Dx 836.1
717.9
719.86
701.4
CPT 29880
I feel like I am missing something can somoeone look this over??
Thank you
POSTOPERATIVE DIAGNOSES:
1. Degenerative complex tear, posterior horn, medial meniscus.
2. Degenerative mid-substance tear, lateral meniscus, with
calcification.
3. Diffuse grade 2 and early grade 3 chondrosis of medial femoral
condyle.
4. Diffuse undersurface patella and proximal trochlea grade 2
chondrosis, patellofemoral axis.
5. Distal femoral notch stenosis with distal femoral bone
overgrowth, and concomitant knee flexion contracture.
6. Extensive hypertrophic synovial scar resection.
PROCEDURES/OPERATIONS:
1. Partial medial meniscectomy.
2. Partial lateral meniscectomy.
3. Limited chondroplasty of medial femoral condyle.
4. Limited chondroplasty of undersurface of the patella and distal
trochlea.
5. Distal femoral notch resection with concomitant notchplasty,
removal of scar tissue and acquisition of full extension.
6. Extensive hypertrophic synovial scar resection.
7. Injection to the portal sites with 1% Xylocaine.
SURGEON:
ASSISTANT
:
ANESTHESIA: General anesthesia with local.
TOURNIQUET TIME: None.
DRAINS: None.
COMPLICATIONS: None.
FLUIDS GIVEN: 600 mL of LR.
INDICATIONS FOR SURGERY: This is a middle-aged male who describes
progression of mechanical left knee symptoms. At this time, he has
failed initial conservative measures and has clinical and
radiographic findings consistent with meniscal pathology. At this
time, the benefits and risks of surgery were advised. We will
proceed with surgery as per protocol.
TECHNIQUE: The patient was brought to the operating room and was put
to sleep using endotracheal anesthesia. The left lower extremity was
placed into a leg holder. A tourniquet was applied; the tourniquet
was never elevated. Standard prep and drape was provided to the
patient's left lower extremity. Arthroscopic portals were made
proximal and medial and also 2 distal working portals were made.
Small nicks were made into the skin to allow blunt entrance technique
to visualize the joint proper. Upon assessment and evaluation at the
patellofemoral access, there was an extensive amount of scar tissue
which was resected. The undersurface of the patella did have some
diffuse chondrosis (grade 2). A limited chondroplasty was performed
to contour the surface as a small distal patellar spur was removed.
The proximal trochlea was with some chondrosis as well. A limited
chondroplasty was performed. This was grade 2. Both medial and
lateral gutters had no evidence of meniscal or chondral loose flaps.
The medial compartment did have a generative tear involving the
posterior horn of the medial meniscus. A partial medial meniscectomy
was performed. The medial femoral condyle did have some surface
delamination of the cartilage, which was a grade 2 lesion, and a
diffuse early grade 3 lesion. Diffuse limited chondroplasty was
performed to contour the surfaces and remove any loose cartilaginous
debris. The central notch was stenotic. The anterior cruciate
ligament (ACL) was intact. The posterior cruciate ligament (PCL) was
intact. There was a notch contracture with limitation of full
extension. A distal femoral notch resection was performed. This
allowed for full extension as the base of the ACL was dbrided. The
lateral compartment did have a mid-substance lateral meniscus tear
with calcification. A partial meniscectomy was performed. At this
time, the knee joint was arthroscopically lavaged using an
antimicrobial solution. Each of the portals was sequentially closed
using simple sutures. An injection of Xylocaine 1% was infused into
each of the portal sites.
PLAN: At this time, the patient will be touch-down weightbearing
status. Thigh-high TEDs, icing modalities, activity restrictions,
and analgesic medications. I would like to see this patient back
within the next 24 hours for postoperative assessment, wound
evaluation and dressing changes.
717.9
719.86
701.4
CPT 29880
I feel like I am missing something can somoeone look this over??
Thank you
POSTOPERATIVE DIAGNOSES:
1. Degenerative complex tear, posterior horn, medial meniscus.
2. Degenerative mid-substance tear, lateral meniscus, with
calcification.
3. Diffuse grade 2 and early grade 3 chondrosis of medial femoral
condyle.
4. Diffuse undersurface patella and proximal trochlea grade 2
chondrosis, patellofemoral axis.
5. Distal femoral notch stenosis with distal femoral bone
overgrowth, and concomitant knee flexion contracture.
6. Extensive hypertrophic synovial scar resection.
PROCEDURES/OPERATIONS:
1. Partial medial meniscectomy.
2. Partial lateral meniscectomy.
3. Limited chondroplasty of medial femoral condyle.
4. Limited chondroplasty of undersurface of the patella and distal
trochlea.
5. Distal femoral notch resection with concomitant notchplasty,
removal of scar tissue and acquisition of full extension.
6. Extensive hypertrophic synovial scar resection.
7. Injection to the portal sites with 1% Xylocaine.
SURGEON:
ASSISTANT
:
ANESTHESIA: General anesthesia with local.
TOURNIQUET TIME: None.
DRAINS: None.
COMPLICATIONS: None.
FLUIDS GIVEN: 600 mL of LR.
INDICATIONS FOR SURGERY: This is a middle-aged male who describes
progression of mechanical left knee symptoms. At this time, he has
failed initial conservative measures and has clinical and
radiographic findings consistent with meniscal pathology. At this
time, the benefits and risks of surgery were advised. We will
proceed with surgery as per protocol.
TECHNIQUE: The patient was brought to the operating room and was put
to sleep using endotracheal anesthesia. The left lower extremity was
placed into a leg holder. A tourniquet was applied; the tourniquet
was never elevated. Standard prep and drape was provided to the
patient's left lower extremity. Arthroscopic portals were made
proximal and medial and also 2 distal working portals were made.
Small nicks were made into the skin to allow blunt entrance technique
to visualize the joint proper. Upon assessment and evaluation at the
patellofemoral access, there was an extensive amount of scar tissue
which was resected. The undersurface of the patella did have some
diffuse chondrosis (grade 2). A limited chondroplasty was performed
to contour the surface as a small distal patellar spur was removed.
The proximal trochlea was with some chondrosis as well. A limited
chondroplasty was performed. This was grade 2. Both medial and
lateral gutters had no evidence of meniscal or chondral loose flaps.
The medial compartment did have a generative tear involving the
posterior horn of the medial meniscus. A partial medial meniscectomy
was performed. The medial femoral condyle did have some surface
delamination of the cartilage, which was a grade 2 lesion, and a
diffuse early grade 3 lesion. Diffuse limited chondroplasty was
performed to contour the surfaces and remove any loose cartilaginous
debris. The central notch was stenotic. The anterior cruciate
ligament (ACL) was intact. The posterior cruciate ligament (PCL) was
intact. There was a notch contracture with limitation of full
extension. A distal femoral notch resection was performed. This
allowed for full extension as the base of the ACL was dbrided. The
lateral compartment did have a mid-substance lateral meniscus tear
with calcification. A partial meniscectomy was performed. At this
time, the knee joint was arthroscopically lavaged using an
antimicrobial solution. Each of the portals was sequentially closed
using simple sutures. An injection of Xylocaine 1% was infused into
each of the portal sites.
PLAN: At this time, the patient will be touch-down weightbearing
status. Thigh-high TEDs, icing modalities, activity restrictions,
and analgesic medications. I would like to see this patient back
within the next 24 hours for postoperative assessment, wound
evaluation and dressing changes.