# Knee Avulsion Help



## twilson@fmchosp.com (Jun 19, 2012)

What CPT codes would you guys use?  Thanks!

PREOPERATIVE DIAGNOSIS: Left knee lateral collateral ligament avulsion fracture with tear of posterolateral ligament complex. 

POSTOPERATIVE DIAGNOSIS: 1) Left knee lateral collateral ligament avulsion fracture with tear of posterolateral ligament complex. 2) Avulsion of lateral meniscal coronary ligament. 

OPERATION: 1) Open reduction internal fixation of avulsed lateral collateral ligament, left knee. 2) Primary repair of posterolateral corner ligament tear. 3) Primary repair of lateral coronary ligament complex. 

COMPLICATIONS: None
ESTIMATED BLOOD LOSS: Less than 10 ml
ANESTHESIA: General
TOURNIQUET TIME: 72 minutes

JUSTIFICATION: The patient is a 17 year old white male with a 4-wheeler injury to his left lateral collateral ligament, an avulsed fragment with the MRI suggesting additional ligament damage, who presented for surgical treatment. 

The patient was placed in the right lateral decubitus position on a bean bag, given general anesthesia, and tourniquet placed on the left leg. The left leg, knee and thigh were prepped with DuraPrep and draped in a sterile manner. A 6-8 inch incision was made over the mid lateral knee. With the knee flexed, skin flaps were developed. The space between the iliotibial band and biceps femoris was developed, and with the knees flexed, retracted posteriorly. The biceps femoris attachment was still attached to the fibula. Dissection of the popliteus tendon was able to be done, and there was a small avulsed fragment off the lateral collateral ligament. It was too small to entertain using a screw, and therefore #1 Ethibond sutures were utilized. Further dissection and examination demonstrated that just posterior to the fibula a small amount of posterolateral corner capsular avulsion was seen. This appeared to be a mid substance type tear, and this would later be repaired. Also the coronary ligament just anterior to the fibula stabilizing the lateral meniscus was avulsed off the tibia, but no bone fragments were avulsed. It was only the periosteum and the ligament complex. All of this would be repaired. 

Now, after careful identification of the lateral collateral ligament and the popliteus tendon and the biceps tendon, a 2 cm posterolateral arthrotomy was done just posterior to the lateral collateral ligament. Examination at the peripheral aspect of the lateral meniscus demonstrated no posterolateral peripheral tears. 

Later, the posterolateral corner would be advanced in a pants-over-vest manner with two interrupted figure-of-eight 0 Ethibond sutures for slight tightening. 

Now the lateral collateral ligament avulsed fragment was cleaned of all its granulation tissue, and it was put back in its anatomical position by putting four bone holes through the fibula and two separate #1 Ethibond sutures through the bone fragment, around to the lateral collateral ligament, and then back out through the distal end of the repair over the proximal fibula. Once these were secured they were tagged. The bone holes through the coronary ligament were put into the tibia and then into the lateral coronary ligament, and finally the posterolateral corner which was torn just posterior to the tib/fib joint was repaired in its mid substance with a single interrupted 0 Ethibond suture. Now the lateral collateral ligament was then tied, pulled into its anatomical position with the knee at about 70 degrees of flexion, tied securely. It was a very solid repair. The coronary ligament sutures were now tied securely completing the repair of the coronary ligament with 0 Ethibond and the posterolateral corner repaired as previously stated. This allowed the knee to easily go out to about 10 degrees lacking full extension, and even though it would go further, I did not want to push it any further, and the lateral collateral ligament complex was very tight and secure of the posterolateral corner was also tight and repaired well, and I felt that he would be able to gain the last ten degrees of extension without any trouble in his rehab. Very thorough irrigation was performed. The tourniquet was deflated. Further hemostasis was achieved with electrocautery. Closure of the fascial layers was then done with running interrupted 0 Vicryl on the fascial iliotibial band area. Deeper subcutaneous tissues were closed with 0 Vicryl, superficial subcutaneous tissues with 3-0 Vicryl, skin staples, Xeroform dressing, 4x4's, ABD pads, Kling, Ace wrap, TED hose stocking, and the patient placed in a Bledsoe brace, lacking 30 degrees of extension, and CryoCuff. The avulsed fibular fracture was anatomical in its reduction and very stable and solid.


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