staceywall1
New
Good Morning All! I am just getting back into Podiatric Field and I need some help coding the below....
Procedure in Detail: Patient was brought to the oprating room and put in a lateral decubitus position using a bean bag under general anesthesia. thig tourniquet was inflate to 280-290mmHG pressure. A linear incision was made over the lateral aspect of the left ankle and foot with careful attention not to disrupt the surreal nerve or the immediate dorsal cutaneous nerve. These were reflected out of the way.
The incision was carried down into the sinus tarsus area initially and it was noted that there was a significant deformity of the fibula, as well as the talus. The subtalar joint then was isolated and the cartilage on both sides of the subtalar joint was denuded using a curette. It was flushed copiously with sterile saline. At this time, it was also fish scaled using osteotome and mallet. Another incision was made then in dorsum of the ankle just lateral to the _anterior and medial to the extensor halluces longus. This was carried down to the bone and under Carm evaluation, a guide pin was put throught the talus into the calcaneus. After visualization, a 6.5 millimeter screw was used. It was 90 millimeters in length. It was a Synthes cannulated, large thread cannulated screw. The osteotome site was noted to be quite stable. At hthis time, prior to the running of the pin, the heel was put in a slight valgus position.
At this time, attention was then directed to the peroneal. It was noted after some dissection, that the peroneal brevis was gone and degenerated, apparently an old injury, so At this time there was no peroneal. The peroneus longus was intact but quite diseased. It was yellowish with multiple hard areas, not healthy at all. Tendon was evaluated but it was intact. There was a large exostosis enveloping around the peroneal tendons just below the fibula. This was removed in toto using soteotome and mallet and rongeur and it as sent for histological evaluation. It did not look like pathological bone but it was huge exostosis, possibly from an old fracture or injury to the area.
At this time, the ankle was still noted to be quite unstable and it was felt that a modified ChrismanSnook procedure would be indicated to stabilize the ankle. Half of the peroneus longus tendon was used as a free graft. This was put through the fibula throught a drill hole from anterior to posterior and then a drill hole was put into the calcaneus and the tendonwas attachedto this into the hole using a Mitek Anchor. The Mitek anchor that was used was a quick anchor, a G-2 anchor. Bone was packed into the hole with the tendon. the tendon again was put into a drill hole in calcaneus trying to foloow the anatomy of the calcaneal fibula ligament. Also, the drill hole in the fibula, in an attempt to mimic the anterior talus fibula ligament. The peroneus longus tendon at its distal aspect did seem to send a piece of peroneal into the insertion of the peroneus brevis. It appears that the ends of these tendons merged into the peroneus long tendon. The midsubstance of the peroneus brevis was nonexistent at this time. After this was undertaken, the ankle and subtalar were quite stable and in postion of slight valgus of the heel. The ankle was in more neutral position.
Wound was flushed copiously with saline. The peroneal retinaculum was closed using 3-0 Vicryl, Subcutanous 3-0 Vicryl, subcutaneous tissue 4-0 Vicryl and skin using 3-0 nylon in simple locking fashion. The other owund closed similarly.
In conclusion, th peroneal tendon was tracked down to the midcalf area. It was merged with peroneus longus at this time. There was remnants distally. This tendon was completely gone. The peroneus longus tendon also was quite diseased and quite hypertrophitic with large nodules. A graft was used from the peroneus longus. The attachement distal to the base of the fifth metatarsal was kept in place and again through a drill hole from anterior to posterior and the down to the calcaneus it was anchored.
The surgeon gave us codes....27691, 28725, 28118 and I do not agree
Thank You in Advance!!!!
Stacey
Procedure in Detail: Patient was brought to the oprating room and put in a lateral decubitus position using a bean bag under general anesthesia. thig tourniquet was inflate to 280-290mmHG pressure. A linear incision was made over the lateral aspect of the left ankle and foot with careful attention not to disrupt the surreal nerve or the immediate dorsal cutaneous nerve. These were reflected out of the way.
The incision was carried down into the sinus tarsus area initially and it was noted that there was a significant deformity of the fibula, as well as the talus. The subtalar joint then was isolated and the cartilage on both sides of the subtalar joint was denuded using a curette. It was flushed copiously with sterile saline. At this time, it was also fish scaled using osteotome and mallet. Another incision was made then in dorsum of the ankle just lateral to the _anterior and medial to the extensor halluces longus. This was carried down to the bone and under Carm evaluation, a guide pin was put throught the talus into the calcaneus. After visualization, a 6.5 millimeter screw was used. It was 90 millimeters in length. It was a Synthes cannulated, large thread cannulated screw. The osteotome site was noted to be quite stable. At hthis time, prior to the running of the pin, the heel was put in a slight valgus position.
At this time, attention was then directed to the peroneal. It was noted after some dissection, that the peroneal brevis was gone and degenerated, apparently an old injury, so At this time there was no peroneal. The peroneus longus was intact but quite diseased. It was yellowish with multiple hard areas, not healthy at all. Tendon was evaluated but it was intact. There was a large exostosis enveloping around the peroneal tendons just below the fibula. This was removed in toto using soteotome and mallet and rongeur and it as sent for histological evaluation. It did not look like pathological bone but it was huge exostosis, possibly from an old fracture or injury to the area.
At this time, the ankle was still noted to be quite unstable and it was felt that a modified ChrismanSnook procedure would be indicated to stabilize the ankle. Half of the peroneus longus tendon was used as a free graft. This was put through the fibula throught a drill hole from anterior to posterior and then a drill hole was put into the calcaneus and the tendonwas attachedto this into the hole using a Mitek Anchor. The Mitek anchor that was used was a quick anchor, a G-2 anchor. Bone was packed into the hole with the tendon. the tendon again was put into a drill hole in calcaneus trying to foloow the anatomy of the calcaneal fibula ligament. Also, the drill hole in the fibula, in an attempt to mimic the anterior talus fibula ligament. The peroneus longus tendon at its distal aspect did seem to send a piece of peroneal into the insertion of the peroneus brevis. It appears that the ends of these tendons merged into the peroneus long tendon. The midsubstance of the peroneus brevis was nonexistent at this time. After this was undertaken, the ankle and subtalar were quite stable and in postion of slight valgus of the heel. The ankle was in more neutral position.
Wound was flushed copiously with saline. The peroneal retinaculum was closed using 3-0 Vicryl, Subcutanous 3-0 Vicryl, subcutaneous tissue 4-0 Vicryl and skin using 3-0 nylon in simple locking fashion. The other owund closed similarly.
In conclusion, th peroneal tendon was tracked down to the midcalf area. It was merged with peroneus longus at this time. There was remnants distally. This tendon was completely gone. The peroneus longus tendon also was quite diseased and quite hypertrophitic with large nodules. A graft was used from the peroneus longus. The attachement distal to the base of the fifth metatarsal was kept in place and again through a drill hole from anterior to posterior and the down to the calcaneus it was anchored.
The surgeon gave us codes....27691, 28725, 28118 and I do not agree
Thank You in Advance!!!!
Stacey