Lacybarfield
Contributor
i would use CPT code 27132, is this right? would there be any other CPT codes to add to this?
this is the opnote:
POSTOPERATIVE DIAGNOSIS
osttraumatic arthritis, right hip with retained hardware, rightfemur.PROCEDURES PERFORMED:1. Right total hip arthroplasty using a size 19 standard REDAPT 300stem from Smith and Nephew, a 52 R3 trabecular metal cup with asingle screw placed in the superior safe zone and a neutral liner, a36 mm Oxinium femoral head and six 2.0 cobalt chrome cables.2. Removal of hardware, right femur.
BRIEF DESCRIPTION OF OPERATION:The patient was identified by name, given preoperative antibiotics,taken to the operating room. General anesthesia was administered. She was carefully positioned in the left lateral decubitus position. The right hip and lower extremity were then prepped and draped instandard sterile fashion. A 30 cm incision was made over thelateral aspect of the femur and a straight lateral approach to thefemur was performed using standard technique. Great care was takento protect all neurovascular structures throughout the case. Wealso engaged hypotensive anesthesia to reduce blood loss. At thatpoint, I exposed the plate and there were 5 distal locking screwsthat had a flat tip Phillip's head design and most of the screwswere stripped and so the hospital was able to provide me with ascrewdriver that worked somewhat for these screws, however, was notthe ideal screwdriver for the screw. This was a very unusual screw. I had never seen it before and I was able to remove 4 of the 5screws with a screwdriver. Unfortunately, the second screw wasstripped and so I was unable to remove it despite spending a greatdeal of time using multiple pieces of equipment and multipletechniques to try and remove the stripped screw and so I elected touse a Midas saw to cut the plate to expose the head of the screw, soI could use some pliers to remove it. I then obtained a Midas sawand I cut the plate at the level of the screw hole with the strippedscrew. I was able to remove the distal aspect of the plate, whichgave me access to the screw head and I was able to remove the screwusing pliers. I then used a plate remover tongs to remove the bladeplate and proximal portion of the plate. This completely removedthe hardware. The femur fracture had a very thin portion of healedcortex at the mid portion of the femur and the process ofmanipulating the hip caused the femur to fracture completelythrough. I believe that this was likely to happen as I removed theplate and so we were prepared for this set of circumstances. Atthat point, I then turned my attention to the hip joint where Icompleted a standard lateral approach to the hip joint. The capsulewas incised in an L-shaped fashion and I was able to use a corkscrewawl to dislocate the hip anteriorly. I then used an oscillating sawto perform my femoral neck cut in an appropriate position. Due tothe loss of anatomy as a result of her prior proximal femurfracture, I had no lesser trochanter or landmarks to help meidentify the proper length and offset of the hip replacement. Therewas also a significant amount of osteophytes involving theacetabulum. At that point, I used an osteotome, a curette and arongeur to remove osteophytes around the acetabulum and I did mybest to create the proper leg length and size. After gainingexposure to the hip, I then used a series of broaches and reamers to open the proximal femoral fragments. I then was able to perform anopen reduction of the distal fragment and get the reamer to crossthe fracture site and into the distal part of the femur. I reamedup several sizes until I got some chatter and at that point, I useda claw plate, which went over the top of the greater trochanteralong the lateral aspect of the femur. I laid the plate right onthe same location that the prior blade plate had been sitting andthis helped me with reduction of the intraoperative femur fracture. I then achieved compression of the medial cortex of the fracturesite of the femur and I affixed the claw plate to the lateral aspectof the femur using six 2.0 cobalt chrome cables, which I tensionedusing standard technique and this achieved a very stable reductionof the femur fracture and reduced it in an excellent position andallowed me to continue to ream to the appropriate size for thefemoral implant. At that point, I irrigated the wound with copiousamounts of sterile antibiotic saline through pulse lavage. I wasthen able to trial a size 19 standard REDAPT 300 stem with a 36 mmstandard offset 0 neck length trial head. I located the hip andtook the hip through range of motion. It was found to be extremelystable and the patient was noted to have clinically symmetric leglengths. This was able to lengthen the leg slightly because thepatient had approximately a 2 cm shortened right lower extremitypreoperatively and this essentially restored normal leg length. Atthat point, the trial components were removed. The wound wasirrigated with copious amounts of sterile antibiotic saline viapulse lavage. Hemostasis was again obtained using Bovie cautery. Ithen press fit the final components into position. Fluoroscopy wasused to confirm appropriate reduction of the intraoperative femurfracture and placement of the hardware and I was very pleased withthe outcome. At that point, I reduced the hip joint using standardtechnique. A drain was placed out the lateral aspect of the hip. The anterior third of the abductor was also repaired back to itsinsertion site using #5 Ethibond. The tensor fascia was repairedusing #5 Ethibond. As I stated the drain was placed out of theanterior aspect of the hip. The skin was closed in a layered closureusing Vicryl subcutaneous sutures and Monocryl subcuticular sutures.Steri-Strips were applied. A sterile dressing was applied. Anabduction pillow was applied and the patient was awakened andtransported to the PACU in stable condition.
