# Podiatry help!!



## smcbroom (Dec 30, 2008)

OK, so here's my dilemma.  I think I was able to come up with the codes for this but I wanted to have others review it to verify it they are correct.  These feet procedures get tricky sometimes.

28250 - plantar fasciotomy
28290 - Silver bunionectomy
28110 - fifth metatarsal ostectomy
28285&28270 x 3 - hammertoe repairs w/capsulotomies
28293 - joint resection with implant

POSTOPERATIVE DIAGNOSES:
1.  Right foot painful bunion.
2.  Right foot painful fifth metatarsal tailor's bunion/metatarsal head.
3.  Right foot painful second, fourth, and fifth digit hammertoes.
4.  Right foot second metatarsophalangeal joint degenerative arthritis.
5.  Right foot chronic proximal plantar fascitis.

PROCEDURES PERFORMED:
1.  Right foot open plantar fasciotomy.
2.  Right foot silver bunionectomy.
3.  Right foot fifth metatarsal ostectomy.
4.  Right foot second digit proximal interphalangeal joint arthroplasty hammertoe repair.
5.  Right foot fourth digit proximal interphalangeal joint arthroplasty hammertoe repair.
6.  Right foot fifth digit proximal interphalangeal joint arthroplasty hammertoe repair.
7.  Right foot second metatarsophalangeal joint resection with implant.


PROCEDURE IN DETAIL:
The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation per Anesthesia, general anesthesia was induced.  Following induction of general anesthesia, the patient's right lower extremity was scrubbed, prepped, and draped in the usual aseptic manner.  The foot was exsanguinated and the tourniquet was inflated.

Attention was directed to the medial instep where a transverse incision was made in the direction of the relaxed skin tension lines.  The incision was dissected down to the level of the medial band of the fascia.  Care was taken to identify and retract all vital neurovascular structures.  A medial fasciotomy was performed.  The abductor hallucis was identified as well as the flexor digitorum brevis muscle bellies.  Care was taken to maintain the central and lateral bands for postoperative lateral column stability.  The wound was flushed.  The deep tissue was reapproximated with 3-0 Vicryl, subcutaneous tissue was reapproximated with 4-0 Vicryl, and the skin was reapproximated with 5-0 nylon.

Attention was directed to the first metatarsophalangeal joint where a linear longitudinal incision was made medial and parallel to the EHL tendon.  Dissection continued down to the level of the joint capsule.  An inverted L?capsulotomy was performed.  The capsular tissue was reflected.  At this time, a sagittal was used to remove the prominent medial bunion.  Dorsal exostosis production was removed as well.

Attention was directed to the first interspace via the original skin incision.  A lateral capsulotomy was performed.  The adductor hallucis was released and the short extensor tendon was released as well.  The toe was noted to sit in much better alignment in the transverse plane following the sequential lateral releases.  Prominent medial bunion was no longer present and first MPJ range of motion was improved.  The entire wound was flushed.  Capsular tissue was reapproximated with 3-0 Vicryl, the subcutaneous tissue was reapproximated with 4-0 Vicryl, and the skin was reapproximated with 5-0 nylon.

Attention was directed to the fifth metatarsophalangeal joint where a linear longitudinal incision was made just lateral to the extensor tendon.  Dissection continued down to the joint capsule.  A linear capsulotomy was performed.  At this time, a lateral fifth metatarsal ostectomy was performed.  The wound was flushed and closed in identical fashion with 3-0 and 4-0 Vicryl and the skin was reapproximated with 5-0 nylon.

Attention was directed to the fifth digit where a derotational elliptical incision was made.  The skin ellipse was removed.  Dissection continued down to the level of the proximal interphalangeal joint where a proximal interphalangeal joint arthroplasty was performed on the head of the proximal phalanx.  The wound was flushed.  The capsular and tendon tissue were reapproximated with 4-0 Vicryl as was the subcutaneous tissue and the skin was reapproximated with 5-0 nylon.  The foot was loaded in the prominent lateral bunionette and adductovarus hammertoe was corrected.  The toe sat in excellent alignment and the prominent tailor's bunion was no longer present.

Attention was directed to the fourth digit where a derotational proximal interphalangeal joint arthroplasty was performed in identical fashion to the fifth and closed in identical fashion.

Attention was directed to the second digit.  A linear longitudinal was made over the proximal interphalangeal joint.  At this time, dissection continued down to the head of the proximal phalanx.  It was resected and an arthroplasty was performed and closed in identical fashion.

The final procedure was the second metatarsophalangeal joint release.  A linear incision was made over the metatarsophalangeal joint.  Dissection continued down up to the joint.  The extensor tendon was reflected.  The metatarsophalangeal joint release was performed thus exposing the head of the second metatarsal base of the proximal phalanx.  Avascular necrosis and severe degenerative arthritis appears to have taken place at the second metatarsal head.  All of this was cleaned up and the reciprocating rasp was used to smooth rough edges and dorsal exostosis production was removed.  Next, the base of the proximal phalanx was resected and the hemi-implant was placed.  An 11.75 Biomet implant was placed in the base of the proximal phalanx.  Second MPJ range of motion was significantly improved with no crepitation.  The wound was flushed.  Deep tissue and subcutaneous tissue were reapproximated with 4-0 Vicryl and the skin was reapproximated with 5?0 nylon.  The foot was loaded and the second MPJ sat in better alignment with increased range of motion that was free of crepitation and improved range of motion.

All incisions were dressed with Xeroform nonadherent dressing.  A regional nerve block with 30 cc of 0.5% Marcaine plain was performed.  A sterile compressive dressing was applied to the foot.  The tourniquet was deflated.  Immediate hyperemia was noted to extend to all digits of the right foot.  The foot was placed in a below-knee pneumatic compression Aircast walking boot.  She will be made partial weightbearing with crutches.  She tolerated the procedure and anesthesia well and left the operating room for recovery with vital signs stable and vascular status intact to all digits.  Following a brief period of postoperative monitoring, she will be discharged home with written and oral postoperative instructions.

Any help would be greatly appreciated.  Oh, and I work at an ASC in case that wasn't clear already.

Thanks,
Susan


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