dyoungberg
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I am stumped on this one. Does anyone know how I should code this for an ASC?
PREOPERATIVE DIAGNOSIS: LEFT KNEE POSSIBLE SEVERE VARUS INSTABILITY SECONDARY TO FALL REMOTE FROM SURGERY RESULTING IN AVULSION OF LATERAL COLLATERAL LIGAMENT
POSTOPERATIVE DIAGNOSIS: LEFT KNEE GROSS VARUS INSTABILITY AT 30, 60, 90 DEGREES OF FLEXION SECONDARY TO FALL REMOTE FROM SURGERY RESULTING IN AVULSION OF LATERAL COLLATERAL LIGAMENT
PROCEDURE: EVALUATION UNDER ANESTHESIA
ANESTHESIA: GENERAL MASK
INTRODUCTION: Routine preoperative evaluation revealed no medical contraindications to surgery. The patient and family were consulted at length regarding the relative risks, benefits, and alternatives to the above elective procedure. The patient and family understood these risks to include, but not be limited to, infection, sepsis, osteomyelitis, deep venous thrombosis, pulmonary embolus, stroke, myocardial infarction, death, nerve or blood vessel damage, reflex sympathetic dystrophy, persistent pain, persistent stiffness, loss of motion, wound dehiscence, synovial fistula, requirement of future open or operative intervention or revision, among others. Understanding all the above risks and that no guarantees were made nor implied, the patient freely consented to proceed.
RATIONALE: The patient who is morbidly obese underwent left total knee arthroplasty approximately a year ago. She had done initially quite well with the total knee. Remote from her total knee arthroplasty and after having done well, she had a fall in which she sustained a significant varus rotational stress of the knee. She had acute onset of pain and swelling. She was seen in the ER where no findings were noted. When she was seen in our office, however, we noted a relatively small avulsion of the proximal fibular tip. This was, of course, the lateral collateral insertion site. She was treated with immobilization and nonweightbearing. She has had continued pain with efforts at weightbearing and flexion, associated with feeling of gross instability. Clinical exam in the office was inadequate due to the patient's pain and body habitus. She was brought at this time to the operating room for evaluation under anesthesia with stress radiographic views.
DESCRIPTION OF PROCEDURE: Patient taken to the operating room on 09/21/2012. There she was transferred to the OR table and placed in the supine position without event. She was induced under general anesthesia and maintained by mask. Fluoroscope was arranged to allow views in the AP plane. Notably, first off, there was full passive range of motion of the knee from 0 to approximately 115 degrees at which time her body habitus prevented any further flexion. There was no sagittal plane instability to anterior posterior drawer or Lachman or posterior drawer near extension. In full extension, there was no varus or valgus instability. In 30 degrees of flexion we noted significant opening of the lateral joint line, confirmed radiographically, approximately 30 degrees open to varus stress. This continued at 60 and 90 degrees, although radiographs were not obtained, demonstrating gross flexion varus instability. In full extension this was not found. There was absolutely no valgus instability. There was moderate rotational instability with markedly increased internal rotation at 30, 60 and 90 degrees. There was, however, likely physical design of the implant, no recurvatum.
The patient was reversed from general anesthesia and thereafter returned to the recovery room in good condition. There were no noted complications. Sponge and needle and instrument counts were not applicable. The patient will be seen back in our office early next week and plans will be discussed for reconstructive surgery, likely revision to a more highly constrained implant.
Thanks!
Dyoungberg
PREOPERATIVE DIAGNOSIS: LEFT KNEE POSSIBLE SEVERE VARUS INSTABILITY SECONDARY TO FALL REMOTE FROM SURGERY RESULTING IN AVULSION OF LATERAL COLLATERAL LIGAMENT
POSTOPERATIVE DIAGNOSIS: LEFT KNEE GROSS VARUS INSTABILITY AT 30, 60, 90 DEGREES OF FLEXION SECONDARY TO FALL REMOTE FROM SURGERY RESULTING IN AVULSION OF LATERAL COLLATERAL LIGAMENT
PROCEDURE: EVALUATION UNDER ANESTHESIA
ANESTHESIA: GENERAL MASK
INTRODUCTION: Routine preoperative evaluation revealed no medical contraindications to surgery. The patient and family were consulted at length regarding the relative risks, benefits, and alternatives to the above elective procedure. The patient and family understood these risks to include, but not be limited to, infection, sepsis, osteomyelitis, deep venous thrombosis, pulmonary embolus, stroke, myocardial infarction, death, nerve or blood vessel damage, reflex sympathetic dystrophy, persistent pain, persistent stiffness, loss of motion, wound dehiscence, synovial fistula, requirement of future open or operative intervention or revision, among others. Understanding all the above risks and that no guarantees were made nor implied, the patient freely consented to proceed.
RATIONALE: The patient who is morbidly obese underwent left total knee arthroplasty approximately a year ago. She had done initially quite well with the total knee. Remote from her total knee arthroplasty and after having done well, she had a fall in which she sustained a significant varus rotational stress of the knee. She had acute onset of pain and swelling. She was seen in the ER where no findings were noted. When she was seen in our office, however, we noted a relatively small avulsion of the proximal fibular tip. This was, of course, the lateral collateral insertion site. She was treated with immobilization and nonweightbearing. She has had continued pain with efforts at weightbearing and flexion, associated with feeling of gross instability. Clinical exam in the office was inadequate due to the patient's pain and body habitus. She was brought at this time to the operating room for evaluation under anesthesia with stress radiographic views.
DESCRIPTION OF PROCEDURE: Patient taken to the operating room on 09/21/2012. There she was transferred to the OR table and placed in the supine position without event. She was induced under general anesthesia and maintained by mask. Fluoroscope was arranged to allow views in the AP plane. Notably, first off, there was full passive range of motion of the knee from 0 to approximately 115 degrees at which time her body habitus prevented any further flexion. There was no sagittal plane instability to anterior posterior drawer or Lachman or posterior drawer near extension. In full extension, there was no varus or valgus instability. In 30 degrees of flexion we noted significant opening of the lateral joint line, confirmed radiographically, approximately 30 degrees open to varus stress. This continued at 60 and 90 degrees, although radiographs were not obtained, demonstrating gross flexion varus instability. In full extension this was not found. There was absolutely no valgus instability. There was moderate rotational instability with markedly increased internal rotation at 30, 60 and 90 degrees. There was, however, likely physical design of the implant, no recurvatum.
The patient was reversed from general anesthesia and thereafter returned to the recovery room in good condition. There were no noted complications. Sponge and needle and instrument counts were not applicable. The patient will be seen back in our office early next week and plans will be discussed for reconstructive surgery, likely revision to a more highly constrained implant.
Thanks!
Dyoungberg