Hi group
I have come up with
28262-LT
28304-LT
28230-LT
Can others weigh in if I have my codes correct?
SURGEON:
ASSISTANT SURGEON:
POSTOPERATIVE DIAGNOSIS(ES):
Left recurrent clubfoot deformity.
POSTOPERATIVE DIAGNOSIS(ES):
Left recurrent clubfoot deformity.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Posteromedial release of the left.
2. Left Achilles tendon lengthening.
3. Left posterior tibialis tendon lengthening.
4. Left adductor hallucis intramuscular lengthening.
5. Left flexor hallucis longus and flexor digitorum longus
*** intramuscular lengthening.
6. Toe flexor tenotomy x5 (greater toe to the small toe).
7. Cuboid closing wedge osteotomy.
8. Open reduction and pinning of talonavicular joint
ANESTHESIA:
General anesthesia.
FLUIDS:
Please see anesthesia records.
ESTIMATED BLOOD LOSS:
20 mL.
TOURNIQUET TIME:
120 minutes at 225 mmHg.
IMPLANT:
0.062 inch K-wires x2.
BRIEF HISTORY OF PRESENT ILLNESS:
This is a pleasant 4-year-old male, who underwent had underwent
serial manipulation and casting as a young child.* There was
issues with brace compliance postoperatively and he subsequently
had a recurrence.* He was seen in clinic and discussions had
regarding operative intervention.
INTRAOPERATIVE FINDINGS:
He had fixed equinus of 20 degrees with the knee flexed.* He had
varus and cavus present as well and metatarsus adductus.
Completion procedure had well corrected foot and a well reduced
talonavicular joint under direct inspection.
SUMMARY OF THE PROCEDURE:
The patient and the family met in the preop holding area, where a
lengthy discussion was had in regard to the proposed procedure as
well as the attendant risks and complications associated with the
procedure.* Informed consent had been obtained in the past clinic
evaluation.
Next, the operative marked in the presence of the family.* The
patient was then taken back to the operating theater, and laid on the
operating table.* Here, general anesthesia was induced.* Once
this was felt to be adequate, a caudal block was supplied by the
anesthesia team.* Next, the left lower extremity had tourniquet
applied and was then prepped and draped in a sterile standard
fashion.* A time-out was conducted indicating the correct
operative site, patient, and procedure as well as confirmation of
the administration of preoperative antibiotics.* Once all were in
agreement, we began the procedure.* The left leg was elevated and
the Esmarch was used to exsanguinate the limb before placing the
tourniquet to 225 mmHg.* Next, a Turco-type incision was made beginning
at the navicular cuneiform joint and extending just beneath the
medial malleolus to just posterior to the Achilles tendon.
Dissection was carried through the skin and subcutaneous tissue.
Crossing bleeders were coagulated.
Posteriorly, we incised decisively through subcutaneous tissue
and fascia around the Achilles tendon.* There was a fair amount
of scarring present from the percutaneous tenotomy.* Next, the
tendon was isolated proximally and distally down to its insertion
on the os calcis.* Then a lengthening in a Z-type fashion with a
sagittal cut freeing the medial half from the calcaneus.* We then
carefully dissected upon the ankle and identified the sural nerve
and lesser saphenous vein.* These were carefully protected. The
posterior tibial artery and tibial nerve were also identified
behind the ankle joint.
These were carefully dissected and a vessel loop was secured
around the neurovascular bundle to allow mobilization.* We then
incised the sheath of the flexor hallucis longus tendon.
Dissection was then taken beneath the flexor hallucis longus
medially and laterally to identify the entirety of the tibiotalar
joint.* We then placed the FHL tendon in the vessel loop with the
neurovascular bundle so as to allow some protection during
retraction.
