fafersmom
New
I am new to Podiatry and wondering if these codes would be correct for this procedure--28297 and 28313. I appreciate your help!
1. Bunion correction with arthrodesis right foot first tarsometatarsal joint
2. Correction of angular deformity at the first metatarsophalangeal joint
Procedure:
The patient has failed conservative treatment with continued pain
and instability with ambulation. The patient elects for surgical
intervention at this time. History and physical and all preoperative
studies were reviewed and revealed no contraindications to the proposed
procedure. Consent was signed and placed in the chart. All questions
answered. No guarantees stated or implied. foot was marked.
The patient received a popliteal block from anethesia in preop.
The patient was transported from the
preoperative holding area to the operating room, placed on the operating
table.
The extremity was then scrubbed, prepped and draped in the
usual sterile manner. A timeout was performed and all were in agreement.
Pneumatic tourniquet was then applied to the right thigh over copious amounts of Webril padding.
The extremity was then exsanguinated and elevated and tourniquet was
Inflated to 325mmgh.
Attention was directed to the right first metatarsophalangeal joint where the great toe
is angulated laterally. A 0.5 cm stab incision is created laterally to the joint, and
outside the joint capsule. The incision is bluntly deepened down to the lateral
aspect of the joint and a lateral release of the adductor tendons is performed with
a sharp scissor. Good resolution of the angular deformity is noted upon completion.
This tiny incision is closed utilizing 4.0 nylon.
Attention was directed towards the dorsomedial aspect of the right foot where the
first tarsometatarsal joint was identified. An incision was made across the joint just
medial to the extensor hallucis longus tendon utilizing a #15 blade. The incision was
then deepened down through the subcutaneous tissue
utilizing a #15 blade. All bleeders were clamped and cauterized as deemed
necessary. A capsular incision was then created just medial to the
extensor hallucis longus tendon while remaining at the dorsal aspect of the
tarsometatarsal joint. The capsule was then reflected both medially and
laterally along with the periosteal tissue. All soft tissue and
ligamentous attachments were then released at the tarsometatarsal joint.
The guide for the Zimmer system was then positioned so that the
largest pad was between the medial cuneiform and the first metatarsal and
the smaller paddle was placed between the medial cuneiform and the second
metatarsal. A K-wire was then placed through the post-drill guide and
into the medial cuneiform from dorsal to plantar. Fluoroscopy was then utilized to
ensure appropriate K-wire position within the medial cuneiform
centrally.
After this the cutting guide was utilized to create two cuts to resect the articular surfaces of the joint.
The guide was positioned under mini c arm to ensure correct angulation of the
cuts was ideal to correct the IM angle of the bunion deformity.
Next a 5.9 mm post reamer was then inserted over the K-wire and drilled until
appropriate depth of the drill bit was achieved and hard stop was noted. The bone from this drill
was then retrieved and passed to the back table to be used as a graft later
in the case. The targeting guide assembly were then inserted into
the reamed hole. The post was fully seated into the bone utilizing a
mallet.
The K-wire was then driven from dorsal to plantar into the first
metatarsal and used as a joystick to achieve frontal plane correction.
This was checked under fluoroscopy until adequate relocation of the sesamoids
was appreciated.
Two K-wires were then placed through the compression distraction
fixture and into the metatarsal, which stabilized the correction. A Weber
clamp was then utilized to achieve and maintain correction of the
intermetatarsal angle. A K-wire was placed through the compression
distraction and fixation into the cuneiform proximal to the post. The
driver was then utilized to turn the screw in the compression and
distraction fixture to distract the tarsometatarsal joint.
Surgical site was then flushed with copious amounts of sterile saline.
The joint was then prepared with a combination of sagittal saw, osteotome
resection, curettage and fish scaling with an osteotome and mallet. The
joint was then fenestrated. Following the joint preparation, the bone auto
graft was placed into the fusion site that was previously taken from the drill flutes,
and the screw was turned clockwise to compress the joint while
ensuring that the metatarsal base did not translate plantarly and the post
did not shift dorsally. Excellent reduction of the bunion deformity is noted
upon compression and correction achieved is checked under fluoroscopy.
The drill bushing was then placed into the medial hole of the gig and the targeting
guide. A 3.6 mm drill bit was then inserted through the drill bushing. A 50
x 3.5 mm screw was measured and inserted.
The drill bushing and drilling was again repeated for the lateral hole with
a 30 x 3.5 mm screw inserted. The K-wires and targeting guide were then removed and the
post-plug screw was threaded into the top of the post. The surgical site
was then once again flushed with copious amounts of sterile saline.
Intraoperative fluoroscopy was then utilized and correction was achieved.
The incision was then closed utilizing 3-0 monocryl deeply, 4-0 monocryl for subcutaneous tissue and 4-0 nylon for skin.
The tourniquet was deflated and brisk reperfusion was noted to the foot and the digits.
A postoperative dressing was then applied to the surgical site, followed by a fiberglass cast.
The patient tolerated the procedure and anesthesia well. The patient was transported from the operating room to the postoperative recovery area
with vital signs stable and neurovascular status intact. The patient is to be non weight bearing to the extremity in the fiberglass cast, received all
postoperative care instructions, as well as scripts to be taken as
necessary for pain, and is to follow up in the office for all postoperative care management.
