Wiki Knee Revision, patella fx, I+D- HELP!

[Kaitbohrer]

Patient underwent total knee arthroplasty approximately 10 or 11 weeks ago. He did well for several weeks. He subsequently fell, sustained a periprosthetic patellar fracture, nondisplaced lateral femoral condyle fracture. He underwent an open reduction and internal fixation of the patella fracture. Postoperatively, the fracture displaced. However, given his intact extensor mechanism, an attempt at leaving the patella in situ was undertaken. However, at week 6, developed an opening in the anterior aspect of his knee, over the open communication with the joint at the site of the patellar nonunion. He presents today for irrigation and debridement, poly liner exchange, revision patellar open reduction and internal fixation. QUESTION: I am torn on coding 27524 OR 27486-52 for the 3rd procedure of irrigation and debridement, poly liner exchange, revision patellar open reduction and internal fixation. Op note: DESCRIPTION OF PROCEDURE: After the induction of anesthesia, proper preoperative identification and preoperative antibiotics, the left lower extremity was prepped and draped in a sterile fashion. The area about the opening, which communicated with the joint, a photograph was taken. It measured approximately 1 cm x 3 cm. The previous incision was used. Skin and subcutaneous flaps were developed medially and laterally, exposing the extensor mechanism, patella, quadriceps tendon. The suture had broken. All suture material was removed. The retinaculum medially was opened. The proximal tibial retinaculum and capsule was taken off. The extensive amount of scar on the medial gutter, lateral gutter, medial aspect of the knee and retropatellar surface was excised sharply. The 12 mm polyethylene spacer was removed. The knee was subsequently irrigated with 3 L of normal saline irrigant under a pulse lavage system. One liter of Bactisure was then used, followed by 1 L of normal saline rescue. A 10 mm polyethylene spacer was subsequently reimplanted within the knee. Then, set on the patellar repair. A #5 FiberTape and #5 FiberWire were woven up the lateral and central portion of the patellar tendon and similarly a #5 FiberWire and #5 FiberTape were woven up medially and centrally up the quadriceps tendon. The bone edges at the proximal pole of the patella as well as the remnant patella were debrided of soft tissue. Three drill holes were placed through the patellar surface. The #5 FiberWire and FiberTape were passed through these 3 drill holes, one lateral, one medial, one central. Such that 2 loops were placed lateral to loops medial and 4 loops centrally. The proximal portion of the patella was reduced to the distal portion and held with a clamp. The sutures were then tied. Intraoperatively, the proximal portion of the patella was intimately associated to the distal portion. The knee was able to be flexed to about 30 degrees with no separation in the fragments. It should be noted the quadriceps mechanism was mobilized by elevating the quadriceps off the femur, releasing adhesions medially and laterally. Excising the scar material from the undersurface of the quadriceps tendon. This allowed to freely mobile proximal quadriceps to be approximated to the distal portion of the patella. Upon tying these sutures, additional backup sutures with #5 FiberWire were used. Two grams of powdered vancomycin was sprinkled in the wound through the medial retinacular incision. The medial retinaculum was then subsequently closed with interrupted #2 Vicryl suture. Intraoperative photographs document the reconstruction of the extensor mechanism. The subcutaneous tissue was then closed with 2-0 Vicryl and the skin with interrupted 3-0 nylon. A sterile Prevena dressing was placed. Anterior and posterior splints were applied. Tolerated the procedure and transferred to the recovery room satisfactorily.