aleach
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I need some help coding this case. Any help is appreciated. Thx
POSTOPERATIVE DIAGNOSIS: Degenerative arthritic changes, right first metatarsophalangeal joint complications with joint replacement implant.
PROCEDURE PERFORMED: Arthrotomy with debridement of multiple exostoses and revision of total joint implant with utilization of cement fixative.
OPERATIVE PROCEDURE: The patient was seen in no acute distress, and placed in supine position on the operating room table. Noting vital signs to be stable, general anesthesia was induced. A well-padded pneumatic ankle tourniquet was placed about the right ankle. The right lower extremity was then scrubbed, prepped, and draped in the usual aseptic technique. The right lower extremity was then elevated and exsanguinated and pneumatic ankle tourniquet was inflated to 250 mmHg.
Attention was then directed to the dorsal aspect to the right first metatarsophalangeal joint where dorsal linear incision was made overlying the extensor hallucis longus tendon extending from a distal more proximal orientation approximately 4-cm in length. The initial incision was deepened through the subcutaneous tissues utilizing sharp and blunt dissection. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were cauterized and/or ligated as necessary. Upon further inspection of the operative site, multiple constrictures and scar tissue formation were appreciated about the joint capsule and these were excised as necessary. The extensor hallucis longus tendon was also noted to be scarred down within the first metatarsal joint capsule region. A synovectomy was performed thus freeing the extensor hallucis longus tendon. At this time, the capsule was approached via a linear capsular incision. The capsule was freed of all osseous and fibrous attachments thus exposing the first metatarsophalangeal joint. Prominent well-defined exostoses were appreciated about the dorsal, lateral, and plantar lateral aspect of the first metatarsal neck. These were all resected utilizing a rongeur as well as the Joseph nasal rasp. Dorsiflexion of the great toe at this time yielded. Range of motion approximately is 45 degrees, dorsiflexion.
Upon doing so, the proximal stem implant was noted to move freely about the first metatarsal. The plantar capsular ligaments and adhesions were freed utilizing the McGlamery elevator and the right hallux was distracted and plantar flexed exposing the proximal implant. The implant was dissected free of all capsular adhesions and periosteal structures and removed from the first metatarsal and placed in warm sterile saline on the back table. Further inspection of the residual first metatarsal neck yielded and degenerative changes within the medullary canal as well as gray to tan color changes of the surrounding capsular structures. Careful debridement and dissection of all devitalized tissue was then performed. A Joseph nasal rasp was then introduced and all cortical prominences were filed until fresh clean bleeding viable bone was obtained. Medullary canal was then reamed. Copious amount of sterile normal saline was then irrigated throughout the operative site. An Osteomed cement fixative was then prepared upon the back table and allowed to set for approximately one minute. The cement fixative was intact within the medullary canal and the proximal stem implant was then re-impacted upon the first metatarsal neck. This was allowed to set for approximately five minutes. The wounds were then copiously irrigated with sterile normal saline and all further excess cement-type material was removed. Range of motion was noted to be adequate to 45 degrees at this time in good dorsiflexory range with no further pistoning or crepitus appreciated. The implant appeared to be seated solid. Fluoroscope was introduced and alignment was noted to be anatomic.
The capsule was then débrided of all hypertrophic areas reapproximated utilizing 4-0 Vicryl in a simple interrupted suture technique. Once again, range of motion was assessed to be right at 45 degrees dorsiflexion of the hallux. Subcutaneous tissue was then reapproximated and coapted utilizing 4-0 Vicryl in a simple interrupted suture technique. The skin was then coapted and reapproximated utilizing 3-0 Prolene in a continuous running subcuticular suture technique. Bactroban was then applied about the operative site. A postoperative block consisting of 20 cc and 0.5% Marcaine was then infiltrated about the right forefoot. 4 mg of Decadron phosphate was also infiltrated about the operative site. Adaptic, sterile 4 x 4s, Kerlix, and a loose thick compressive CoFlex dressing were applied to the right lower extremity. The tourniquet was deflated and capillary refill time was noted to be instantaneous to all five digits of the right foot. The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room without further incident.