Findings:
consistent with preoperative findings
Implants:
zimmer incore lapidus system, post, screws sized 50 and 30
Anesthesia: GETA and regional (popliteal)
Surgeon: Rory N Cocks
Estimated blood loss (mL): 5
Pathology: none sent
Condition: stable
Disposition: PACU
1. Bunion correction with arthrodesis right foot first tarsometatarsal joint
2. Correction of angular deformity at the first metatarsophalangeal joint
Procedure:
The patient has failed conservative treatment with continued pain
and instability with ambulation. The patient elects for surgical
intervention at this time. History and physical and all preoperative
studies were reviewed and revealed no contraindications to the proposed
procedure. Consent was signed and placed in the chart. All questions
answered. No guarantees stated or implied. foot was marked.
The patient received a popliteal block from anethesia in preop.
The patient was transported from the
preoperative holding area to the operating room, placed on the operating
table.
The extremity was then scrubbed, prepped and draped in the
usual sterile manner. A timeout was performed and all were in agreement.
Pneumatic tourniquet was then applied to the right thigh over copious amounts of Webril padding.
The extremity was then exsanguinated and elevated and tourniquet was
Inflated to 325mmgh.
Attention was directed to the right first metatarsophalangeal joint where the great toe
is angulated laterally. A 0.5 cm stab incision is created laterally to the joint, and
outside the joint capsule. The incision is bluntly deepened down to the lateral
aspect of the joint and a lateral release of the adductor tendons is performed with
a sharp scissor. Good resolution of the angular deformity is noted upon completion.
This tiny incision is closed utilizing 4.0 nylon.
Attention was directed towards the dorsomedial aspect of the right foot where the
first tarsometatarsal joint was identified. An incision was made across the joint just
medial to the extensor hallucis longus tendon utilizing a #15 blade. The incision was
then deepened down through the subcutaneous tissue
utilizing a #15 blade. All bleeders were clamped and cauterized as deemed
necessary. A capsular incision was then created just medial to the
extensor hallucis longus tendon while remaining at the dorsal aspect of the
tarsometatarsal joint. The capsule was then reflected both medially and
laterally along with the periosteal tissue. All soft tissue and
ligamentous attachments were then released at the tarsometatarsal joint.
The guide for the Zimmer system was then positioned so that the
largest pad was between the medial cuneiform and the first metatarsal and
the smaller paddle was placed between the medial cuneiform and the second
metatarsal. A K-wire was then placed through the post-drill guide and
into the medial cuneiform from dorsal to plantar. Fluoroscopy was then utilized to
ensure appropriate K-wire position within the medial cuneiform
centrally.
After this the cutting guide was utilized to create two cuts to resect the articular surfaces of the joint.
The guide was positioned under mini c arm to ensure correct angulation of the
cuts was ideal to correct the IM angle of the bunion deformity.
Next a 5.9 mm post reamer was then inserted over the K-wire and drilled until
appropriate depth of the drill bit was achieved and hard stop was noted. The bone from this drill
was then retrieved and passed to the back table to be used as a graft later
in the case. The targeting guide assembly were then inserted into
the reamed hole. The post was fully seated into the bone utilizing a
mallet.
The K-wire was then driven from dorsal to plantar into the first
metatarsal and used as a joystick to achieve frontal plane correction.
This was checked under fluoroscopy until adequate relocation of the sesamoids
was appreciated.
Two K-wires were then placed through the compression distraction
fixture and into the metatarsal, which stabilized the correction. A Weber
clamp was then utilized to achieve and maintain correction of the
intermetatarsal angle. A K-wire was placed through the compression
distraction and fixation into the cuneiform proximal to the post. The
driver was then utilized to turn the screw in the compression and
distraction fixture to distract the tarsometatarsal joint.
Surgical site was then flushed with copious amounts of sterile saline.
The joint was then prepared with a combination of sagittal saw, osteotome
resection, curettage and fish scaling with an osteotome and mallet. The
joint was then fenestrated. Following the joint preparation, the bone auto
graft was placed into the fusion site that was previously taken from the drill flutes,
and the screw was turned clockwise to compress the joint while
ensuring that the metatarsal base did not translate plantarly and the post
did not shift dorsally. Excellent reduction of the bunion deformity is noted
upon compression and correction achieved is checked under fluoroscopy.
The drill bushing was then placed into the medial hole of the gig and the targeting
guide. A 3.6 mm drill bit was then inserted through the drill bushing. A 50
x 3.5 mm screw was measured and inserted.
The drill bushing and drilling was again repeated for the lateral hole with
a 30 x 3.5 mm screw inserted. The K-wires and targeting guide were then removed and the
post-plug screw was threaded into the top of the post. The surgical site
was then once again flushed with copious amounts of sterile saline.
Intraoperative fluoroscopy was then utilized and correction was achieved.
The incision was then closed utilizing 3-0 monocryl deeply, 4-0 monocryl for subcutaneous tissue and 4-0 nylon for skin.
The tourniquet was deflated and brisk reperfusion was noted to the foot and the digits.
A postoperative dressing was then applied to the surgical site, followed by a fiberglass cast.
The patient tolerated the procedure and anesthesia well. The patient was transported from the operating room to the postoperative recovery area
with vital signs stable and neurovascular status intact. The patient is to be non weight bearing to the extremity in the fiberglass cast, received all
postoperative care instructions, as well as scripts to be taken as
necessary for pain, and is to follow up in the office for all postoperative care management.
Findings:
consistent with preoperative findings
Implants:
zimmer incore lapidus system, post, screws sized 50 and 30
Anesthesia: GETA and regional (popliteal)
Surgeon: Rory N Cocks
Estimated blood loss (mL): 5
Pathology: none sent
Condition: stable
Disposition: PACU