# medical patellofemoral ligament reconstruction



## freemacl47

this always throws me for a bit of a loop         any advise is appreciated

the patient has recurrent dislocations of the knee

the physician obtained gracilis tendon for the graft

he then made an incision medial patella down to expose the lateral part of the knee to avoid the joint

drilled holes medial patella

incision over femur attachmant site down to the bone and made holes

plugged the graft into holes tensioned and screwed into place


i am looking at 27422 -- but the description doesnt seem to match

also looking at 27428 -- which describes it better


your opinion????   your help is appreciated


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## lorebe22

*27422 and 27427*

I struggle with this case scenario too.   My ortho did medial patellofemoral ligament reconstruction utilizing quadriceps tendon turndown and VMO advancement.

He lists 27422 and 27427.  These bundle but 27428 does not bundle with 27422 and I'm wondering if his work is more intraarticular and 27428 may be more specific.

The surgeon states he first harvests the central third quadriceps, drills into the medial femoral condyle, then "released the VMO for imbrication reinforcement."   "...placed the graft, tensioned it appropriately, and placed a .... screw to hold this within the tunnel."  "We then reinforced this with our hamstring semitendinous graft and advanced the VMO to the lateral third of the patella."  

I am wondering if 27422 and 27428 with 718.86 and 717.89 is appropriate?

Please any help will be greatly appreciated.   And I'm sure that "freemac" will appreciate any feedback too.

Thanks again,
Lori


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## maryanneheath

Hello,

We use CPT 27428 for MPFL reconstruction....


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## nyyankees

maryanneheath said:


> Hello,
> 
> We use CPT 27428 for MPFL reconstruction....



MPFL is an extra-articular Ligament (medial)...even though there is work performed inside the knee. 27427 is what we use. You can use 27422 and capture the Graft Harvest as well. Intra-articular is really for ACL and PCL reconstruction.


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## coder311

JULY 2013 MD Strategies

Medial Patellofemoral Ligament Reconstruction

The following is an example of an operative report describing a medial patellofemoral ligament reconstruction.

PROCEDURE PERFORMED:

Open medial patellofemoral ligament reconstruction with semitendinosus allograft.
The patient was taken to the operating suite and placed in the supine position on the operating table where general anesthesia was administered. The knee was examined. The 4 ligaments to the knee were normal. The knee had good motion. There was lateral patellar subluxation with range of motion. There was marked laxity of the medial retinaculum and medial restraints with fourth quadrant lateral subluxation of the patella with applied translation. At this time, her leg was prepped and draped in the usual sterile fashion. The previous medial patellar incision was re-incised. It was lengthened a bit inferiorly and superiorly. Dissection carried down through the skin and subcutaneous tissues. 
The medial retinaculum along the medial patellar border was incised to expose the medial border of the patella.  Previous sutures were seen. Dissection was then carried down between the vastus medialis obliquus in the underlying femur to create a tunnel for the position of the medial patellofemoral ligament. Along the posterior aspect of the vastus medialis obliquus, the femur was exposed. We could see the adductor tubercle and the medial femoral epicondyle with the depression in between the two for positioning of the femoral attachment of the medial patellofemoral ligament. At this point, a guidepin was placed drilling from posterior to anterior and from inferior to superior traversing the femur and exiting percutaneously along the lateral side of the femur. The looped end of the semitendinosus allograft, which was prepared by the physician's assistant, was 7.5 mm, therefore, 7.5 mm tunnel was created in the femur. The total distance of the tunnel was 40 mm. The femoral tunnel was completed with the EndoButton drill to exit femoral cortex. Total length of the tunnel and EndoButton hole was 70 mm. At this point, the 2 drill holes were created on the patella, 1 drill hole more superiorly was created from medial to lateral. It was about 7 mm distal to the superior patellar pole. A 5 mm drill was used. It was drilled 20 mm across the patella from medial to lateral.  A second 5 mm tunnel also 20 mm in length was created about a centimeter distal to the first tunnel but still superior to the mid portion of the patella. Next, the looped end of the graft was passed into the femoral tunnel with the attached TightRope and button device. The button was flipped and deployed along the lateral femoral cortex. The looped end of the graft was then advanced up into the femoral socket. Next, the 2 free ends of the graft were passed beneath the vastus medialis obliquus and then brought up to the medial border of the patella. The free end of each graft was brought into the corresponding patellar drill hole. The sutures on the free end of the graft were then ligated over the lateral patellar border tensioning the medial patellofemoral ligament.


Based on information from the AMA this procedure would be reported as 27422 - Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release.


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