# HELP Knee Coders!



## smcbroom (Mar 23, 2010)

Can I please get anyone's opinion regarding this operative report... It's a worker's comp and the consulting company wants to use 
29877-RT
27422-RT
27425-59-RT
I know it's a long report but any assistance would be appreciated!

PREOPERATIVE DIAGNOSIS:
1.	Recurrent right patellar dislocation with lateral patellar facet chondrosis and medial patellar facet fragment.

POSTOPERATIVE DIAGNOSIS:
1.	Recurrent right patellar dislocation with lateral patellar facet chondrosis and medial patellar facet fragment.

OPERATIONS PERFORMED:
1.	Right knee arthroscopy with chondroplasty of patella.
2.	Open lateral release.
3.	Open medial reefing.
4.	Excision of unstable medial patellar fragment.
5.	Fulkerson tibial tubercle osteotomy.

ANESTHESIA:  General.

INDICATIONS FOR PROCEDURE:  The patient is a 23-year-old who sustained an industrial injury what sounds like a recurrent patellar dislocation.  He has ongoing patellar pain and feeling some instability.  Radiographically, appears to have an unstable medial patellar facet fragment, which is tender.  He is indicated for proximal distal realignment.

FINDINGS:  Exam under anesthesia revealed a small-to-moderate effusion with full range of motion, three quadrants of lateral patellar glide, two quadrants of medial glide, and negative 10 degrees of passive patellar tilt.  Ligamentous exam was stable.  Arthroscopic examination of the suprapatellar pouch and medial and lateral gutters revealed a medial patellar fragment adjacent to the medial patellar facet.  This was unstable to probing and was scarred into the medial retinaculum

There was diffuse grade III chondrosis on the lateral patellar facet.  There was a hypoplastic shallow trochlea.  Examination of the notch revealed the cruciate ligaments to be intact.  Examination of the medial and lateral compartment showed no significant chondral lesions or meniscal tears.  Open exploration did reveal some instability of a large medial patellar fragment in the medial retinaculum adjacent to the medial patellar facet.

Examination of tracking arthroscopically did show that the patella remained laterally subluxated throughout the range of motion.

DESCRIPTION OF PROCEDURE:  Following induction of general anesthesia, the right thigh tourniquet and thigh holder were applied.  The right leg was placed in a well-leg holder.  Under sterile conditions, the right knee was injected with 30 mL of 0.25% Marcaine with epinephrine in a standard fashion.  The right lower extremity was prepped and draped in the usual fashion.

Standard anteromedial and anterolateral portals with superolateral outflow were established, and diagnostic arthroscopy was performed with the findings as above.  The shaver was used to debride the unstable lateral patellar facet lesion.  This was done through both the anteromedial portal and the superolateral portal.

The arthroscope was removed.  The extremity was exsanguinated, and the tourniquet was inflated.  An anterior longitudinal incision was made incorporating the lateral portal, extending 5-cm distal to the tubercle and extending up to the superior pole of the patella.  Dissection was carried down sharply through the subcutaneous tissues and the skin flaps were elevated.  A lateral release was performed by incising the fibrous capsule along the lateral aspect of the patella from the superior pole down along the lateral patellar tendon to the tibial tubercle.  The plane between the fibrous capsule and the synovial capsule was developed, and more posteriorly, the synovial capsule was incised to provide an adequate lateral release and to allow Z-lengthening of the retinaculum.  Next, the insertion of the patellar tendon on the tibial tubercle was well outlined.  The line of the primary osteotomy cut was outlined with Bovie on the anteromedial patella, and the superior and inferior aspects were demarcated with 3.2 drill bits placed in the appropriate plane to allow nearly equal anteriorization and medialization.  The primary osteotomy cut was then made with the sagittal saw.  This was completed superiorly with the osteotome in the standard fashion with an intact small distal pedicle.  The tubercle was then rotated anteromedially to neutralize the tubercle sulcus angle and was fixed in that position with two 4.5 lag screws placed in standard fashion.  This provided a good compression at the osteotomy site and good alignment


Next, attention was focused on the medial patella.  A longitudinal incision in the medial retinaculum was made extending from the level of the superior pole of the patella down over the medial patellar fragment.  The medial patellar fragment was subperiosteally dissected out and removed.  The medial retinaculum was then advanced and repaired with #2 FiberWire sutures.  Mattress-type sutures were applied to advance the medial retinaculum and VMO appropriately.  Following the repair, the knee was flexed at 90 degrees to ensure that the repair was stable.  The patella at this point centered by about 30 degrees of flexion.  Next, the synovium and fibrous capsule were loosely approximated with 2-0 Vicryl sutures laterally with the knee flexed.  The tourniquet was deflated.  The wound was thoroughly irrigated.  A deep Hemovac drain was placed.  The skin was closed in layers with 2-0 Vicryl subcutaneous and staples on skin.  A sterile dressing was applied followed by a TED hose and a knee immobilizer.  The patient was awakened and extubated in the operating room and transferred to the recovery room in stable condition.

It seems that there should be more codes but I'm not quite sure.

Thanks for any help
Susan, CPC-H


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## rkmcoder (Mar 23, 2010)

*Post in Ortho forum*

I would repost this in the Ortho forum.


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## smcbroom (Mar 23, 2010)

I will do that also, it's just that when I post something I usually do it on the ASC forum since I work for an ASC & the rules are a little different.

Thank you!


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