Wiki 4th and 5th Interpositional arthroplasty

[bostonmom]

Hi everyone,

I am stuck on a surgery. Hoping someone can help me with the coding for the interpositional arthroplasty of the 4th and 5th TMTJ.

PROCEDURE:
1. Open reduction, internal fixation 5th metatarsal base fracture left foot - code 28485
2. Repair and reattachment of peroneus brevis tendon left - code 28200
3. Excision cuboid fracture with interpositional arthroplasty 4th and 5th TMT J - code ????

Attention was directed to 5th metatarsal base where a longitudinal linear incision was made overlying the metatarsal base and proximal to expose the peroneus brevis tendon. Incision was made down to epidermis and dermis with care protect neurovascular structures in the area. We then bluntly dissected down to level of bone to identify the peroneus brevis attachment which was then reflected to allow for placement of the hardware. A lateral locking plate was placed along 5th metatarsal base. This was confirmed clinically and with C-arm fluoroscopy. Screws were then placed according manufacture guidelines. Screw sizes noted above. We then inserted the Arthrex 3.5 mm anchor into the bone and reattached the peroneus brevis tendon with multiple stitches as well as 1 running stitch.

There is significant comminution to the distal aspect of the cuboid secondary to prolonged nail union in fracture to the 5th metatarsal base causing significant arthritis. This portion of the cuboid was then completely excised due to its severe arthritic nature with no benefit to open reduction and internal fixation. Once smooth margins were obtained we then placed an arthro flex graft which was sutured together in an "accordion" type fashion. The multiple drill holes to the 4th and 5th metatarsal base and remaining cuboid we then sutured the graft into place to allow for interpositional arthroplasty.

 

[amyjph]

What does the rest of the header state? Is this a new injury? Was there disruption of or tear of the peroneus from injury? Reading the description, " peroneus brevis attachment which was then reflected to allow for placement of the hardware" sounds like it was repaired and reattached to do the work on the MT. You wouldn't code for that if it was since it was done for access to the MT.

It sounds like there was a previous injury and surgery in the same area? How old is this fracture? "comminution to the distal aspect of the cuboid secondary to prolonged nail union in fracture to the 5th metatarsal base causing significant arthritis" You might call it 28122 but I think it's unlisted.

 

[bostonmom]

What does the rest of the header state? Is this a new injury? Was there disruption of or tear of the peroneus from injury? Reading the description, " peroneus brevis attachment which was then reflected to allow for placement of the hardware" sounds like it was repaired and reattached to do the work on the MT. You wouldn't code for that if it was since it was done for access to the MT.

It sounds like there was a previous injury and surgery in the same area? How old is this fracture? "comminution to the distal aspect of the cuboid secondary to prolonged nail union in fracture to the 5th metatarsal base causing significant arthritis" You might call it 28122 but I think it's unlisted.

This is the whole op note:

PRE-OP DIAGNOSIS:
1. Malunion 5th metatarsal base left foot
2. Peroneus brevis tendonitis left
3. Intra-articular fracture left cuboid
POST-OP DIAGNOSIS: same as above
PROCEDURE:
1. Open reduction, internal fixation 5th metatarsal base fracture left foot
2. Repair and reattachment of peroneus brevis tendon left
3. Excision cuboid fracture with interpositional arthroplasty 4th and 5th TMT J
4. Application adult short leg splint left

This is a female admitted to hospital for elective surgery consisting of the above mentioned procedures due to persistent pain. The patient failed conservative care and desires to have the surgical correction at this time. The nature of deformity/problem, anticipated procedures, post-operative recovery/convalescence, risks/complications, including but not limited to numbness, tingling, neuritis, nerve damage, over/under correction, recurrence, problems healing of soft tissue or bone, persistent pain and disability, chronic pain, complex regional pain syndrome / reflex sympathetic dystrophy, need for further surgery, need for revision surgery, need for hardware removal, deep venous thrombosis, pulmonary embolus, have been explained to the patient in detail. All questions have been answered to the patient's satisfaction. No promises or guarantees have been given.

Procedure: under mild sedation, the patient was brought into the operating room and was placed on the operating table in the supine position. No pneumatic tourniquet was then placed on the left, which was then scrubbed, prepped and draped in the usual aseptic manner.

Pre op block applied

Attention was directed to 5th metatarsal base where a longitudinal linear incision was made overlying the metatarsal base and proximal to expose the peroneus brevis tendon. Incision was made down to epidermis and dermis with care protect neurovascular structures in the area. We then bluntly dissected down to level of bone to identify the peroneus brevis attachment which was then reflected to allow for placement of the hardware. A lateral locking plate was placed along 5th metatarsal base. This was confirmed clinically and with C-arm fluoroscopy. Screws were then placed according manufacture guidelines. Screw sizes noted above. We then inserted the Arthrex 3.5 mm anchor into the bone and reattached the peroneus brevis tendon with multiple stitches as well as 1 running stitch.

There is significant comminution to the distal aspect of the cuboid secondary to prolonged nail union in fracture to the 5th metatarsal base causing significant arthritis. This portion of the cuboid was then completely excised due to its severe arthritic nature with no benefit to open reduction and internal fixation. Once smooth margins were obtained we then placed an arthro flex graft which was sutured together in an "accordion" type fashion. The multiple drill holes to the 4th and 5th metatarsal base and remaining cuboid we then sutured the graft into place to allow for interpositional arthroplasty.

Thorough flush was then performed. Deep tissue was closed with 2 0 Vicryl and skin with 3 0 Prolene

A dry sterile dressing was then applied along with adult short leg splint. The patient tolerated the procedure and anesthesia well in apparent satisfactory condition, and was transported to the PACU with VSS and VSI to all the digits for further monitoring prior to discharge.