nsteinhauser
Expert
I need help. The first part of the procedure was (28750-LT) fusion of hallux MTP joint with screw and plate for hallux rigidus. So the 'was harvest of bone distant'? answer is 'not really'.....from the already opened incision over the MTP of the hallux next to the 2nd MTP and PIP she was working on. Here is the op note portion for the left 2nd hammer toe which at the header says: 'left 2nd revision proximal interphalangeal arthroplasty.'
Attention was turned to the 2nd toe. A new incision was made over the 2nd MTP joint and PIP joint longitudinally through her previous incision. Incision was made through the skin and subcutaneus tissue. Bovie electrocaudery was used for hemostasis. The extensor tendons were found to have scar tissue around them that was debrided with a 15 blade. The MTP joint was opened medially and laterally. There was scar tissue around the joint from previous surgery. The proximal interphalangeal joint was opened. There was no bone healing only scar tissue in the joint. This joint was very unstable. It was opened dorsally. The extensor tendon was preserved and brought laterally. The joint was cleaned out with currettes and rongeur to good cancellous bleeding. The second toe was found to be short. We used local bone graft from the 1st MTP joint and packed the bone in the PIP joint. A 0.62 k wire was drilled from distal phalanx, middle phalanx, and into the proximal phalanx and forefoot while holding to toe straight. C arm fluoroscopy was used to confirm pin placement. The wounds were copiously irrigated. More bone graft from her 1st MTP joint was placed around the 1st MTP joint and 2nd PIP joint. We did check clinically and found the toe was in good position. We then closed the capsular tissue with a running 3-0 Monocryl suture. Subcutaneous tissue was closed with buried 3-0 Monocryl. The skin was closed with 3-0 nylon and 35 mL of 1% lidocaine and 0.25% Marcaine plain was injected around the toe. Wound was then dressed with Xeroform, 4 x 4's, Webril......
The MTP and PIP were 'opened' so I was thinking 28270 and 28272 for capsulotomy of MTP and PIP. But it was all one incision, 2 separate joints but just one incision...that's questionable. But the PIP was 'cleaned out with curettes and a rongeur'.....more than just capsule opening. But no partial bones were removed so I hesitate to use the 28285. So then I was thinking arthotomy codes 28022 for MTP and 28024 for PIP. But then there's the auto grafting. Not really from a 'distant' source, is it? I've read somewhere that it has to be from a 'distant' area and through a separate incision. But the incision was already made because of the fusion of the first MTP that happened before this part of the session.
Anyone have any thoughts, guidance, knowledge?
ANY ideas would be much appreciated!
Thank you!
Attention was turned to the 2nd toe. A new incision was made over the 2nd MTP joint and PIP joint longitudinally through her previous incision. Incision was made through the skin and subcutaneus tissue. Bovie electrocaudery was used for hemostasis. The extensor tendons were found to have scar tissue around them that was debrided with a 15 blade. The MTP joint was opened medially and laterally. There was scar tissue around the joint from previous surgery. The proximal interphalangeal joint was opened. There was no bone healing only scar tissue in the joint. This joint was very unstable. It was opened dorsally. The extensor tendon was preserved and brought laterally. The joint was cleaned out with currettes and rongeur to good cancellous bleeding. The second toe was found to be short. We used local bone graft from the 1st MTP joint and packed the bone in the PIP joint. A 0.62 k wire was drilled from distal phalanx, middle phalanx, and into the proximal phalanx and forefoot while holding to toe straight. C arm fluoroscopy was used to confirm pin placement. The wounds were copiously irrigated. More bone graft from her 1st MTP joint was placed around the 1st MTP joint and 2nd PIP joint. We did check clinically and found the toe was in good position. We then closed the capsular tissue with a running 3-0 Monocryl suture. Subcutaneous tissue was closed with buried 3-0 Monocryl. The skin was closed with 3-0 nylon and 35 mL of 1% lidocaine and 0.25% Marcaine plain was injected around the toe. Wound was then dressed with Xeroform, 4 x 4's, Webril......
The MTP and PIP were 'opened' so I was thinking 28270 and 28272 for capsulotomy of MTP and PIP. But it was all one incision, 2 separate joints but just one incision...that's questionable. But the PIP was 'cleaned out with curettes and a rongeur'.....more than just capsule opening. But no partial bones were removed so I hesitate to use the 28285. So then I was thinking arthotomy codes 28022 for MTP and 28024 for PIP. But then there's the auto grafting. Not really from a 'distant' source, is it? I've read somewhere that it has to be from a 'distant' area and through a separate incision. But the incision was already made because of the fusion of the first MTP that happened before this part of the session.
Anyone have any thoughts, guidance, knowledge?
ANY ideas would be much appreciated!
Thank you!