D.R.
Networker
My doc gave me this op note. I'm curious to see what you guys can come up with for codes.
Preop DX: Impending pathologic Fx, LT proximal femur and hip, metastatic lesion
Posterolateral incision was made, extended somewhat distally to allow for proximal femoral resection. This incision was carried down through significant adipose tissues until fascia was reached. The fascia, tensor fascia lata and gluteus maximus were then incised along the length of the incision with padding. Retractors were then placed. Using bovie electrocautery the bursa was dissected off the greater trochanter following which the esternal rotators were dissected off the insertion site. All bleeders were snapped and Bovie electrocoagulated. With retractors in place, external rotators were then excised from their insertion site and swept off the capsule. The capsule was then entered creating a posterior flap for later repair. A #1 Tycron suture was rolled into the capsule and tied to the retractor to further protect soft tissues and sciatical nerve throughout the case. The hip was then dislocated. The tumor had not broken through the cortical bone except the area where there was a presumed fx of the greater trochanter was significantly softened. Resection at approximately the level of right below the lesser trochanter, this would resect the tumor, using a cemented straight stem we would bypass the one proximal third lytic femorallesion. Using Bovie electrocautery we then carefull dissected all soft tissue including abductors off the greater trochanter and proximal femur giving exposure of the hip. Proximal femoral resection guide was then selected, guidepin was drilled into the central portion of the femoral head, then using this a neutral cut the proximal femoral resection was marked at about the level slightly distal to the lesser trochanter.With retractors in place the proximal cut was made using an oscillating saw and the proximal femur in hip was removed. The acetabulum was then trialed with a 45 head. At this point and throughout the procedure we used aggresive antibiotic irrigation. Using a starting reamer, we reamed down the proximal canal reaming up to 13 mm getting cortical contact. Also used facing reamer to plane the osteotomy site and ensure accurate seating of the prosthesis. Trial was assembled using the 70 mm proximal femur, the 127 mm stem, and the -3 head with a 45 mm bipolar. X-rays were taken which demonstrated good positioning and range of motion. It felt however since the stem had not fully seating that we would most likely increase to a neutral +0 head once the true stem had been inserted. We vigorously irrigated the canal. A distal canal plug was placed approximately an inch distal to the rip of the prosthesis. Using SurgiLav irrigation we vigorously irrigated the canal impacted dry, two packs of antibiotic cement was then mixed. Packing was removed and the cement was inserted down the canal and pressurized. It should be noted that prior to this we assembled our prothesis with the component as noted using the impaction tube insert. Prothesis was then inserted down the canal and tapped into position maintaing approx. 15 degrees of anteversion. We had excellent seating. Once cement hardened, all extraneous cement was removed. trial reduction was carried out. Trial reduction was carried out and as expected the +0.45 gave excellent range of motion, restored our tension and had excellent stability. After irrigating the Morse taper neck and drying it the +0 head with bicentric were tamped into position, seating check and hip was reduced. Using #5 sutures that were woven into the capsule using a Houston suture passing these were passed through the fixation holes and tied to each other giving good fixation of the capsule tothe greater trochanter. We then placed 3 woven sutures into the abductor tendon beginning w/ the most distal pass using Houston suture passers passed through each sequential fixation hole after which each were tied to each other recreating our abductors. We further reinforced the abductor insertion w/ #0 Vicryl suture. We vigorously irrigated w/antibiotic irrigation, fascia, tensor fascia lata and gluteus maximus were closed using #1 interrupted Tycron suture, a fat drain was placed for stab wound incision, subcutaneous tissues closed in multiple layers. It should be noted the proximal was sent to pathology for further evaluation.
Preop DX: Impending pathologic Fx, LT proximal femur and hip, metastatic lesion
Posterolateral incision was made, extended somewhat distally to allow for proximal femoral resection. This incision was carried down through significant adipose tissues until fascia was reached. The fascia, tensor fascia lata and gluteus maximus were then incised along the length of the incision with padding. Retractors were then placed. Using bovie electrocautery the bursa was dissected off the greater trochanter following which the esternal rotators were dissected off the insertion site. All bleeders were snapped and Bovie electrocoagulated. With retractors in place, external rotators were then excised from their insertion site and swept off the capsule. The capsule was then entered creating a posterior flap for later repair. A #1 Tycron suture was rolled into the capsule and tied to the retractor to further protect soft tissues and sciatical nerve throughout the case. The hip was then dislocated. The tumor had not broken through the cortical bone except the area where there was a presumed fx of the greater trochanter was significantly softened. Resection at approximately the level of right below the lesser trochanter, this would resect the tumor, using a cemented straight stem we would bypass the one proximal third lytic femorallesion. Using Bovie electrocautery we then carefull dissected all soft tissue including abductors off the greater trochanter and proximal femur giving exposure of the hip. Proximal femoral resection guide was then selected, guidepin was drilled into the central portion of the femoral head, then using this a neutral cut the proximal femoral resection was marked at about the level slightly distal to the lesser trochanter.With retractors in place the proximal cut was made using an oscillating saw and the proximal femur in hip was removed. The acetabulum was then trialed with a 45 head. At this point and throughout the procedure we used aggresive antibiotic irrigation. Using a starting reamer, we reamed down the proximal canal reaming up to 13 mm getting cortical contact. Also used facing reamer to plane the osteotomy site and ensure accurate seating of the prosthesis. Trial was assembled using the 70 mm proximal femur, the 127 mm stem, and the -3 head with a 45 mm bipolar. X-rays were taken which demonstrated good positioning and range of motion. It felt however since the stem had not fully seating that we would most likely increase to a neutral +0 head once the true stem had been inserted. We vigorously irrigated the canal. A distal canal plug was placed approximately an inch distal to the rip of the prosthesis. Using SurgiLav irrigation we vigorously irrigated the canal impacted dry, two packs of antibiotic cement was then mixed. Packing was removed and the cement was inserted down the canal and pressurized. It should be noted that prior to this we assembled our prothesis with the component as noted using the impaction tube insert. Prothesis was then inserted down the canal and tapped into position maintaing approx. 15 degrees of anteversion. We had excellent seating. Once cement hardened, all extraneous cement was removed. trial reduction was carried out. Trial reduction was carried out and as expected the +0.45 gave excellent range of motion, restored our tension and had excellent stability. After irrigating the Morse taper neck and drying it the +0 head with bicentric were tamped into position, seating check and hip was reduced. Using #5 sutures that were woven into the capsule using a Houston suture passing these were passed through the fixation holes and tied to each other giving good fixation of the capsule tothe greater trochanter. We then placed 3 woven sutures into the abductor tendon beginning w/ the most distal pass using Houston suture passers passed through each sequential fixation hole after which each were tied to each other recreating our abductors. We further reinforced the abductor insertion w/ #0 Vicryl suture. We vigorously irrigated w/antibiotic irrigation, fascia, tensor fascia lata and gluteus maximus were closed using #1 interrupted Tycron suture, a fat drain was placed for stab wound incision, subcutaneous tissues closed in multiple layers. It should be noted the proximal was sent to pathology for further evaluation.