# Knee Contracture Release's - HELP



## Sara82 (Jan 5, 2011)

Very confused about what to code for this surgery. I have codes 27310 and 11981, but obviously way more was done and I dont know how to bill for this. A copy of the Op Note is below. Any help would be greatly appriciated.

OPERATION

POSTOPERATIVE DIAGNOSIS:
Previously infected left total knee with 90 degrees or more
flexion contracture spasticity and potential persistent
infection.

POSTOPERATIVE DIAGNOSIS:
1.  Arthrotomy removal of infection
2.  Debridement and soft tissue contracture release.
3.  Placement of articulating antibiotic spacer.


INDICATIONS FOR OPERATION:
The patient is a 49-year-old female who has a history of previous
cervical spine injury when she was younger.  This left her with
bit of spasticity bit more affecting the left leg and the right
leg.  She reports that she more or less led a normal life and was
reasonably active.  She did use assistive device occasionally a
cane or more likely a crutch.  She developed significant
arthritis in her left knee.  She ultimately had a corticosteroid
injection with that knee and became septic with
methicillin-resistant Staph aureus.  She was hospitalized which
led to long protracted septic state with multiorgan system
failure and prolonged ICU stay.  This left away with end-stage
renal disease and destroyed left knee.  During that time, she was
non-ambulatory basically for the last 9 months.  She developed
severe contracture of that knee.  Significant pain chondrolysis
and spasticity in that leg appeared to get worse somewhere along
the way.  Now, preventing her from ambulation.  We discussed the
complexity of the situation on multiple occasions.  Her
sedimentation rate and C-reactive protein were normal.  An
aspiration was negative.  An indium scan, however, showed
continued collection of suggestive infection persisting in the
metaphyseal segment of the tibia and the femur.  We discussed her
contracture of her spasticity her nonambulatory status all as
being significantly is complicated.  She had a previous opinion
that suggested of fusion.  This certainly would be a suitable
operation which would get her leg out straight potentially give
her the opportunity to ambulate again.  She has quite focused
that she wanted to knee replacement.  We talked about the issues
of persistent infection.  We talked about the issues of a
contracture.  We talked about the spasticity magnifying this as
well.

I am not entirely sure what her capacity for full extension is.
 The quadriceps works since she reports that she was more or less
straight and ambulatory before this infection.  We basically
conceded that we would do a 2-staged approach which would involve
going into the knee, taking cultures and specimens.  We were
doing all these soft tissue releases and bone cuts for knee
replacement getting the leg out essentially straight in a brace
and seeing how she did.  Based on this, we could contemplate the
potential for our reconstruction as developed quadriceps strength
and some propensity to keep her leg out straight.  We talked
about a variety of other issues.  She was adamant that she could
not continue along her current course of disability and
wheelchair-bound painful status.  Ultimately with full consent,
appropriate medical clearance, she wished to proceed with the
operation on December 20, 2010.

SPECIMENS REMOVED:
Multiple frozen sections were sent.  Cultures were taken from
both the femur and the tibia as well as the joint fluid.  All of
the medial Gram stains and frozen sections were called back as
negative for organisms or ketones infection.

