peporter
Guru
Hello Coders, my surgeon did a knee surgery that combines a lot of open and Arthroscopic procedures. I wasn't sure what parts would be bundled and if I can bill the arthroscopic when so much was done open. I did bill the 29888 as the primary procedure along with 27405, 29876 and 27380. I thought the ligament repairs would be bundled with the ACL repair. It is quite a detailed op note and if someone has the time to review it, I would really appreciate some pointers on where to start on this big an op report. If I missed something that was billable, please let me know so I can appeal it. Thanks, Paula
PROCEDURES
1. Left knee arthroscopy with anterior cruciate ligament (ACL)
reconstruction with allograft.
2. Left knee open reconstruction fibular collateral ligament with
allograft.
3. Left knee open reconstruction of popliteal femoral ligament with
allograft.
4. Left knee open repair popliteus tendon rupture, femoral insertion.
5. Left knee open repair, posterolateral capsule.
6. Left knee arthroscopy with chondroplasty of the patellofemoral
joint.
7. Left knee arthroscopy with synovectomy.
OPERATIVE PROCEDURE
I did talk to the patient prior about use of allograft versus autograft
for his reconstruction, and the patient did choose allograft for the
reconstruction. I did choose 2 posterior tibial tendons and placed #2
FiberWires in a whipstitch manner at both ends and then measured the
tendons. The one tendon was a 9.5 mm in diameter tendon looped upon
itself. The other tendon was a 9-mm tendon looped upon itself. I
initially did the exposure to the posterolateral corner. I took an
Esmarch bandage and exsanguinated the extremity. We inflated the
tourniquet to 350 mmHg.
A lateral incision was made staying on the posterior aspect of the
iliotibial band proximally, and the incision was turned distally to
around the posterior aspect of the proximal fibular head. The skin was
incised with a scalpel. Blunt retractor was placed in the wound. All
hemostasis obtained throughout the case with Bovie. Blunt dissection
was taken with tenotomies and scissors down to the deep fascia. The
patient had significant scarring from the injury. It was difficult to
identify the structures. The iliotibial band could be identified. The
biceps femoris was scarred in. The head of the fibula was scarred in
too. I did dissect around posteriorly and did find the peroneal nerve.
This was tagged and kept out of harm's way throughout the case. The
biceps femoris was split anteriorly over the fibular head, and the
fibular head was dissected out subperiosteally. Retractors were placed
around the fibular head. Once this could be fully seen, the fibular
collateral ligament and the popliteal fibular ligament were obviously
torn and scarred in. The patient's knee was very grossly unstable.
Once the fibular head was exposed, retractors were placed around this,
and a guide pin was placed from anterior to posterior in the fibular
head. A 5-mm reamer was taken with care to protecting the peroneal
nerve posteriorly. Once this was completed, I split the iliotibial band
over the lateral epicondyle proximally. Blunt dissection was taken down
to the lateral epicondyle of the femur. The popliteus tendon could be
seen and was avulsed off the femur. This was tagged with a #2
FiberWire. This would be later repaired.
I exposed the lateral epicondyle, and at this point with my exposure, I
went to arthroscopy. I made 2 standard incisions inferomedial and
inferolateral on the knee through the skin with a scalpel. Blunt trocar
and cannula were placed in the inferolateral portal, and suprapatellar
pouch was entered. Upon initial inspection, a significant amount of
synovitis and scarring. A shaver was placed in the inferomedial portal,
and a synovectomy was completed of the suprapatellar pouch, medial and
lateral compartments. This allowed better visualization.
Patellofemoral joint could be seen. There was some articular cartilage
injury to the patellofemoral joint. There was some mild chondromalacia.
A chondroplasty was completed on this with a shaver to a stable border
when probed. There was just some mild flaking cartilage, but this was
not significant. The medial and lateral gutters were inspected, and
there were no loose bodies. Femoral notch was inspected, and the ACL
stump could be seen and this was almost completely avulsed. PCL was
intact. The medial compartment was entered, and the articular cartilage
and meniscus were without injury.
Lateral compartment was entered. The articular cartilage and meniscus
were without injury. The popliteus tendon could be seen and was
avulsed. There was a significant amount of hemorrhagic tissue and
scarring from prior injury. I then removed the ACL stump with a shaver.
I cleared the lateral wall of the femur with thermal wand by ArthroCare.
I used a bur and completed a notchplasty as well. I placed the tibial
guide by Arthrex through the inferomedial portal on the footprint of the
ACL. This was placed anterior to the posterior cruciate ligament and
beside the anterior horn of the lateral meniscus. The pin was placed up
to the skin, and a small incision was made, and blunt dissection was
taken down to the bone medially. This was done medially to the tibial
I used a bur and completed a notchplasty as well. I placed the tibial
guide by Arthrex through the inferomedial portal on the footprint of the
ACL. This was placed anterior to the posterior cruciate ligament and
beside the anterior horn of the lateral meniscus. The pin was placed up
to the skin, and a small incision was made, and blunt dissection was
taken down to the bone medially. This was done medially to the tibial
tubercle. A pin was placed up through the tibia into the footprint.
The guide was removed. This had excellent position.
I did again size the graft to 9.5 mm. This was the posterior tibial
tendon allograft. I reamed over the wire up into the tibia 9.5 mm in
diameter. Care was taken to protect the PCL while doing this. Once
this was done, the pin and reamer were removed. The shaver was placed
back into the joint, and the debris was excised. This had excellent
position in front of the PCL and beside the anterior horn of the lateral
meniscus. The over-the-top guide was placed to the tibial tunnel on the
posterior wall of the femur. This was placed in a slightly more
horizontal position at approximately the 1:30 to 2 o'clock position.