this is the opnote:
POSTOPERATIVE DIAGNOSIS
osttraumatic arthritis, right hip with retained hardware, rightfemur.PROCEDURES PERFORMED:1. Right total hip arthroplasty using a size 19 standard REDAPT 300stem from Smith and Nephew, a 52 R3 trabecular metal cup with asingle screw placed in the superior safe zone and a neutral liner, a36 mm Oxinium femoral head and six 2.0 cobalt chrome cables.2. Removal of hardware, right femur.BRIEF DESCRIPTION OF OPERATION:The patient was identified by name, given preoperative antibiotics,taken to the operating room. General anesthesia was administered. She was carefully positioned in the left lateral decubitus position. The right hip and lower extremity were then prepped and draped instandard sterile fashion. A 30 cm incision was made over thelateral aspect of the femur and a straight lateral approach to thefemur was performed using standard technique. Great care was takento protect all neurovascular structures throughout the case. Wealso engaged hypotensive anesthesia to reduce blood loss. At thatpoint, I exposed the plate and there were 5 distal locking screwsthat had a flat tip Phillip's head design and most of the screwswere stripped and so the hospital was able to provide me with ascrewdriver that worked somewhat for these screws, however, was notthe ideal screwdriver for the screw. This was a very unusual screw. I had never seen it before and I was able to remove 4 of the 5screws with a screwdriver. Unfortunately, the second screw wasstripped and so I was unable to remove it despite spending a greatdeal of time using multiple pieces of equipment and multipletechniques to try and remove the stripped screw and so I elected touse a Midas saw to cut the plate to expose the head of the screw, soI could use some pliers to remove it. I then obtained a Midas sawand I cut the plate at the level of the screw hole with the strippedscrew. I was able to remove the distal aspect of the plate, whichgave me access to the screw head and I was able to remove the screwusing pliers. I then used a plate remover tongs to remove the bladeplate and proximal portion of the plate. This completely removedthe hardware. The femur fracture had a very thin portion of healedcortex at the mid portion of the femur and the process ofmanipulating the hip caused the femur to fracture completelythrough. I believe that this was likely to happen as I removed theplate and so we were prepared for this set of circumstances. Atthat point, I then turned my attention to the hip joint where Icompleted a standard lateral approach to the hip joint. The capsulewas incised in an L-shaped fashion and I was able to use a corkscrewawl to dislocate the hip anteriorly. I then used an oscillating sawto perform my femoral neck cut in an appropriate position. Due tothe loss of anatomy as a result of her prior proximal femurfracture, I had no lesser trochanter or landmarks to help meidentify the proper length and offset of the hip replacement. Therewas also a significant amount of osteophytes involving theacetabulum. At that point, I used an osteotome, a curette and arongeur to remove osteophytes around the acetabulum and I did mybest to create the proper leg length and size. After gainingexposure to the hip, I then used a series of broaches and reamers to open the proximal femoral fragments. I then was able to perform anopen reduction of the distal fragment and get the reamer to crossthe fracture site and into the distal part of the femur. I reamedup several sizes until I got some chatter and at that point, I useda claw plate, which went over the top of the greater trochanteralong the lateral aspect of the femur. I laid the plate right onthe same location that the prior blade plate had been sitting andthis helped me with reduction of the intraoperative femur fracture. I then achieved compression of the medial cortex of the fracturesite of the femur and I affixed the claw plate to the lateral aspectof the femur using six 2.0 cobalt chrome cables, which I tensionedusing standard technique and this achieved a very stable reductionof the femur fracture and reduced it in an excellent position andallowed me to continue to ream to the appropriate size for thefemoral implant. At that point, I irrigated the wound with copiousamounts of sterile antibiotic saline through pulse lavage. I wasthen able to trial a size 19 standard REDAPT 300 stem with a 36 mmstandard offset 0 neck length trial head. I located the hip andtook the hip through range of motion. It was found to be extremelystable and the patient was noted to have clinically symmetric leglengths. This was able to lengthen the leg slightly because thepatient had approximately a 2 cm shortened right lower extremitypreoperatively and this essentially restored normal leg length. Atthat point, the trial components were removed. The wound wasirrigated with copious amounts of sterile antibiotic saline viapulse lavage. Hemostasis was again obtained using Bovie cautery. Ithen press fit the final components into position. Fluoroscopy wasused to confirm appropriate reduction of the intraoperative femurfracture and placement of the hardware and I was very pleased withthe outcome. At that point, I reduced the hip joint using standardtechnique. A drain was placed out the lateral aspect of the hip. The anterior third of the abductor was also repaired back to itsinsertion site using #5 Ethibond. The tensor fascia was repairedusing #5 Ethibond. As I stated the drain was placed out of theanterior aspect of the hip. The skin was closed in a layered closureusing Vicryl subcutaneous sutures and Monocryl subcuticular sutures.Steri-Strips were applied. A sterile dressing was applied. Anabduction pillow was applied and the patient was awakened andtransported to the PACU in stable condition.