Provider reconstructed 2 flexor tendons in the right small finger. Can I bill 26502 x 2?
POSTOPERATIVE DIAGNOSIS: Right little finger A2 and A4 pulley ruptures.
PROCEDURE:
1. Right little finger A2 and A4 pulley reconstruction.
2. Harvest of extensor retinaculum for pulley reconstruction.
3. Harvest of palmaris longus tendon for pulley reconstruction.
SURGERY IN DETAIL: The patient was identified in the holding area and the right hand was identified as surgical site. He was then seen by Anesthesia, taken to the operating room, and placed supine on the table and underwent general anesthesia per Anesthesia Department. All bony prominences were well padded. A well-padded arm tourniquet was placed. The right upper extremity was prepared and draped in sterile fashion. Surgical pause was undertaken confirming the site and procedure as well as administration of perioperative antibiotics. Arm was exsanguinated and tourniquet inflated to 250 mmHg. Total time was approximately 84 minutes.
The little finger was approached through a Bruner incision extending from the metacarpophalangeal joint distally to the distal interphalangeal joint. Brunner flaps were elevated. The radial and ulnar neurovascular bundles are identified and protected. The pulley sheath was identified and found with complete deficiency of the A2 pulley as well as attenuation of the A4 pulley. Attention was first directed towards the A2 pulley, which was opened up anteriorly revealing complete bowstringing of the profundus and superficialis tendons as well as significant scarring beneath the tendons between the tendons and bone. This scar tissue was sharply excised, protecting neurovascular bundles and tendons. This allowed for placement of the bowstrung tendons down into their correct location. The A1 pulley proximally was preserved. With this confirmed, attention was first directed towards the extensor retinaculum as this had a synovial lining and felt to be the best tissue for reconstruction of the pulley, which was harvested from a dorsal approach.
A transverse incision from the ulnar styloid to the radial styloid was first created followed by blunt dissection, identification, and preservation of the dorsal ulnar cutaneous nerve branches and radial sensory nerve branches. While protecting underlying extensor tendons, an 8 to 10 mm wide sliver of the distal extensor retinaculum was harvested from ulnar to radial. This tissue was then whipstitched and placed around the pulley system at the level of the A2 pulleys deep to the extensor tendon passed with a curved clamp. This only allowed for 2 passes and it was felt to be not sufficient for this pulley. However, this was preserved on the back table in a moist sponge for possible A4 pulley reconstruction.
Attention was directed towards the palmaris longus. This was harvested through a transverse incision at the volar wrist flexion crease. This was clearly identified and released distally. A whipstitch was placed and a tendon stripper was then applied harvesting a nice long portion of the palmaris longus. This palmaris longus was then passed deep to the extensor retinaculum, 4 passes were achieved with this reconstructing the pulley system from the level of the proximal interphalangeal joint to the metacarpophalangeal joint. This was sewn into place to the remaining remnants of the pulley system distally. The finger was flexed and allowed to reconstruct the A2 pulley with the tendon in the correct orientation and sewn proximally into the proximal ulnar portion of the remaining remnant. Multiple simple sutures were then placed between the tendons to secure these in position, protecting the underlying flexor tendons. With this in place, the tendons were pulled proximally and found to have good excursion of the interphalangeal joint without recurrence of the bowstringing proximally, but this did reveal attenuation of the A4 pulley.
The A4 pulley reconstruction was then undertaken as well. This was opened up revealing significant scar tissue beneath the profundus tendon between the tendon and bone. This was removed allowing the tendon to be placed into a proximal position and close to the bone. The previously harvested extensor retinaculum was then used to reconstruct this pulley system superficial to the dorsal extensor tendons and around the pulley system anteriorly. This was sewn into place to the remnants proximally and distally and then multiple sutures to the adjacent reconstructed pulley system tensioning it nicely. Proximal excursion of the tendons resulted in excellent excursion of the flexor tendons with correction of the previous bowstringing with good full digital extension and flexion achieved intraoperatively. The wounds were thoroughly and copiously irrigated out. Digital block placed to the small finger with 10 cc of 1% lidocaine plain. Local anesthetic infiltrated over the dorsal and volar incisions with lidocaine with epi, followed by skin closure with multiple nylon sutures and a bulky sterile dressing and protective splint in the intrinsic plus position.
