hello coders! I am at a complete loss of how to code what my doc titled "I&D/Realignment".-(??) I APPRECIATE ANY HELP!!!
Shelli
OP Report:
procedure: irrigation, debridement, and realignment of right knee
findings: The patient is a 73 year old gentleman who has been seen and evaluated and treated for an acute postoperative infection regarding his right TKA. He underwent irrigation, debridement, and implantation of antibiotic-impregnated cement spacers. He has developed an approximately 30-degree flexion contracture of the right knee postoperatively requiring the above stated procedure.
description: The previously created incision was recreated after removal of PDS suture material. Medical retinacular approach was carried out to the right knee joint. Continued 30-degree flexion contracture was identified. Antibiotic-impregnated cement spacers were removed in their entirety with the use of a revision tibial block. Approximately 2 mm was removed from the proximal right tibia. The patient continued to have an approximately 10-degree flexion contracture with extension and was found to have good flexion without significant loosening. The decision was then carried out to remove some distal right femur to facilitate full extension. An approximate 2 mm distal cut of the right femur was carried out. Resected bone was removed. Antibiotic-impregnated cement spacers were replaced. The knee was found to go into full extension. Antibiotic-impregnated cement spacers were removed. The wounds were again copiously irrigated with pulsatile irrigation. Antibiotic-impregnated cement spacers were reinserted. The medial retinacular approach was reapproximated with #0 Ethibond suture in a running-locking horizontal fashion. The skin was reapproximated with #0 PDS suture in interruped vertical mattress fashion. Local anesthetic was injected into the incision site for postoperative pain management. Sterile dressing was applied and the patient was placed into a knee immobilizer and transported to the recovery room in stable condition. Estimated blood loss was minimal. Sponge and needle counts remained correct througout the case.
THANKS!!
Shelli
OP Report:
procedure: irrigation, debridement, and realignment of right knee
findings: The patient is a 73 year old gentleman who has been seen and evaluated and treated for an acute postoperative infection regarding his right TKA. He underwent irrigation, debridement, and implantation of antibiotic-impregnated cement spacers. He has developed an approximately 30-degree flexion contracture of the right knee postoperatively requiring the above stated procedure.
description: The previously created incision was recreated after removal of PDS suture material. Medical retinacular approach was carried out to the right knee joint. Continued 30-degree flexion contracture was identified. Antibiotic-impregnated cement spacers were removed in their entirety with the use of a revision tibial block. Approximately 2 mm was removed from the proximal right tibia. The patient continued to have an approximately 10-degree flexion contracture with extension and was found to have good flexion without significant loosening. The decision was then carried out to remove some distal right femur to facilitate full extension. An approximate 2 mm distal cut of the right femur was carried out. Resected bone was removed. Antibiotic-impregnated cement spacers were replaced. The knee was found to go into full extension. Antibiotic-impregnated cement spacers were removed. The wounds were again copiously irrigated with pulsatile irrigation. Antibiotic-impregnated cement spacers were reinserted. The medial retinacular approach was reapproximated with #0 Ethibond suture in a running-locking horizontal fashion. The skin was reapproximated with #0 PDS suture in interruped vertical mattress fashion. Local anesthetic was injected into the incision site for postoperative pain management. Sterile dressing was applied and the patient was placed into a knee immobilizer and transported to the recovery room in stable condition. Estimated blood loss was minimal. Sponge and needle counts remained correct througout the case.
THANKS!!