Alfaro33
Networker
Looking for a CPT code to cover the bold and underlined part of the procedure. Any input is appreciated!
Preoperative Diagnosis
1) Closed right LC 2 pelvis fracture dislocation
2) Closed pubic symphysis disruption
3) Closed complete left sacroiliac joint dislocation
Postoperative Diagnosis
Same
Operation
1) Removal anterior pelvic external fixation
2) Manipulation pelvis under anesthesia
3) Removal right SI screw and washer
4) Open reduction right SI joint
5) L4, L5-S2AI spinopelvic fixation
6) Right SI fusion
Anesthesia
General
Technique
Stryker
Estimated Blood Loss
250cc
2 Units PRBC given intra-op
Specimen(s)
Right SI screw and washer
Complications
None
Indications for Procedure
40-year-old male admitted status post motor vehicle accident. Patient was taken to the operating room the week of arrival for pelvic stabilization with placement of left S1 and S2 screws, right S1 screw and anterior external fixation. Patient returns to the OR today for open reduction of the right SI joint with revision of hardware secondary to right SI diastasis. Risks and benefits of the procedure were described to the patient and patient family which include but are not limited to the need for further surgery, bleeding, neurovascular injury, hardware failure, hardware irritation, heart attack, stroke, DVT, PE, or even death. Informed consent was obtained. All questions were answered.
Procedure in Detail
The patient was taken to the operating room he was identified as medical record number as ID band. He is placed supine on flat Jackson table. The anterior external fixation device was then removed from the pelvis. Fluoroscopy was then brought into the field and stressing the Shantz pins with internal external rotation pubic symphysis was noted to diastase freely without any significant signs of healing or scar tissue formation. Shantz pins were removed. Patient was then placed prone on an open Jackson table. The lumbosacral spine was then prepped and draped in usual sterile manner. Incision was then made from L4-S2 with a midline incision using a 10 blade. Electrocautery used deepen incision down. Percutaneous screw fixation was then plan for L4 and L5 screws. We then performed an open reduction of the right SI joint. Subperiosteal elevation was then carried out across the right side of the sacrum to the right SI joint. Question fractures identified as well as the large diastasis. The right SI screw was then removed through a percutaneous stab incision over the right side. Screw and washer were removed and given to the back table for specimen. Using pituitary and a curette after open booking fracture on the right SI joint fracture site was then cleaned out of interposing hematoma tissue and debris. Using a bone hook to pull up on the sacrum with Schanz pin placed into the right ilium downward force with internal external rotation was then used to reduce the right SI joint compression forces with a ball spike a disc were then used. The reduction was then held with point-to-point clamps. At this point attention was then turned to spinal pelvic fixation. Using jam she has the pedicles of the right and left L4 and L5 the lumbar vertebral bodies were then cannulated guidewires were placed. S2AI screws were then placed with our starting position at the lateral margin of the sacrum in line with the S2 foramen. Visualizing the tear drop we placed our guidewire in acceptable position. Ensuring to be out of the notch and the hip joint. We tapped the lumbar screws with a 5.5mm tap and tapped the sacral screws within a 8.5 mm tap 6 5 x 45 screws at L4 bilaterally. Six at L5 bilaterally. A 0.5 x 90 mm screws in the S2AI corridor. 110 mm rod was passed on the right-sided 100 mm rod was passed on the left side through the Tulip heads. Set caps were placed counter torqued and final tightened. The point-to-point clamps removed and the right SI joint remained reduced. We decorticated the right SI joint. Copious irrigation of wound was undertaken with saline. 10 cc of by allograft was then placed over the right SI joint. Hemostasis was maintained with Surgiflo and Arista. Medium Hemovac was placed on the right SI joint. Fascia was closed with 0 PDS. Subcutaneous tissue was closed. Skin was closed with 3-0 Monocryl and covered with a Prineo bandage. Stab incision was then closed with 2-0 PDS and Monocryl. Incisions were then covered with 4x4s and tape. Patient tolerated procedure well. He has returned to his hospital bed and returned to the surgical intensive care unit. Postoperatively patient received 24 hours antibiotics. The per trauma protocol. Patient is weight-bearing as tolerated in the bilateral lower extremities. Patient will follow up my office in 2 weeks for incision check.
