# Help with bone grafting of femoral and tibial tunnel.



## frampe (Apr 27, 2009)

Hi,
  Could someone help with the CPT coding for hospital facility billing of the CPT codes? How do you capture the bone grafting of the femoral and tibial tunnel? I get 29888 and 29881 for the rest of the services provided. 
Thanks

PREOPERATIVE DIAGNOSIS
Left knee failed anterior cruciate ligament reconstruction with probable medial meniscus tear, retained hardware. 

POSTOPERATIVE DIAGNOSIS


PROCEDURE
Left knee staged anterior cruciate ligament revision surgery with removal of two interference screws, partial medial meniscectomy, bone grafting of the femoral and tibial tunnel. 

ANESTHESIA
General. 


NARRATIVE
The patient was taken to the operating room, laid supine, had successful general anesthesia performed. The knee was examined. The knee had a very positive pivot shift with a large clunk anteriorly. There was an endpoint to the Lachman exam, although the Lachman exam extended about anteriorly at least 15 mm greater than the other side. PCL exam was noted to be very tight and equal to the other side. Varus and valgus exams tested at 0 and 30 degrees showed very solid endpoints equivalent to the other side. Dial test was performed at 30 and at 90 degrees and showed no difference side to side. 

We then proceeded by preparing the left leg and the right leg for surgery. The left leg was the operative leg having the ACL revision. The right leg was going to be the donor graft. 

We then proceeded with our ACL revision. The standard knee arthroscopy was performed. The superior pouch, the medial and the lateral gutters were pristine. There was no obvious abnormality. The patella, all four quadrants were intact. The patellofemoral groove intact. The notch showed ACL that was rather loose, had some minor damage to it. The PCL was completely intact and robust. The medial joint had intact articular cartilage on the femur and the tibia, but a very complex tear of the posterior horn of the medial meniscus extending from the midthird to the posterior third right at zone one, but it was very ripped up in multiple small pieces and had a radial tear right in the posterior third. The anterior third of the meniscus was intact. The articular cartilage on the lateral side was intact. On the tibial side it was a little soft and the meniscus was intact. 

We then began with a partial medial meniscectomy. An auxiliary portal very medial needed to be done to get to the posterior aspect of the meniscus. Biters and shavers were used in order to get it out, and we had to go through the notch in order to get out the very posterior root. 

We then proceeded with our ACL revision surgery. We created an incision over the tibia and identified the screw. The interference screw was removed. We then passed a guidewire through this and secured it on the inside of the knee, and then sequentially reamed to a 10 mm reamer. We had good bony contact and chatter at this point in time and removed all the debris from this tunnel. We then flexed the knee past 90 degrees. Things got a little confusing at this point in time. It was very difficult to find the old tunnel. The old orifice was found. It was noted to be very horizontal rather than vertical, and was running from a posterior to anterior position. Its insertion in the joint was actually 12-13 mm out from the back wall and it was laying very parallel to the roof. After this was figured out, I then passed a wire from the inside of the knee to outside the knee, cut down over this wire, created a stab incision, and then lengthened it to about 2 cm. We cut down through the quad, identified the tunnel, and then slowly started working through here. It was then obvious that the last screw was put in very horizontal, and so we needed to make a small 10 mm stab incision down more posterior in the leg and cut down over the wire, remove the screw. We then worked through the more anterior tunnel. 

We then thoroughly irrigated and then debrided to a 10 mm reamer, and then placed a 10 mm straight reamer in with protection down to the bone and then reamed a straight tunnel. 

So both tibial and femoral interference screws were removed, both tunnels were reamed to a 10, we had good chatter and fixation on our last graft, and we used an OATS reamer to verify that we were at a 10 mm tunnel. 

We then fashioned rectangular bone grafts that were allograft on the back table to fit through 10 mm tunnels. We used the OATS set to pass the femoral one first and tapped it down to its orifice. We then secured it in place and were very pleased. The tibial one was then placed second up into the joint and we were pleased also. We then used a probe and were not able to push it. They were nice press fit. We placed more bone graft up into the femoral side. We thoroughly irrigated the femoral wound as well as the tibial wound and then closed. Then2-0 Vicryl was used for deep in the thigh, then monofilament was used, absorbable in the skin, and then we used staples. This was done for the tibial insertion wound, too, as well as the portal sites. We then thoroughly irrigated and closed. We placed her into a sterile dressing postoperatively. 

It is important to say that there was no way to do a staged ACL revision at this point in time due to the position of the last surgery. I was too worried about drilling through the tunnel that I had just made with bone graft in it, that it would fracture and then cause more difficult problems. We will wait and do this staged, come back in six months. 

SPECIMENS
None. 

COMPLICATIONS
None.


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