Would someone please take a look at this OP Report and tell me what they believe I can code. Any help, opinions, etc are greatly appreciated.
DETAILS OF THE OPERATION: He was brought to the operating theater and general anesthetic was administered followed by an adductor canal block by Dr. Johnson. The surgeon initials were identified in the operative extremity and timeout was performed. The left lower extremity was then prepped and draped in the usual sterile fashion for surgery. We began by making an anterior medial skin incision dissecting sharply through the skin and subcutaneous tissues. The extensor mechanism was identified. The tibial tubercle was isolated and an oblique osteotomy was made with the medial aspect much thinner than the lateral aspect. An anteromedial arthrotomy was performed. We then did a lateral lengthening doing a Z-plasty type cut through the lateral retinaculum. The patella was everted. The chondral defect was identified. Unfortunately, it was un-contained distally which we were aware of preoperatively. The vertical walls were created proximally and on the medial and lateral margins, the damage cartilage was curetted away down to calcified layer. We then isolated the defect on the trochlea. Likewise vertical margins created. The mixed juvenile cartilage was then placed into the defects both in the patella and the trochlea. Fibrin glue was allowed to set up. A chondral glide patch was then sewed over the patellar defect utilizing 6-0 Vicryl sutures to secure to the cartilage borders and then distally 1 mm micro JuggerKnot suture anchor was utilized to secure the patch. Once the glue had hardened, we turned our attention to the medial patellofemoral ligament reconstruction. Two 3-mm anchors were placed in the medial border of the patella. The graft was secured to the medial patella. We isolated the starting point for the femoral tunnel fluoroscopically at the junction of the posterior cortical line and Blumensaat line. Guidepin was then directed out to the lateral femoral cortex, over-reamed with a 7-mm reamer. The graft was secured to the medial patella. It was passed deep to the capsule but superficial to the synovium and placed in the femoral tunnel. The tibial tubercle osteotomy was then fixed medializing at 1 cm and fixing with two 4.5 mm lag screws. The graft was taken through several cycles of motion with the knee at approximately 40 degrees of flexion. The graft was fixed on the femoral side with a 7 x 23 mm Bio-interference screw. The knee was then taken through full range of motion. No excessive tension was placed on the graft. We had one quadrant both of medial and lateral translation. The lateral lengthening was repaired with #1 Vicryl. The medial capsule was repaired with #1 Vicryl. The skin and subcutaneous tissues were closed in multilayer fashion. A sterile dressing was placed. The patient was awoken from anesthesia and taken to PACU in stable condition.
DETAILS OF THE OPERATION: He was brought to the operating theater and general anesthetic was administered followed by an adductor canal block by Dr. Johnson. The surgeon initials were identified in the operative extremity and timeout was performed. The left lower extremity was then prepped and draped in the usual sterile fashion for surgery. We began by making an anterior medial skin incision dissecting sharply through the skin and subcutaneous tissues. The extensor mechanism was identified. The tibial tubercle was isolated and an oblique osteotomy was made with the medial aspect much thinner than the lateral aspect. An anteromedial arthrotomy was performed. We then did a lateral lengthening doing a Z-plasty type cut through the lateral retinaculum. The patella was everted. The chondral defect was identified. Unfortunately, it was un-contained distally which we were aware of preoperatively. The vertical walls were created proximally and on the medial and lateral margins, the damage cartilage was curetted away down to calcified layer. We then isolated the defect on the trochlea. Likewise vertical margins created. The mixed juvenile cartilage was then placed into the defects both in the patella and the trochlea. Fibrin glue was allowed to set up. A chondral glide patch was then sewed over the patellar defect utilizing 6-0 Vicryl sutures to secure to the cartilage borders and then distally 1 mm micro JuggerKnot suture anchor was utilized to secure the patch. Once the glue had hardened, we turned our attention to the medial patellofemoral ligament reconstruction. Two 3-mm anchors were placed in the medial border of the patella. The graft was secured to the medial patella. We isolated the starting point for the femoral tunnel fluoroscopically at the junction of the posterior cortical line and Blumensaat line. Guidepin was then directed out to the lateral femoral cortex, over-reamed with a 7-mm reamer. The graft was secured to the medial patella. It was passed deep to the capsule but superficial to the synovium and placed in the femoral tunnel. The tibial tubercle osteotomy was then fixed medializing at 1 cm and fixing with two 4.5 mm lag screws. The graft was taken through several cycles of motion with the knee at approximately 40 degrees of flexion. The graft was fixed on the femoral side with a 7 x 23 mm Bio-interference screw. The knee was then taken through full range of motion. No excessive tension was placed on the graft. We had one quadrant both of medial and lateral translation. The lateral lengthening was repaired with #1 Vicryl. The medial capsule was repaired with #1 Vicryl. The skin and subcutaneous tissues were closed in multilayer fashion. A sterile dressing was placed. The patient was awoken from anesthesia and taken to PACU in stable condition.