kcoyne1109
New
any assistance on this is greatly appreciated. She elevates and reattaches the flexor pronator which in my opinion is done to reach the nerve so I believe that should not be billed because it is inclusive.
I'm stuck on 64718 and 64708.
Procedure
Revision right ulnar nerve decompression at the elbow with axogen nerve wrap - 64718
Reattachment of the flexor pronator tendon to medial epicondyle - 24341
MABC neurolysis from scarring to sutures along prior repair - 64708
Operative Report:
I utilized his prior incision. The incision was carried sharply through the dermis. Subcutaneous tissues were then bluntly spread and bipolar cautery used to coagulate crossing vessels. I began by identifying the ulnar nerve. I found it proximally in the triceps and placed a vessel loop around it. I then continued to dissect it distally. A large full-thickness anterior flap was then carefully elevated off the flexor pronator fascia. At the level of the epicondyle, there were multiple sutures. I carefully dissected this from the fat above it. Within the fat, I realized the MABC had scarred to the more anterior sutures. I then had to carefully neurolyse the MABC and its branches off these sutures and scar. Once this was completed I placed a vessel loop around the MABC. I then removed all the prior sutures. I then elevated the felxor pronator mass off the medial epicondyle to allow for the decompression of the ulnar nerve. At the level where the nerve dove back into the FCUS heads there was a very tight fascial band constricting the nerve. At his was incised and at this level, there was a clear hour glass of the nerve. I continued my dissection through the 2 heads of the FCU. The first branch of the FCU was identified and carefully protected. This was mobilized with the ulnar nerve in order to allow for anterior mobilization. Once the nerve had been fully freed up, I mobilized it back behind the epicondyle. This would allow me to repair the tendon back down to the medial epicondyle. I copiously irrigated the wound. I then used a 0 fiber wire to repair the flexor pronator tendon back to its insertion. I had a good repair. I then identified any remaining segments of the medial intra muscular septum and this was excised. The nerve was then placed in a subcutaneous position. I then wrapped the nerve with an axogen nerve wrap to prevent rescarring. The wrap was placed in saline and then around the nerve at the level of the pronator mass. A small segment of the wrap was then wrapped around the area of most scaring of the MABC. Once this was complete, I dropped the tourniquet to ensure hemostasis was obtained. Lastly, a 3-0 vicryl suture was next used to place 3 horizontal mattress sutures from the fascial flap into the overlying subcutaneous tissue. A Freer was used to ensure that the nerve was not being constricted in its anterior position. The elbow was then brought through a full range of motion again. There was no residual sites of compression identified. The nerve was stable in its anterior position. The wound was then copiously irrigated. Subcutaneous tissue was closed with a 3-0 vicryl. Skin was then closed with a 4-0 prolene in running fashion. The arm was then placed into a bulky dry sterile dressing with a posterior splint. The tourniquet was let down and the fingers pinked up immediately. The patient was awoken from anesthesia and taken the PACU in stable condition.
I'm stuck on 64718 and 64708.
Procedure
Revision right ulnar nerve decompression at the elbow with axogen nerve wrap - 64718
Reattachment of the flexor pronator tendon to medial epicondyle - 24341
MABC neurolysis from scarring to sutures along prior repair - 64708
Operative Report:
I utilized his prior incision. The incision was carried sharply through the dermis. Subcutaneous tissues were then bluntly spread and bipolar cautery used to coagulate crossing vessels. I began by identifying the ulnar nerve. I found it proximally in the triceps and placed a vessel loop around it. I then continued to dissect it distally. A large full-thickness anterior flap was then carefully elevated off the flexor pronator fascia. At the level of the epicondyle, there were multiple sutures. I carefully dissected this from the fat above it. Within the fat, I realized the MABC had scarred to the more anterior sutures. I then had to carefully neurolyse the MABC and its branches off these sutures and scar. Once this was completed I placed a vessel loop around the MABC. I then removed all the prior sutures. I then elevated the felxor pronator mass off the medial epicondyle to allow for the decompression of the ulnar nerve. At the level where the nerve dove back into the FCUS heads there was a very tight fascial band constricting the nerve. At his was incised and at this level, there was a clear hour glass of the nerve. I continued my dissection through the 2 heads of the FCU. The first branch of the FCU was identified and carefully protected. This was mobilized with the ulnar nerve in order to allow for anterior mobilization. Once the nerve had been fully freed up, I mobilized it back behind the epicondyle. This would allow me to repair the tendon back down to the medial epicondyle. I copiously irrigated the wound. I then used a 0 fiber wire to repair the flexor pronator tendon back to its insertion. I had a good repair. I then identified any remaining segments of the medial intra muscular septum and this was excised. The nerve was then placed in a subcutaneous position. I then wrapped the nerve with an axogen nerve wrap to prevent rescarring. The wrap was placed in saline and then around the nerve at the level of the pronator mass. A small segment of the wrap was then wrapped around the area of most scaring of the MABC. Once this was complete, I dropped the tourniquet to ensure hemostasis was obtained. Lastly, a 3-0 vicryl suture was next used to place 3 horizontal mattress sutures from the fascial flap into the overlying subcutaneous tissue. A Freer was used to ensure that the nerve was not being constricted in its anterior position. The elbow was then brought through a full range of motion again. There was no residual sites of compression identified. The nerve was stable in its anterior position. The wound was then copiously irrigated. Subcutaneous tissue was closed with a 3-0 vicryl. Skin was then closed with a 4-0 prolene in running fashion. The arm was then placed into a bulky dry sterile dressing with a posterior splint. The tourniquet was let down and the fingers pinked up immediately. The patient was awoken from anesthesia and taken the PACU in stable condition.