# trouble with feet



## abevan (Sep 11, 2008)

I am having trouble with this surgery on the foot please help and thank you in advance op report:
OPERATION 
1. LEFT FOOT HALLUX VALGUS CORRECTION WITH DISTAL SOFT TISSUE RELEASE (MODIFIED MCBRIDE). 
2. MEDIAL EMINENCE RESECTION AND CAPSULAR PLICATION. 
3. PROXIMAL FIRST METATARSAL CRESCENTIC OSTEOTOMY. 
4. EXCISION, DORSAL FIRST METATARSAL HEAD BUNION, AND FIRST MTP JOINT DEBRIDEMENT. 
5. DORSAL MEDIAL SENSORY CUTANEOUS NERVE DECOMPRESSION. 


A first webspace incision was made dorsally for the distal soft tissue release. The skin was incised longitudinally with a #15 blade, blunt dissection carried down digitally through the subcutaneous tissue. A Weitlaner retractor was then placed. The bursal space overlying the adductor tendon was carefully opened and the adductor tendon identified. A #15 blade was then placed in approximately at a 45-degree angle between the metatarsal and the sesamoid. carried out distally and then laterally to release the adductor. 

This was then freed up proximally between the metatarsal and sesamoid. The adductor was then carefully dissected off the lateral sesamoid and freed. The transverse metatarsal ligament was then released under direct visualization. The wound was irrigated and 2-0 Vicryl sutures were placed into the adductor tendon stump. The first MTP joint was perforated and varus stress applied. 

Attention was then directed to the medial aspect of the first MTP joint where a longitudinal midline incision was made through the skin. Dissection was carried down to the joint capsule. Plantar and dorsal dissection was then performed under direct visualization. The dorsal medial cutaneous sensory nerve was identified and carefully freed up. We came across a significant bunion prominence. Some mild adhesions were carefully dissected and the nerve retracted. No further impingement or adhesions could be identified. 

At this point, the nerve was retracted and protected. The joint capsule was then incised longitudinally just proximal to the base of the proximal phalanx. Approximately a 4-mm section of capsule was removed in a vertical inverted V. Dissection was then carried deep plantarly to the sesamoid, the scalpel kept on the inside of the capsule using the sesamoid as protection for the plantar digital nerve. The capsule was then carefully excised, the longitudinal component made over the dorsal aspect. It was carried back and the capsule released off the medial eminence. The medial eminence was then resected starting approximately 2 mm medial to the articular joint surface and parallel to the medial shaft of the metatarsal. 

At this point, the joint was inspected. Some grade 2 to 3 degenerative changes were identified over the dorsal aspect of the prominent dorsal bunion of the first metatarsal head. A separate osteotomy cut was then made across the dorsal bunion, removing the dorsal portion, which resulted in increased range of motion and decreased impingement. Approximately 80 degrees of dorsiflexion was obtained after this. The dorsal surface bone wax was then applied. The joint was further inspected and carefully debrided and irrigated. The edges from the median eminence resection and dorsal dissection were carefully rongeured and contoured. Attention was then directed to the base of the first metatarsal proximal crescentic osteotomy. 

A longitudinal incision was made. The extensor hallucis longus tendon was retracted laterally. Dissection was carried down to the base of the first metatarsal. The TMT joint was identified, at approximately 1 cm distal the planned osteotomy site was marked. The crescentic saw was utilized. Some malfunction of the saw causing rotation of the blade occurred after the majority of the cut was made. The cut was then finished on the medial side with a small osteotome. The osteotomy site was protected and retracted with baby Homans on either side. 

At this point, the osteotomy site was carefully freed up and rotated approximately 4 mm. This was carefully held in position. A temporary K wire was placed from the medial aspect. C-arm was used to confirm overall position and alignment, and good correction of the hallux was identified with improvement in the intermetatarsal angle. 

At this point, it was decided to place a Synthes mini-fragment T plate. The plate was carefully contoured and placed over the dorsal aspect. The 2 proximal screws were then drilled. The C-arm was used to visualize position and alignment of the hardware osteotomy site. No evidence of penetration into the metatarsal cuneiform joint could be identified. The distal screws were appropriately drilled and sized with the osteotomy site with gentle compression. Excellent stability was obtained. Good apposition of the bone surfaces could be visualized.


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## lavanyamohan (Sep 12, 2008)

Reply-
My suggestion:
Capsulotomy not coded separately. The rest all can be bundled up to one procedure code-28296, followed by 64726 for decompression of plantar digital nerve.
Dx-hallux Valgus that supports medical necessity- 735.0


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