We entered into compartment of peroneal tendons.* This was open
down to the distal fibula so as to access the calcaneofibular
ligament.* We then had the entire posterior ankle exposed from
the tip of the fibula to the posterior edge of the medial
malleolus.* A knap was used to enter into the joint and scissors
were then carefully used to open up the tibiotalar joint upon the
posteromedial malleolus down through the CFL distal to the
fibula.* We also opened up the posterior extent of subtalar
joint.* We then performed the dissection of the subtalar joint
medially beneath the neurovascular bundle.* We then freed the
neurovascular bundle up to the adductor hallucis.* This allowed
it to be mobilized so that we could dissect the flexor hallucis
longus as it passed beneath the sustentaculum tali.* This was used then to help to confirm the location of the subtalar joint.* We extended the
release of the subtalar joint through to the anterior at talus.
We identified and preserved interosseous ligament.* We then
identified the three heads of the adductor hallucis origin from
around the neurovascular bundle and released each of these.
Next, we released flexor digitorum longus and posterior tibialis
from the flexor tendon sheath.* We did the Z-lengthening of the
posterior tibialis tendon.* We then used the tendon to trace back
to the talonavicular joint.* This was carefully entered into the
scissors and release the medial and plantar extent.* A small
portion dorsally was needed to fully reduce the talonavicular
joint.* Next, there is felt to be persistent forefoot adductus.
We then made a longitudinal incision over the cuboid.* Dissection
was carried down through the skin and subcutaneous tissue.* The
sural nerve was identified and carefully were protected.* We then
reflected peroneus longus and brevis plantarly to isolate the
cuboid.* A closing wedge osteotomy was performed with a sagittal
saw.* We left an intact medial hinge on the cuboid.* Next, this
osteotomy was closed and a percutaneous wire was used to secure
the fixation.* We then placed the K-wire from the posterior
process of the talus through the talar body into the head and
neck region.* The talonavicular joint was then reduced under
direct evaluation.* A K-wire then driven through the navicular to
hold the reduction.* It was then driven anteriorly so that we
could retract the posterior wire, so that was flushed with the
posterior process of the talus, it was now protruding from the
dorsum of the foot.* The fluoroscopy revealed excellent
correction of the foot as did a gross inspection.* The wounds
were then thoroughly irrigated.* He had significant tightness of
his toes when the foot was placed in a plantar grade position.
We then performed an intramuscular lengthening proximally at the
flexor hallucis longus and flexor digitorum longus.* This
produced only partial correction as he still had curly toes of 1
through 5 with the foot in neutral.* We then made oblique
incisions beneath each toe.* Careful dissection with a blunt
hemostat was used to isolate the flexor tendon sheath while
protecting the neurovascular bundles on the tibial and fibular
sides.* The flexor tendon sheath was entered anterior in the two
leads of the longus tendon were* transected.* This was done on
toes 1 through 5 and produced neutral toes with the foot in a
plantigrade position.* We then irrigated the wound once again.
We repaired the posterior tibialis tendon and the Achilles tendon
under slight tension with the foot in a plantigrade position.* We
repaired the lacinate ligament over the posterior tibialis and
flexor digitorum longus.* We closed the Achilles sheath as well.
Next, deep dermal sutures were used to reapproximate the skin
followed by an interrupted Monocryl skin closure.* The skin was
had reasonable tension when the foot was placed in 10 degrees of
dorsiflexion.* We closed the lateral side with a layer closure as
well after adequate hemostasis was obtained.* The tourniquet had
been released before closure of the wounds to obtain hemostasis.
Next, we closed the plantar toe incisions with a chromic suture.
The tape was applied around the pin sites after they were bent
and foreshortened.* Xeroform was applied around the medial wound
and beneath the toes and a spacer was placed beneath the toes to
keep them extended.* We then removed the tourniquet and drapes
and placed into a well-padded and placed them into a well-padded
long-leg cast with a bent knee and the foot held in a corrected
position.* He was awoken from anesthesia and transferred to PACU
in stable condition.* Sponge and needle counts were correct at
the completion of the case.* I was scrubbed, present, and
actively participated in the entirety of the case.
POSTOPERATIVE PLAN:
I will see him back in six weeks and remove the cast and the
pins.* We will then have him molded for an AFO and return him to
another cast for a total of two to three weeks while the AFO is
made.