POSTOPERATIVE DIAGNOSIS: Degenerative arthritic changes, right first metatarsophalangeal joint complications with joint replacement implant.
PROCEDURE PERFORMED: Arthrotomy with debridement of multiple exostoses and revision of total joint implant with utilization of cement fixative.
OPERATIVE PROCEDURE: The patient was seen in no acute distress, and placed in supine position on the operating room table. Noting vital signs to be stable, general anesthesia was induced. A well-padded pneumatic ankle tourniquet was placed about the right ankle. The right lower extremity was then scrubbed, prepped, and draped in the usual aseptic technique. The right lower extremity was then elevated and exsanguinated and pneumatic ankle tourniquet was inflated to 250 mmHg.
Attention was then directed to the dorsal aspect to the right first metatarsophalangeal joint where dorsal linear incision was made overlying the extensor hallucis longus tendon extending from a distal more proximal orientation approximately 4-cm in length. The initial incision was deepened through the subcutaneous tissues utilizing sharp and blunt dissection. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were cauterized and/or ligated as necessary. Upon further inspection of the operative site, multiple constrictures and scar tissue formation were appreciated about the joint capsule and these were excised as necessary. The extensor hallucis longus tendon was also noted to be scarred down within the first metatarsal joint capsule region. A synovectomy was performed thus freeing the extensor hallucis longus tendon. At this time, the capsule was approached via a linear capsular incision. The capsule was freed of all osseous and fibrous attachments thus exposing the first metatarsophalangeal joint. Prominent well-defined exostoses were appreciated about the dorsal, lateral, and plantar lateral aspect of the first metatarsal neck. These were all resected utilizing a rongeur as well as the Joseph nasal rasp. Dorsiflexion of the great toe at this time yielded. Range of motion approximately is 45 degrees, dorsiflexion.
Upon doing so, the proximal stem implant was noted to move freely about the first metatarsal. The plantar capsular ligaments and adhesions were freed utilizing the McGlamery elevator and the right hallux was distracted and plantar flexed exposing the proximal implant. The implant was dissected free of all capsular adhesions and periosteal structures and removed from the first metatarsal and placed in warm sterile saline on the back table. Further inspection of the residual first metatarsal neck yielded and degenerative changes within the medullary canal as well as gray to tan color changes of the surrounding capsular structures. Careful debridement and dissection of all devitalized tissue was then performed. A Joseph nasal rasp was then introduced and all cortical prominences were filed until fresh clean bleeding viable bone was obtained. Medullary canal was then reamed. Copious amount of sterile normal saline was then irrigated throughout the operative site. An Osteomed cement fixative was then prepared upon the back table and allowed to set for approximately one minute. The cement fixative was intact within the medullary canal and the proximal stem implant was then re-impacted upon the first metatarsal neck. This was allowed to set for approximately five minutes. The wounds were then copiously irrigated with sterile normal saline and all further excess cement-type material was removed. Range of motion was noted to be adequate to 45 degrees at this time in good dorsiflexory range with no further pistoning or crepitus appreciated. The implant appeared to be seated solid. Fluoroscope was introduced and alignment was noted to be anatomic.
The capsule was then débrided of all hypertrophic areas reapproximated utilizing 4-0 Vicryl in a simple interrupted suture technique. Once again, range of motion was assessed to be right at 45 degrees dorsiflexion of the hallux. Subcutaneous tissue was then reapproximated and coapted utilizing 4-0 Vicryl in a simple interrupted suture technique. The skin was then coapted and reapproximated utilizing 3-0 Prolene in a continuous running subcuticular suture technique. Bactroban was then applied about the operative site. A postoperative block consisting of 20 cc and 0.5% Marcaine was then infiltrated about the right forefoot. 4 mg of Decadron phosphate was also infiltrated about the operative site. Adaptic, sterile 4 x 4s, Kerlix, and a loose thick compressive CoFlex dressing were applied to the right lower extremity. The tourniquet was deflated and capillary refill time was noted to be instantaneous to all five digits of the right foot. The patient tolerated the procedure and anesthesia well and left the operating room to the recovery room without further incident.
