius & an incision was made in the volar capsule.  The capsule was dissected off the bufurcating ligament as the ligament was attached to the lunate, triquetrum & the radial volar aspect of the triangle fibrocartilage complex.  The vickers ligament was dissected off the ulnar half of the lunate & off the volar aspect of the triquetrum.  A volar portion of the TFCC was also needed to be excised to remove the ligament.  The distal radioulnar joint was stable following resection of the ligament  & the small portion of the TFCC.  With a small 27-gauge needle, the distal radial epiphysis on the ulnar aspect was identified. The epiphysis was elevated @ its proximal base & a free fat graft from the forearm subcutaneous tissues was then placed in the elevated epiphysis to hold into position.  This was sutured to the epiphysis with sutures.  The capsular tissues were then closed over the volar aspect of the wrist.  The lunate & truquetrum was stable.  The scaphoid lunate & triquetrum were stable.  The pronator quadratus was then repaired with sutures as was the volar capsule.  

So I am coming up with 25450 for #2.  I am thinking 25337 for #1 procedure.

Any help would be appreciated.  Thanks.
Sheila


----------



## preserene (Jun 7, 2011)

I am afraid to say that both are NOT appropriate for these procedures:

Procedures done are : *Excision Vicker's ligament + Epiphysiolysis of fused physis with fat graft *. We have to go  to assign codes for these .

[AND, 

*NOT EPIPHYSIAL ARREST WHICH IS EPIPHYSIODESIS (FUSION) OR CLIPPING OR STAPLING( 25450).
*25337- for Reconstruction for *UNSTABLE DISTAL *ULNAR OR *RADIOULNAR JOINT[/B 
This has  nothing to do with the Vickers ligament release or excision.]

 I would go for the code sets option: 
1.a 25107:Arthrotomy distal radioulnar joint including repair of triangular cartilage ,complex. - which he has performed and documented. 
and
 1b.25076 excision tumor, soft tissue of forearm and or wrist  deep - for excision release of volar ligament (sift tissue) [ I select  this for vickers ligament excision because the description says excision ........., soft tissue of wrist deep.
OR
2.  25332-  Wrist arthroplasty with interposition with or without  internal or external fixation.  ( instead of 1a)
Because : The surgeon has performed surgery for changing the bony anatomy of the metaphysis of radius (distal radius) or salvage procedure of the distal radius which is the main stay of procedure for madelung deformity for a girl (13years old) of this category of skeletal maturity (ie skeletal immaturity is not found).
OR

2. 25107:Arthrotomy distal radioulnar joint including repair of triangular cartilage ,complex. - which he has performed and documented.-alone  
  OR and,
25076 excision tumor, soft tissue of forearm and or wrist  deep - for excision release of volar ligament (soft tissue) [ I select  this for vickers ligament excision because the description says excision ........., soft tissue of wrist deep.

Since we do not have a CPT code in its name(Vickers ligament) , I thought it is ideal to go for soft tissue excision.

The following is only a moment to ponder:
I  did  have a different school of though for this Vickers ligament whether this can be familied into the transverse carpal ligament being a part of that an dits relation to median nerve and the symptom. the idea of release is to release the nerve pain too. if can be accepted then we could think of the code 64721 , because in the page 129 , parenthesis notes of 29848 gives for open procedure 64721.*


----------



## seslinger (Jun 8, 2011)

thanks for your imput.  This was a hard one for me.


----------

