# Bunions/Osteotomies



## awest (Dec 21, 2009)

I'm confused as to the codes I should use for this case, 28296, 28292, 
28306, 28299???

OPERATION REPORT

PREOPERATIVE DIAGNOSES
1.	Hallux valgus bunion deformity, left foot.
2.	Hallux interphalangeus, left foot.

POSTOPERATIVE DIAGNOSES
1.	Hallux valgus bunion deformity, left foot.
2.	Hallux interphalangeus, left foot.

PROCEDURES
1.	McBride-Akin bunionectomy, left foot.
2.	Double osteotomy, first metatarsal, left foot.

ANESTHESIA:  General  

REPORT OF OPERATION:  The patient was brought into the operating room and placed on the operating table in a supine position.  General anesthesia was administered per Dr. Thomas and Jimmy Strickland, C.R.N.A.  The left foot and ankle were prepped and draped in the usual sterile manner.  Hemostasis was obtained utilizing a left ankle tourniquet inflated to 250 mmHg after elevation and exsanguination of the left foot with an Esmarch bandage.  Attention was directed to the dorsomedial aspect of the first metatarsophalangeal joint where an approximately 5-cm curvilinear incision was made.  The incision was deepened via both sharp and blunt dissection with the care being taken to retract and preserve all vital structures as encountered.  An adductor hallucis tenotomy and extensor hallucis brevis tenotomy were performed.  An inverted L-shaped capsular incision was made centered over the dorsomedial aspect of the first metatarsal head.  Capsular and periosteal structures were reflected away from the head of the first metatarsal.  The foot was repositioned and a wedge-shaped osteotomy was performed at the level of the neck of the first metatarsal with the apex of the wedge being distal and the base being proximal.  An additional second osteotomy was performed with a wedge shaped portion of bone created wider medially and then laterally to decrease the noted increased proximal articular set angle of the first metatarsal head.  The wedge shaped portion of bone created was resected in toto.  The head of the metatarsal was transposed laterally, impacted, and fixed utilizing an 18-mm compression screw.  Good fixation was noted.  The remaining dorsomedial eminences were resected.  The extensor hallucis longus tendon was noted to be tight and bowstrung as such an extensor hallucis longus Z-plasty tendon lengthening was performed.

The foot was placed in its neutral position and additional deformity was noted at the level of the great toe with notable hallux interphalangeus as such a 2-cm curvilinear incision was made centered over the proximal phalanx.  The incision was deepened via both sharp and blunt dissection with the care being taken to retract and preserve all vital structures as encountered.  Capsular and periosteal structures were reflected away from the base of the proximal phalanx and utilizing power-oscillating saw, the dorsoplantar wedge-shaped osteotomy was performed with the apex of the wedge being lateral and the base being medial.  The wedge portion bone created was resected.  The lateral cortex was noted to be left intact.  The wound was flushed with copious amounts of sterile saline.  The osteotomy site was closed and fixed utilizing a 0.045-inch K-wire.  Good fixation and reduction of first ray deformity was noted.  The wound was flushed with copious amounts of sterile saline.  All capsular, periosteal, and subcuticular structures were coapted utilizing 4-0 Vicryl.  Skin was coapted utilizing 5-0 Prolene.  The surgical sites were injected with 0.5% Marcaine plain and dressed with Adaptic, sterile gauze, sterile Kling, cast padding, Kerlix, and an Ace bandage.  The tourniquet was deflated and normal hyperemic response was noted to occur in the left foot.  The patient tolerated all procedures well and left the operating room to the recovery room in apparent satisfactory condition.  Postoperative instructions were once again reinforced in oral and written form.


----------



## coderguy1939 (Dec 22, 2009)

Check out this Bulletin from AAOS re bunionectomies--might be helpful.

http://www2.aaos.org/aaos/archives/bulletin/aug02/cod.htm


----------



## awest (Dec 22, 2009)

Thank you


----------