Preoperative Diagnosis
1) Closed right LC 2 pelvis fracture dislocation
2) Closed pubic symphysis disruption
3) Closed complete left sacroiliac joint dislocation
Postoperative Diagnosis
Same
Operation
1) Removal anterior pelvic external fixation
2) Manipulation pelvis under anesthesia
3) Removal right SI screw and washer
4) Open reduction right SI joint
5) L4, L5-S2AI spinopelvic fixation
6) Right SI fusion
Anesthesia
General
Technique
Stryker
Estimated Blood Loss
250cc
2 Units PRBC given intra-op
Specimen(s)
Right SI screw and washer
Complications
None
Indications for Procedure
40-year-old male admitted status post motor vehicle accident. Patient was taken to the operating room the week of arrival for pelvic stabilization with placement of left S1 and S2 screws, right S1 screw and anterior external fixation. Patient returns to the OR today for open reduction of the right SI joint with revision of hardware secondary to right SI diastasis. Risks and benefits of the procedure were described to the patient and patient family which include but are not limited to the need for further surgery, bleeding, neurovascular injury, hardware failure, hardware irritation, heart attack, stroke, DVT, PE, or even death. Informed consent was obtained. All questions were answered.
Procedure in Detail
The patient was taken to the operating room he was identified as medical record number as ID band. He is placed supine on flat Jackson table. The anterior external fixation device was then removed from the pelvis. Fluoroscopy was then brought into the field and stressing the Shantz pins with internal external rotation pubic symphysis was noted to diastase freely without any significant signs of healing or scar tissue formation. Shantz pins were removed. Patient was then placed prone on an open Jackson table. The lumbosacral spine was then prepped and draped in usual sterile manner. Incision was then made from L4-S2 with a midline incision using a 10 blade. Electrocautery used deepen incision down. Percutaneous screw fixation was then plan for L4 and L5 screws. We then performed an open reduction of the right SI joint. Subperiosteal elevation was then carried out across the right side of the sacrum to the right SI joint. Question fractures identified as well as the large diastasis. The right SI screw was then removed through a percutaneous stab incision over the right side. Screw and washer were removed and given to the back table for specimen. Using pituitary and a curette after open booking fracture on the right SI joint fracture site was then cleaned out of interposing hematoma tissue and debris. Using a bone hook to pull up on the sacrum with Schanz pin placed into the right ilium downward force with internal external rotation was then used to reduce the right SI joint compression forces with a ball spike a disc were then used. The reduction was then held with point-to-point clamps. At this point attention was then turned to spinal pelvic fixation. Using jam she has the pedicles of the right and left L4 and L5 the lumbar vertebral bodies were then cannulated guidewires were placed. S2AI screws were then placed with our starting position at the lateral margin of the sacrum in line with the S2 foramen. Visualizing the tear drop we placed our guidewire in acceptable position. Ensuring to be out of the notch and the hip joint. We tapped the lumbar screws with a 5.5mm tap and tapped the sacral screws within a 8.5 mm tap 6 5 x 45 screws at L4 bilaterally. Six at L5 bilaterally. A 0.5 x 90 mm screws in the S2AI corridor. 110 mm rod was passed on the right-sided 100 mm rod was passed on the left side through the Tulip heads. Set caps were placed counter torqued and final tightened. The point-to-point clamps removed and the right SI joint remained reduced. We decorticated the right SI joint. Copious irrigation of wound was undertaken with saline. 10 cc of by allograft was then placed over the right SI joint. Hemostasis was maintained with Surgiflo and Arista. Medium Hemovac was placed on the right SI joint. Fascia was closed with 0 PDS. Subcutaneous tissue was closed. Skin was closed with 3-0 Monocryl and covered with a Prineo bandage. Stab incision was then closed with 2-0 PDS and Monocryl. Incisions were then covered with 4x4s and tape. Patient tolerated procedure well. He has returned to his hospital bed and returned to the surgical intensive care unit. Postoperatively patient received 24 hours antibiotics. The per trauma protocol. Patient is weight-bearing as tolerated in the bilateral lower extremities. Patient will follow up my office in 2 weeks for incision check.