# HELP with ACL reconstruction scope vs open



## ednessa (Mar 10, 2010)

Hello,
could someone out there help me with this type of surgery,  I am very confused. any opinion would be very much appreciated. 


   1 Right knee ACL reconstruction with Achilles tendon allograft.
   2. Medial meniscus arthroscopic repair.
   3. Lateral meniscus arthroscopic repair.
   4. Chondroplasty, patella.
DESCRIPTION OF PROCEDURE: PT was identified in the preoperative area. 
Identified the right knee as the operative site. This was initialed by 
myself. He was then brought to the operating room, where he was placed 
under general anesthetic. Examination under anesthesia of the right knee 
revealed full range of motion from 2 to 3 degrees of hyperextension to 150 
degrees of flexion. Grade 3B Lachman and grade 3B anterior drawer. Grade 2 
pivot shift with near grade 3. Knee stable to varus and valgus stress at 0 
and 30 degrees of flexion.

The leg was then placed into an OSI leg holder. The well leg and all bony 
prominences were well-padded. The right lower extremity was then prepped 
and draped in usual sterile fashion. He received a gram of cefazolin prior 
to incision. A time-out procedure was performed, verifying correct patient, 
operative site, as well as presence of necessary equipment. The procedure 
was then initiated by injecting the right knee with a mixture of half-and-
half 0.25% Marcaine with epinephrine and 1% lidocaine plain. Standard 
anteromedial and anterolateral portal sites were injected, as well as the 
proposed location of anteromedial tibial skin incision. Portals were then 
established with an 11 blade. Arthroscope was introduced through 
anterolateral portal. Diagnostic arthroscopy was performed with the above-
mentioned findings. Chondroplasty of the patella was performed with use of 
a 3.5-mm shaver to assure that no unstable flaps remained. Medial meniscus 
repair was performed after preparation of the tear site with a ball-tip 
meniscal rasp to create a healing surface. A USS Sports meniscal Polysorb 
repair device was utilized. A single Polysorb repair staple was utilized 
medially. On the lateral side again a ball-tip rasp was used to roughen up 
the surfaces of the tear. Two USS Sports meniscal repair Polysorb devices 
were
utilized for fixation on the lateral side. Menisci were probed after repair 
and previous unstable tears were now stable.

Attention was then turned to the intercondylar notch. The OSI leg holder 
was loosened. A 4.2-mm shaver was used to remove the remnant of the ACL, 
which was minimal. The ACL footprint on the tibia at its insertion point 
was débrided for identification and reference of the tibial tunnel 
location. The 6-mm bur was then utilized to perform a notchplasty to assure 
visualization of the over-the-top position and assure that the graft would 
not impinge anteriorly. Over-the-top position was visualized and a curet 
was utilized to mark a 10:30 position on the clock face anterior to the 
over-the-top position for later reference when the knee was flexed. On the 
back table, the assistant prepared an Achilles tendon allograft with a bone 
plug measuring 10 mm in diameter and 25 mm in length. An Arthrex 
RetroCutter was then utilized to retro-ream the tibial tunnel. A 10-mm 
reamer was utilized. A guidewire was drilled and skin incision then made 
and the tunnel reamed in reversed fashion. All debris was removed with the 
shaver and a plug placed in the tibial tunnel hole. Attention was then 
turned to femoral fixation. The knee was flexed by assistant up to 115 
degrees. A 7-mm Arthrex over-the-top guide was placed in the over-the-top 
position in the lateral aspect of the intercondylar notch utilizing the 10:
30 reference point. A guidewire was then drilled through the lateral 
intercondylar notch at the 10:30 position. This was brought out the lateral 
thigh through the skin. A 10-mm Arthrex Low-Profile femoral reamer was the 
utilized to create a femoral tunnel of 10 mm in diameter and 25 mm in 
length. Debris was removed with a shaver. A notcher was then utilized for 
later interference screw fixation. A suture was then passed through the 
guide pin and this was brought into the knee. The passing suture was then 
retrieved through the tibial tunnel from the knee for graft passage. 
Allograft was then brought to the field. Graft was then passed through the 
tibial tunnel through the knee joint and into the femoral tunnel with the 
bone plug seated in the femoral tunnel. This was verified on direct 
visualization. The knee was then flexed to 115 degrees. A soft tissue 
protector was placed over the soft tissue portion of the graft. A guidewire 
for interference screw placement was then placed anterior-superior to the 
cancellous surface of the bone plug. An 8-mm tap for interference screw was 
then utilized and taken to a depth of 25 mm. Fixation was then performed 
with an 8-mm x 23-mm BioComposite interference screw. Excellent purchase 
was obtained. Femoral fixation was then visualized after the knee was 
brought down to 90 degrees. Arthroscope was then removed from the knee 
joint. The
graft was then cycled a dozen times to pretension it. Isometry was also 
checked at that time and found to be excellent. Tibial fixation was then 
accomplished with the knee in 30 degrees of flexion and a posterior drawer 
applied by an assistant. Fixation was performed with an Arthrex 
BioComposite 10-mm x 28-mm fully threaded screw. This was performed while 
holding tension on the graft. Again excellent purchase was obtained. This 
was visualized and palpated to assure that this was not proud and sunk into 
the level of the anteromedial tibial cortex. The arthroscope was then 
inserted back into the knee to assure that the screw did not protrude into 
the joint, which it did not. Guidewire was then removed. Graft was probed 
and found to have excellent tension. The knee was taken through a range of 
motion to ensure that it did not impinge anteriorly, preventing knee 
extension, which it did not. Final photographs were then taken. Arthroscope 
was brought into the suprapatellar pouch. Excess debris and fluid was then 
evacuated from the knee. Remainder of local anesthetic was then injected 
through the arthroscopic sheath. Incisions and portals were then closed 
with buried interrupted #3-0 Vicryl suture. This was performed with the 
anteromedial tibial incision after the excess portion of graft was cut 
flush with the tibial surface. Passing sutures were removed from the 
lateral thigh. Incisions and portals were then covered with Steri-Strips. 
Sterile dressings were then placed about the knee. This was followed by Ace 
wrap and a hinged knee brace set from 0 to 90 degrees of flexion. He was 
then awakened and brought to the recovery room in stable condition.


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## smcbroom (Mar 10, 2010)

Looks like
29888-RT
29883-RT
possibly 29877-59-RT depending upon the carrier, Medicare vs. commercial? as this was done in the patella region and also depending upon your diagnoses, it must support the chondroplasty in the separate compartment.

Also, not sure who you are coding for physician vs ASC? rules are a little different for each one.

Hope this helps!
Susan, CPC-H


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## ednessa (Mar 12, 2010)

Susan,
thanks for your response, yes it did help, I do code for ASC.


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