Job#: 33146 / 10037047911
**
*
* *
*****
I have come up with
28262-LT
28304-LT
28230-LT
Can others weigh in if I have my codes correct?
SURGEON:
ASSISTANT SURGEON:
POSTOPERATIVE DIAGNOSIS(ES):
Left recurrent clubfoot deformity.
POSTOPERATIVE DIAGNOSIS(ES):
Left recurrent clubfoot deformity.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Posteromedial release of the left.
2. Left Achilles tendon lengthening.
3. Left posterior tibialis tendon lengthening.
4. Left adductor hallucis intramuscular lengthening.
5. Left flexor hallucis longus and flexor digitorum longus
*** intramuscular lengthening.
6. Toe flexor tenotomy x5 (greater toe to the small toe).
7. Cuboid closing wedge osteotomy.
8. Open reduction and pinning of talonavicular joint
ANESTHESIA:
General anesthesia.
FLUIDS:
Please see anesthesia records.
ESTIMATED BLOOD LOSS:
20 mL.
TOURNIQUET TIME:
120 minutes at 225 mmHg.
IMPLANT:
0.062 inch K-wires x2.
BRIEF HISTORY OF PRESENT ILLNESS:
This is a pleasant 4-year-old male, who underwent had underwent
serial manipulation and casting as a young child.* There was
issues with brace compliance postoperatively and he subsequently
had a recurrence.* He was seen in clinic and discussions had
regarding operative intervention.
INTRAOPERATIVE FINDINGS:
He had fixed equinus of 20 degrees with the knee flexed.* He had
varus and cavus present as well and metatarsus adductus.
Completion procedure had well corrected foot and a well reduced
talonavicular joint under direct inspection.
SUMMARY OF THE PROCEDURE:
The patient and the family met in the preop holding area, where a
lengthy discussion was had in regard to the proposed procedure as
well as the attendant risks and complications associated with the
procedure.* Informed consent had been obtained in the past clinic
evaluation.
Next, the operative marked in the presence of the family.* The
patient was then taken back to the operating theater, and laid on the
operating table.* Here, general anesthesia was induced.* Once
this was felt to be adequate, a caudal block was supplied by the
anesthesia team.* Next, the left lower extremity had tourniquet
applied and was then prepped and draped in a sterile standard
fashion.* A time-out was conducted indicating the correct
operative site, patient, and procedure as well as confirmation of
the administration of preoperative antibiotics.* Once all were in
agreement, we began the procedure.* The left leg was elevated and
the Esmarch was used to exsanguinate the limb before placing the
tourniquet to 225 mmHg.* Next, a Turco-type incision was made beginning
at the navicular cuneiform joint and extending just beneath the
medial malleolus to just posterior to the Achilles tendon.
Dissection was carried through the skin and subcutaneous tissue.
Crossing bleeders were coagulated.
Posteriorly, we incised decisively through subcutaneous tissue
and fascia around the Achilles tendon.* There was a fair amount
of scarring present from the percutaneous tenotomy.* Next, the
tendon was isolated proximally and distally down to its insertion
on the os calcis.* Then a lengthening in a Z-type fashion with a
sagittal cut freeing the medial half from the calcaneus.* We then
carefully dissected upon the ankle and identified the sural nerve
and lesser saphenous vein.* These were carefully protected. The
posterior tibial artery and tibial nerve were also identified
behind the ankle joint.
These were carefully dissected and a vessel loop was secured
around the neurovascular bundle to allow mobilization.* We then
incised the sheath of the flexor hallucis longus tendon.
Dissection was then taken beneath the flexor hallucis longus
medially and laterally to identify the entirety of the tibiotalar
joint.* We then placed the FHL tendon in the vessel loop with the
neurovascular bundle so as to allow some protection during
retraction.
