# Debridement and Irrigation on knee with bone cement



## SSweetland (Sep 20, 2011)

The only cpt code that my coders can come up with is unlisted--27599.  I need to compare it to something and that where the problem is.  The procedure is:  lt knee wound irrigation and debridement with placement of triple antibiotic impregnated bone cement.
Any suggestions would be greatly appreciated.


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## Laxwido (Sep 21, 2011)

Hm.  Wonder why they went unlsited instead of trying 11981, 27310 (best guess for knee i/d based on little info!)


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## BLumetta (Apr 15, 2019)

*Knee I&D with antibiotic spacer*



SSweetland said:


> The only cpt code that my coders can come up with is unlisted--27599.  I need to compare it to something and that where the problem is.  The procedure is:  lt knee wound irrigation and debridement with placement of triple antibiotic impregnated bone cement.
> Any suggestions would be greatly appreciated.



I have a similar surgery. This is an I&D and placement of antibiotic spacer for recurrent infection of the patient's natural knee, not a replacement knee. The provider used all the same equipment and took all the same steps he would normally need for a arthroplasty. 

After a discussion with the provider I'm thinking 27310-22 for the knee because the infection tracked into the femur, 11981 for the spacer, and 15852 for the negative wound dressing. What do you think? 

An anterior midline incision was utilized and we sharply dissected through the skin and subtenons tissue maintaining hemostasis with Bovie cautery.  The extensor mechanism was identified and a medial parapatellar arthrotomy was completed.  We encountered a large effusion with cloudy, infectious appearing serosanguineous fluid of approximately 200 cc which was evacuated with suction.  We then performed a proximal medial tibial flap to coronal midline.  Medial lateral synovectomies were completed.  Tissue was sent for culture.  Redundant synovium was then resected from the anterior femur, retropatellar fat pad, suprapatellar regions.  Of note patient had a large amount of fibrotic tissue circumferentially around the knee and what appeared to be rind of abscesses along the femur both anteriorly, laterally, and medially.  This tissue was extensively debrided.  Based on her MRI we knew that she had abscesses in the quadriceps muscle both medially and laterally.  We tracked up the medial and lateral aspects of the quadriceps muscle and encountered abscesses along both the lateral and medial sides which were mostly deep to the vastus lateralis laterally and intramuscular medially.  The medial abscess tract tracked all the way up into the proximal thigh.  These areas were debrided with curettage and rongeur and Bovie cautery.  At this point the knee was flexed and the lateral meniscus was released and the cruciate ligaments were resected.  Access was gained to the femoral canal and a flexible guide rod was placed in the distal femoral cutting guide was pinned in position and a distal femoral cut was completed.  The cutting was confirmed by replacing the rod with paddles.  The posterior collar referencing guide was then placed in the distal femur sized to be a size 5 and the 4 cuts were completed without complication.  The tibia was then subluxed anteriorly and an extra medullary tibial cutting guide was pinned in position a proximal tibial cut was created perpendicular to the mechanical axis of the tibia.  The proximal tibia sized to be a size 4 and the cutting was confirmed with the baseplate and drop-down rod.  A lamina spreader was then placed in the flexion gap and the lateral and medial menisci were removed.  Posterior collar osteophytes were removed.  The posterior capsule was debrided with curettage and Bovie cautery.  Trial implants were then placed and based on trialing elected to utilize a size 5 femur and a 4 x 9 all polyethylene insert.  The patella was then calipered to be approximately 25 mm in thickness and a freehand a symmetric cut was completed to a thickness of approximately 14 mm.  The patella was sized to be a 29 patella.  The peg holes were drilled and the patella tracked appropriately.  At this time a box cut was completed for the femur with the chisel and box cutting guide.  We confirmed the PS femur fit appropriately.  The tibia was then prepared with the reamer and punch mechanism.  A guide rod was then placed into the femur and the femur was flexibly reamed to a 13 and half millimeter reamer.  We then turned our attention to the to the tibia and it was flexibly reamed to a 12-1/2 mm reamer.  At this point time we had thoroughly debrided the knee and soft tissues of the quadriceps and surrounding tissues.  We then began with copious irrigation including pulse lavage of both the femoral and tibial canals and previous abscess tracts and all the remaining soft tissue.  The knee was also irrigated with 500 cc of Irricept solution followed by's sterile normal saline.  We then performed a diluted Betadine soak.  We then changed sterile gowns and gloves and hoods and placed new sterile drapes, cautery, pulse lavage, and suction.  We then reirrigated the knee with 3 L of sterile normal saline.  Note we irrigated the knee and soft tissues with approximately 15 L of sterile normal saline total.  We then created to antibiotic cement dowels over stainless wire for the tibia and femoral intramedullary canals.  Once the cement was hardened and replaced in the canals without complication.  We then mixed cement and cemented the femur into place and then cemented the tibia and patella into place.  Please note that we used a total of 3 packages of antibiotic cement and each pack was mixed with 3 g of vancomycin powder and 2.4 g of tobramycin powder.  Implants were held in position until cement was hardened and all excess cement was removed.  We then placed a deep Hemovac drain and soak the wound and topical TXA and then the tourniquet was deflated and bleeders were cauterized.  The arthrotomy was closed with Quill suture and the remainder the wound was closed in layers.  Please note that after the arthrotomy was closed with placed 1 g of vancomycin powder in the superficial tissues.  We then placed an incisional VAC.


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