DESCRIPTION OF OPERATION:
After identification of the patient, induction of general
anesthetic, the patient was positioned on the table.  Bony
prominences were appropriately padded.  A tourniquet applied to
left upper thigh.  Left leg was prepped and draped in usual
sterile fashion.  It should be mentioned that prior to prepping
and draping, we did exam under anesthesia.  She has a fair amount
of Aquinas in both feet.  Worse on the right and the left.  Her
right foot barely comes to neutral.  Actually probably 10 degrees
plantar flexion and neutral pronation supination type position.
 With her asleep and paralyzed, her flexion contracture is
probably in the neighborhood 50 the 55 degrees and quite solid.
 She can flex it up to 120 degrees.  Her hip would extend off the
table to basically neutral.  Once the leg was prepped and draped
in usual sterile fashion, Esmarch exsanguination was carried out,
and the tourniquet was inflated to 300 mmHg.  We opened through a
standard midline incision, a standard medial parapatellar
approach.  The entire knee was all soft and scar tissue.  We
actually looked fairly destroyed.  The bone was quite soft.  The
tissue was very fibrotic.  A little bit juicer than dry.
 Cultures and frozen sections were taken which again were all
called back as negative for acute inflammation and negative Gram
stains.  Additional exposure was gained by elevating the tissue
off the proximal medial tibia around the posterior medial corner.
 Ultimately we would perform a fairly dramatic posterior medial
corner.  Release all the way across the back of the tibia to
release the capsule.  The fat pad was resected.  The patella was
identified.  Complete medial and lateral synovectomies were
performed to free up the gutters again.  The patella was able to
be everted.  We resected the medial and lateral menisci as well.
 It was fairly dramatic bone destruction on both the tibia and
the femur.  We resected the anterior posterior cruciate
ligaments.  The tibia was subluxed forward and in anteriorly and
cut.  Ultimately we cut the tibia total 3 times removing
conservative initially but ultimately removing some additional
bone to make room for the prothesis.  Each time, we recut the
tibia.  We were able to work all around the posterior medial
corner, posterior lateral corner freeing up the posterior
capsule.  We did a fair amount work behind the femur as well.
 Completely releasing all the scar tissue off the back of the
condyle through the notch and up the back of the femur.  This
gave us basically a full capsular release.  Once we had with the
tibia cut, we could bring the leg out and just about full
extension.  We still had a significant amount of balance
posteriorly.  The drill hole was made in the canal of the femur.
 We resected 11 mm off the femur.  We then continued to do some
more additional work.  We were out the full extension with the
cut bony surfaces but not on the components.  We ended up cutting
another 3 mm off the distal femur before it is all said and done.
 We went back and forth in flexion and extension doing more and
more releases posteriorly around the medial and lateral side
freeing up the iliotibial band, etc.  Ultimately, we could get a
spacer block in for a 10 mm insert with probably a 10 degree
residual balance to the knee.  It was felt that this was at least
getting in the direction of adequate.  The tibia was prepared for
3 prosthesis.  The femur was then cut for a 3.  We balanced the
rotation off the soft tissues.  Took very little posterior bone
trying to recreate as much flexion space as possible.  We dropped
the size 3 block the back 2 mm and escaped without notching.
 Again, we took very little posterior bone.  We had mixed a size
3 Sigma mold on the back table with 2 bags of cement, each 1
containing 3 g of vancomycin, 1 g of tobramycin plus 1 g gent per
bag for total of 6, 2, and 2.  This fit the bone quite nicely.
 We trialed the metal component and the 10 polyethylene.  With
this we could get the leg out into extension about probably 10
degrees short.  Feeling that this was adequate, the tourniquet
was deflated.  Hemostasis was achieved.  We mixed up two more
bags of cement with the same antibiotic mixture.  These were
allowed to get good and we.  We curetted out the metaphysis
segment of both the femur and the tibia.  The tibial component
was cemented into place and compacted into place.  The femoral
component was cemented into place as well.  The leg was brought
out into extension.  With some work, we were again able to get to
that same 10 to 15 degree flexion contracture range.  The cement
was allowed to completely harden.  The wound was copiously
irrigated with antibiotic solution.  A single drain was placed,
and the arthrotomy was closed with 0 Vicryl suture.  Subcutaneous
tissue was also resurfaced the patella.  The size 35 patellar
button.  The tracking was quite nice although the plan was to the
leg to be in full extension.  The arthrotomy was closed with 0
Vicryl suture in interrupted fashion.  Subcutaneous tissues were
reapproximated with 2-0 Vicryl suture.  Skin was reapproximated
with staples.  Sterile dressing was applied as was the brace and
10 degrees of flexion to keep around the full extension, as was
the plan.  The patient was awakened and transferred to the
recovery room in stable.


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