We entered into compartment of peroneal tendons.* This was open
down to the distal fibula so as to access the calcaneofibular
ligament.* We then had the entire posterior ankle exposed from
the tip of the fibula to the posterior edge of the medial
malleolus.* A knap was used to enter into the joint and scissors
were then carefully used to open up the tibiotalar joint upon the
posteromedial malleolus down through the CFL distal to the
fibula.* We also opened up the posterior extent of subtalar
joint.* We then performed the dissection of the subtalar joint
medially beneath the neurovascular bundle.* We then freed the
neurovascular bundle up to the adductor hallucis.* This allowed
it to be mobilized so that we could dissect the flexor hallucis
longus as it passed beneath the sustentaculum tali.* This was used then to help to confirm the location of the subtalar joint.* We extended the
release of the subtalar joint through to the anterior at talus.
We identified and preserved interosseous ligament.* We then
identified the three heads of the adductor hallucis origin from
around the neurovascular bundle and released each of these.
Next, we released flexor digitorum longus and posterior tibialis
from the flexor tendon sheath.* We did the Z-lengthening of the
posterior tibialis tendon.* We then used the tendon to trace back
to the talonavicular joint.* This was carefully entered into the
scissors and release the medial and plantar extent.* A small
portion dorsally was needed to fully reduce the talonavicular
joint.* Next, there is felt to be persistent forefoot adductus.
We then made a longitudinal incision over the cuboid.* Dissection
was carried down through the skin and subcutaneous tissue.* The
sural nerve was identified and carefully were protected.* We then
reflected peroneus longus and brevis plantarly to isolate the
cuboid.* A closing wedge osteotomy was performed with a sagittal
saw.* We left an intact medial hinge on the cuboid.* Next, this
osteotomy was closed and a percutaneous wire was used to secure
the fixation.* We then placed the K-wire from the posterior
process of the talus through the talar body into the head and
neck region.* The talonavicular joint was then reduced under
direct evaluation.* A K-wire then driven through the navicular to
hold the reduction.* It was then driven anteriorly so that we
could retract the posterior wire, so that was flushed with the
posterior process of the talus, it was now protruding from the
dorsum of the foot.* The fluoroscopy revealed excellent
correction of the foot as did a gross inspection.* The wounds
were then thoroughly irrigated.* He had significant tightness of
his toes when the foot was placed in a plantar grade position.
We then performed an intramuscular lengthening proximally at the
flexor hallucis longus and flexor digitorum longus.* This
produced only partial correction as he still had curly toes of 1
through 5 with the foot in neutral.* We then made oblique
incisions beneath each toe.* Careful dissection with a blunt
hemostat was used to isolate the flexor tendon sheath while
protecting the neurovascular bundles on the tibial and fibular
sides.* The flexor tendon sheath was entered anterior in the two
leads of the longus tendon were* transected.* This was done on
toes 1 through 5 and produced neutral toes with the foot in a
plantigrade position.* We then irrigated the wound once again.
We repaired the posterior tibialis tendon and the Achilles tendon
under slight tension with the foot in a plantigrade position.* We
repaired the lacinate ligament over the posterior tibialis and
flexor digitorum longus.* We closed the Achilles sheath as well.
Next, deep dermal sutures were used to reapproximate the skin
followed by an interrupted Monocryl skin closure.* The skin was
had reasonable tension when the foot was placed in 10 degrees of
dorsiflexion.* We closed the lateral side with a layer closure as
well after adequate hemostasis was obtained.* The tourniquet had
been released before closure of the wounds to obtain hemostasis.
Next, we closed the plantar toe incisions with a chromic suture.
The tape was applied around the pin sites after they were bent
and foreshortened.* Xeroform was applied around the medial wound
and beneath the toes and a spacer was placed beneath the toes to
keep them extended.* We then removed the tourniquet and drapes
and placed into a well-padded and placed them into a well-padded
long-leg cast with a bent knee and the foot held in a corrected
position.* He was awoken from anesthesia and transferred to PACU
in stable condition.* Sponge and needle counts were correct at
the completion of the case.* I was scrubbed, present, and
actively participated in the entirety of the case.
POSTOPERATIVE PLAN:
I will see him back in six weeks and remove the cast and the
pins.* We will then have him molded for an AFO and return him to
another cast for a total of two to three weeks while the AFO is
made.
Job#: 33146 / 10037047911
**
*
* *
*****