rgarcia04
New
| Please help code this surgery: The doctor originally coded: 23531 x4, 26437 x4, 26442 x4 and 26111x4. However, there are bundling issues. He is now changing the codes to: 26531 x4, 26593x4 and 26135 x4 Please see the operative report below, I would appreciate any coding suggestions: A horizontal incision was made directly over the 2nd through 5th MCP joints taking care to only incise the skin. Blunt dissection down to the extensor tendons with tenotomy scissors was performed taking care not to disrupt the dorsal veins. There were large rheumatoid nodules overlying the index and small finger MP joint. These were excised to expose the underlying extensor structures. Each mass was isolated from the surrounding tissues protecting both veins and dorsal cutaneous nerves to resect as much of the nodule as possible. With the rheumatoid nodules removed, we could then visualize the extensor tendons. The radial sagittal bands were significantly attenuated and the extensor tendons dislocated ulnarly on each of the digits. We approached the arthroplasties in an assembly line manner beginning with the index finger. I began by identifying the ulnar intrinsic tendons, dissecting them away from the surrounding tissues, protecting the neurovascular bundle and releasing their attachments to the extensor hood. The ulnar sagittal band was then incised longitudinally down to the level of the capsule. The capsule was identified and then incised longitudinally creating full-thickness flaps radially and ulnarly releasing the collateral ligaments to expose the joint. This was repeated on the long, ring, and small fingers. The joint surfaces had minimal remaining cartilage with pockets of erosion and areas of eburnation on both the metacarpal head as well as the proximal phalanx base. Extensive synovitis was encountered within each joint and was debrided with a rongeur. We then used an oscillating saw while protecting the underlying structures with 2 skinny Hohmann retractors placed inside the collateral ligaments and made a transverse cut in the metacarpal neck angling slightly proximally with the saw blade. The bone was resected and taken out of the wound. A rongeur was used to clean up any remaining osteophytes or sharp bone edges. We then began broaching for the arthroplasties, starting with the proximal phalanx of the index finger. An awl was used to enter the base of the proximal phalanx and sounded the shaft. We started with a size 2 and went up to a size 4, which seemed to fit very nicely. We then used an awl into the metacarpal and broached from size 2 up until size 4, which also seemed to have a nice fit. We placed a trial implant there and it is felt to be the appropriate size with seating both proximally and distally, and the extensor tendon centralized well over MP joint with it in place. This was removed, and a 0.035 K-wire was used to make 2 bone tunnels in both the dorsal radial aspect of the distal metacarpal at the collateral ligament origin for eventual repair/imbrication. Attention was then turned to the long finger. An awl was used to enter the base of the proximal phalanx and sounded the shaft. We started with a size 2 and went up to a size 4, which seemed to fit very nicely. We then used an awl into the metacarpal and broached from size 2 up until size 4, which also seemed to have a nice fit. We placed a trial implant there and it is felt to be the appropriate size with seating both proximally and distally and the extensor tendon centralized well over MP joint with it in place. This was removed, and a 0.035 K-wire was used to make 2 bone tunnels in both the dorsal radial aspect of the distal metacarpal at the collateral ligament origin for eventual repair. The tourniquet was released for several minutes to allow perfusion to the tissues. Attention was then turned to the ring finger. An awl was used to enter the base of the proximal phalanx and sounded the shaft. We started with a size 2 and went up to a size 3, which seemed to fit very nicely. We then used an awl into the metacarpal and broached from size 2 up until size 3, which also seemed to have a nice fit. We placed a trial implant there and it is felt to be the appropriate size with seating both proximally and distally and the extensor tendon centralized well over MP joint with it in place. This was removed, and a 0.035 K-wire was used to make 2 bone tunnels in both the dorsal radial aspect of the distal metacarpal at the collateral ligament origin for eventual repair. Attention was then turned to the small finger. An awl was used to enter the base of the proximal phalanx and sounded the shaft. We started with a size 2 and went up to a size 3, which seemed to fit very nicely. We then used an awl into the metacarpal and broached from size 2 up until size 3, which also seemed to have a nice fit. We placed a trial implant there and it is felt to be the appropriate size with seating both proximally and distally and the extensor tendon again centralized well over MP joint with it in place. This was removed, and a 0.035 K-wire was used to make 2 bone tunnels in both the dorsal radial aspect of the distal metacarpal at the collateral ligament origin for eventual repair. 2-0 fiberwire suture was placed into the collateral ligaments on each side down through the bone tunnel and then out through the bone tunnels and then again through the collateral ligament for eventual repair of the radial collateral ligament. The touniquet was then reinflated prior to implantation of the MP arthroplasties After irrigating the wound copiously with Xperience, we then selected the Swanson metacarpophalangeal joint silicone implants and placed them with a no-touch technique appropriately into the metacarpal shaft and proximal phalanx of each digit sequentially beginning with the index. The fiberwire was then used to imbricate the radial collateral ligament which was was tied down at this stage. We tested our joint stability and felt to be excellent with minimal shuck and with gentle testing, our range of motion felt to be excellent with a good fit of our implant and centralization of the extensor tendons. We then repaired the capsule with interrupted 4-0 Vicryl suture in a figure-of-eight fashion. The radial sagittal bands were then imbicated using 3 figure of 8 sutures with 3-0 fiberwire over each MP joint. The joints were again ranged and found to be stable. The extensor tendons did not subluxate radially or ulnarly. The wound was again irrigated with saline and Xperience. The tourniquet was released and small bleeding vessels were cauterized with bipolar cautery. Local anesthesia was infiltrated into the tissues. The wound was then closed with interrupted 3-0 vicryl in a deep dermal and 4-0 monocryl in a running subcuticular stitch. The digits had good rotation and improved sagittal alignment. Steri strips and A sterile dressing was placed along with a volar resting splint with the wrist in slight extension, the MP joints in extension and the IP joints resting inc a comfortable position. All digits were warm and well perfused with capillary refill <2 sec. All counts were correct. The patient was then awoken from anesthesia, transferred to the gurney and taken to the PACU in stable condition. |