POSTOPERATIVE DIAGNOSIS: Right little finger A2 and A4 pulley ruptures.
PROCEDURE:
1. Right little finger A2 and A4 pulley reconstruction.
2. Harvest of extensor retinaculum for pulley reconstruction.
3. Harvest of palmaris longus tendon for pulley reconstruction.
SURGERY IN DETAIL: The patient was identified in the holding area and the right hand was identified as surgical site. He was then seen by Anesthesia, taken to the operating room, and placed supine on the table and underwent general anesthesia per Anesthesia Department. All bony prominences were well padded. A well-padded arm tourniquet was placed. The right upper extremity was prepared and draped in sterile fashion. Surgical pause was undertaken confirming the site and procedure as well as administration of perioperative antibiotics. Arm was exsanguinated and tourniquet inflated to 250 mmHg. Total time was approximately 84 minutes.
The little finger was approached through a Bruner incision extending from the metacarpophalangeal joint distally to the distal interphalangeal joint. Brunner flaps were elevated. The radial and ulnar neurovascular bundles are identified and protected. The pulley sheath was identified and found with complete deficiency of the A2 pulley as well as attenuation of the A4 pulley. Attention was first directed towards the A2 pulley, which was opened up anteriorly revealing complete bowstringing of the profundus and superficialis tendons as well as significant scarring beneath the tendons between the tendons and bone. This scar tissue was sharply excised, protecting neurovascular bundles and tendons. This allowed for placement of the bowstrung tendons down into their correct location. The A1 pulley proximally was preserved. With this confirmed, attention was first directed towards the extensor retinaculum as this had a synovial lining and felt to be the best tissue for reconstruction of the pulley, which was harvested from a dorsal approach.
A transverse incision from the ulnar styloid to the radial styloid was first created followed by blunt dissection, identification, and preservation of the dorsal ulnar cutaneous nerve branches and radial sensory nerve branches. While protecting underlying extensor tendons, an 8 to 10 mm wide sliver of the distal extensor retinaculum was harvested from ulnar to radial. This tissue was then whipstitched and placed around the pulley system at the level of the A2 pulleys deep to the extensor tendon passed with a curved clamp. This only allowed for 2 passes and it was felt to be not sufficient for this pulley. However, this was preserved on the back table in a moist sponge for possible A4 pulley reconstruction.
Attention was directed towards the palmaris longus. This was harvested through a transverse incision at the volar wrist flexion crease. This was clearly identified and released distally. A whipstitch was placed and a tendon stripper was then applied harvesting a nice long portion of the palmaris longus. This palmaris longus was then passed deep to the extensor retinaculum, 4 passes were achieved with this reconstructing the pulley system from the level of the proximal interphalangeal joint to the metacarpophalangeal joint. This was sewn into place to the remaining remnants of the pulley system distally. The finger was flexed and allowed to reconstruct the A2 pulley with the tendon in the correct orientation and sewn proximally into the proximal ulnar portion of the remaining remnant. Multiple simple sutures were then placed between the tendons to secure these in position, protecting the underlying flexor tendons. With this in place, the tendons were pulled proximally and found to have good excursion of the interphalangeal joint without recurrence of the bowstringing proximally, but this did reveal attenuation of the A4 pulley.
The A4 pulley reconstruction was then undertaken as well. This was opened up revealing significant scar tissue beneath the profundus tendon between the tendon and bone. This was removed allowing the tendon to be placed into a proximal position and close to the bone. The previously harvested extensor retinaculum was then used to reconstruct this pulley system superficial to the dorsal extensor tendons and around the pulley system anteriorly. This was sewn into place to the remnants proximally and distally and then multiple sutures to the adjacent reconstructed pulley system tensioning it nicely. Proximal excursion of the tendons resulted in excellent excursion of the flexor tendons with correction of the previous bowstringing with good full digital extension and flexion achieved intraoperatively. The wounds were thoroughly and copiously irrigated out. Digital block placed to the small finger with 10 cc of 1% lidocaine plain. Local anesthetic infiltrated over the dorsal and volar incisions with lidocaine with epi, followed by skin closure with multiple nylon sutures and a bulky sterile dressing and protective splint in the intrinsic plus position.