tanya1219
Contributor
How Would you code this?????
PROCEDURE
1. Complex open reduction and internal fixation of periprosthetic
fracture, right femur.
2. Bone grafting, right femoral shaft fracture.
PREOPERATIVE DIAGNOSIS: Periprosthetic femur fracture.
POSTOPERATIVE DIAGNOSIS: Periprosthetic femur fracture.
INDICATIONS: A 52-year-old female with multiple medical problems
including end-stage hemodialysis. She multiple previous orthopedic
procedures including a previous trochanteric nail done elsewhere which
was converted by myself to a complex primary total hip. She was doing
well with this but had some type of twisting injury about 2-3 months
ago and only presented in the office 2 days ago with pain over the
thigh. Subsequent workup showed that there was a violation of the
cortex at the tip of the stem.
OPERATIVE FINDINGS: There was violation of the cortex at the tip of
the stem, but the stem itself was felt to be stable and thus was not
changed. Overall bone quality was poor, as expected, because even
though she is 52, she is a much older 52-year-old due to her multiple
medical problems and osteoporosis.
ANESTHESIA: General.
BLOOD LOSS: About 800 mL.
IMPLANT SYSTEM USED: Zimmer 10-hole periprosthetic plate. We used, I
believe, 7 cables and 4 screws.
COMPLICATIONS: None.
DRAINS: x1.
NOTE: This case was significantly more difficult than normal due to,
first, the patient's large leg size. There was at least 6 inches to
negotiate from the skin down to the femur. In addition, her overall
protoplasm and tissues were poor due to her multiple medical problems
which led to more bleeding than is usual and overall friability of the
tissues. In addition, the type of fracture was certainly difficult and
required grafting of an allograft strut as well.
DESCRIPTION OF PROCEDURE: The patient was taken to the operative
theater and placed supine on the table. After general anesthesia was
obtained, Bier blocks were given. She was placed in a lateral
decubitus position on the pegboard. Care was taken to pad all bony
prominences. The leg was prepped, washed, and draped in normal sterile
fashion. A timeout was done. A long lateral incision was then used,
incorporating the previous incision and extending distally. We opened
up down to the level of the vastus and split that in the normal
fashion and exposed the fracture. There was relatively consistently
oozing and bleeding throughout the case. We just did our best to
maintain hemostasis using a combination of packing, thrombin, Gelfoam,
Surgicel, and other appropriate hemostatic techniques.
The fracture was encountered and irrigated. I tested the stem through
it, and it was stable. We opened up an allograft tibial strut,
because I felt the strongest construct, given her poor quality of
bone, would be to place a strut over the fracture site, more on the
medial aspect, and to place the plate laterally. In addition, this
would allow me to tension the cables firmly without necessarily
pulling them through her osteoporotic bone. I prepared the allograft
with a bur on the back table. We then fixed it and placed our plate
and were able to get 2 cables around it initially. I then placed 2
screws distally, multiple cables proximally, and several cables more
along the allograft. I was taking intraoperative fluoroscopy pictures
of the AP and lateral periodically, and I was very happy with the
final construct. Everything moved as 1 unit. The hip remained reduced,
and the fracture was stable with this hardware. As such, attention
turned towards closure.
The wound was copiously irrigated. I placed a deep Hemovac drain. The
vastus was closed with a running #1 Ethibond suture, the tensor with
an interrupted figure-of-eight #1 Ethibond, and 0 Vicryl, 2-0 Vicryl,
and staples in the skin. A sterile dressing was applied. The patient
was successfully awakened and returned to the PACU in satisfactory
condition.
PROCEDURE
1. Complex open reduction and internal fixation of periprosthetic
fracture, right femur.
2. Bone grafting, right femoral shaft fracture.
PREOPERATIVE DIAGNOSIS: Periprosthetic femur fracture.
POSTOPERATIVE DIAGNOSIS: Periprosthetic femur fracture.
INDICATIONS: A 52-year-old female with multiple medical problems
including end-stage hemodialysis. She multiple previous orthopedic
procedures including a previous trochanteric nail done elsewhere which
was converted by myself to a complex primary total hip. She was doing
well with this but had some type of twisting injury about 2-3 months
ago and only presented in the office 2 days ago with pain over the
thigh. Subsequent workup showed that there was a violation of the
cortex at the tip of the stem.
OPERATIVE FINDINGS: There was violation of the cortex at the tip of
the stem, but the stem itself was felt to be stable and thus was not
changed. Overall bone quality was poor, as expected, because even
though she is 52, she is a much older 52-year-old due to her multiple
medical problems and osteoporosis.
ANESTHESIA: General.
BLOOD LOSS: About 800 mL.
IMPLANT SYSTEM USED: Zimmer 10-hole periprosthetic plate. We used, I
believe, 7 cables and 4 screws.
COMPLICATIONS: None.
DRAINS: x1.
NOTE: This case was significantly more difficult than normal due to,
first, the patient's large leg size. There was at least 6 inches to
negotiate from the skin down to the femur. In addition, her overall
protoplasm and tissues were poor due to her multiple medical problems
which led to more bleeding than is usual and overall friability of the
tissues. In addition, the type of fracture was certainly difficult and
required grafting of an allograft strut as well.
DESCRIPTION OF PROCEDURE: The patient was taken to the operative
theater and placed supine on the table. After general anesthesia was
obtained, Bier blocks were given. She was placed in a lateral
decubitus position on the pegboard. Care was taken to pad all bony
prominences. The leg was prepped, washed, and draped in normal sterile
fashion. A timeout was done. A long lateral incision was then used,
incorporating the previous incision and extending distally. We opened
up down to the level of the vastus and split that in the normal
fashion and exposed the fracture. There was relatively consistently
oozing and bleeding throughout the case. We just did our best to
maintain hemostasis using a combination of packing, thrombin, Gelfoam,
Surgicel, and other appropriate hemostatic techniques.
The fracture was encountered and irrigated. I tested the stem through
it, and it was stable. We opened up an allograft tibial strut,
because I felt the strongest construct, given her poor quality of
bone, would be to place a strut over the fracture site, more on the
medial aspect, and to place the plate laterally. In addition, this
would allow me to tension the cables firmly without necessarily
pulling them through her osteoporotic bone. I prepared the allograft
with a bur on the back table. We then fixed it and placed our plate
and were able to get 2 cables around it initially. I then placed 2
screws distally, multiple cables proximally, and several cables more
along the allograft. I was taking intraoperative fluoroscopy pictures
of the AP and lateral periodically, and I was very happy with the
final construct. Everything moved as 1 unit. The hip remained reduced,
and the fracture was stable with this hardware. As such, attention
turned towards closure.
The wound was copiously irrigated. I placed a deep Hemovac drain. The
vastus was closed with a running #1 Ethibond suture, the tensor with
an interrupted figure-of-eight #1 Ethibond, and 0 Vicryl, 2-0 Vicryl,
and staples in the skin. A sterile dressing was applied. The patient
was successfully awakened and returned to the PACU in satisfactory
condition.