The guide pin was placed up through the femur. A 9.5 mm reamer was
taken to a depth of 40 mm over the guide pin into the femur. Care was
taken to protect the PCL with probe. This was removed, and the debris
was removed with a shaver. This had excellent position of the tunnel.
I then took the U-shaped guide for the bioabsorbable cross pin by
Arthrex up through the tunnels with the arm exiting laterally. The
guide pin was placed up to the bone. I placed the guide pin through the
femur from an inferolateral position to a superior medial position.
This was taken out through the other side. I then reamed the lateral
cortex over the guidewire with a reamer. I then placed a nitinol wire
in the eyelet laterally and took this through the knee using the guide
pin from lateral to medial. I put clamps on the nitinol wire. I then
pulled the guide down to the tibial tunnel, pulling down the nitinol
wire. The looped the posterior tibial tendon allograft onto the wire
and pulled this up into the tunnels. This had excellent position. The
wire slid nicely back-and-forth. The bioabsorbable cross pin was placed
through the nitinol wire laterally through the graft, tapping this into
place. This engaged very nicely. I pulled the graft, and this was very
secure.
Before fixing the graft on the tibial side, I went to the lateral side.
I placed a guide pin on the anterior portion of the lateral femoral
epicondyle. I placed a graft around this pin and took the knee through
range of motion. This appeared to be the isometric point. I then
reamed a 9-mm reamer at a depth of 25 mm into the femur over the pin. I
took the 9-mm graft and then passed it through the fibula using a Hewson
suture passer. The limbs were measured so that approximately 2 mm of
graft would fit in the tunnel. I did have to place two more #2
FiberWire whip stitches at both ends of the graft, cutting the excess
graft proximally. The nitinol wire was loaded with 1 of the sutures
through 1 of the limbs of the graft and then taken through the femur
from lateral to medial. I then made a separate hole, exiting lateral to
medial for the other #2 FiberWire for the other end of the graft so I
could tie this over the bony bridge medially. The graft fit nicely into
the femoral hole proximally. The graft was taken under the biceps
femoris and iliotibial band before passed into the femoral tunnel. This
was placed over the capsule as well. I tensioned this, pulling the
suture with the knee in 30 degrees of flexion, internally rotating and a
medial for the other #2 FiberWire for the other end of the graft so I
could tie this over the bony bridge medially. The graft fit nicely into
the femoral hole proximally. The graft was taken under the biceps
femoris and iliotibial band before passed into the femoral tunnel. This
was placed over the capsule as well. I tensioned this, pulling the
suture with the knee in 30 degrees of flexion, internally rotating and a
valgus stress. This was very tight.
I cycled the knee several times for equal tension of the ACL graft. I
placed the knee at 20 degrees of flexion and placed a nitinol wire over
the graft in the tibial tunnel for the ACL. I placed a 10 mm
biocomposite screw by Arthrex over the graft into the tunnel. This had
excellent position and was very tight. This seated very nicely. I
excised the remaining graft distally. I then secured the graft
laterally, reconstructing the fibular collateral ligament and
popliteofibular ligament. I made a small incision medially and then
took the sutures through the same incision and then tied these down over
a bony bridge. I then took a nitinol wire and placed this over the
graft through the distal femoral hole where the graft was inserting. I
placed a 9 mm bioabsorbable tenodesis screw by Arthrex over the graft in
the hole. This had excellent purchase and was very tight. Nitinol wire
was removed. I then repaired down the popliteus tendon to the graft as
well and the capsule on the distal femur. This was done with a #2
FiberWire. This had excellent repair. I then repaired the posterior lateral
capsule with a #1 Vicryl. I then repaired the split in the iliotibial band and
deep tissue with a running #2 FiberWire. I augmented this with a #1 Vicryl. I
closed the interval through the biceps femoris over the proximal fibula with #1
Vicryl as well.
Once that was complete, I placed the scope back into the knee. The ACL
was very tight in extension, slightly loosened in flexion. This had
excellent position with no impingement on the notch. The lateral
compartment was entered, and the popliteus tendon could be seen in its
normal anatomic position. The lateral compartment was much tighter than
it was prior. I did gently stress the knee in varus and 0 degrees and
30 degrees of flexion. This was very stable. The patient had a
negative anterior Lachman's. I irrigated out the wounds with normal
saline. On the lateral side, I closed the deep tissue with 0 Vicryl and
then placed 2-0 Vicryl to approximate the skin. Nylon was placed in a
horizontal mattress manner on the skin. Portals were closed with
suture. Medial incision was closed with 2-0 Vicryl, then nylon. Local
anesthetic was injected around the knee as well as into the joint. At
that point, sterile dressing was applied as well as a cold therapy pack
placed over the dressing, wrapped with an Ace wrap from the foot to the
thigh. The patient's knee was placed in an immobilizer. The tourniquet
was released.
The patient was then awoken from anesthesia without complication and
transferred to the postanesthesia care unit in stable condition.
PROCEDURES
1. Left knee arthroscopy with anterior cruciate ligament (ACL)
reconstruction with allograft.
2. Left knee open reconstruction fibular collateral ligament with
allograft.
3. Left knee open reconstruction of popliteal femoral ligament with
allograft.
4. Left knee open repair popliteus tendon rupture, femoral insertion.
5. Left knee open repair, posterolateral capsule.
6. Left knee arthroscopy with chondroplasty of the patellofemoral
joint.
7. Left knee arthroscopy with synovectomy.
OPERATIVE PROCEDURE
I did talk to the patient prior about use of allograft versus autograft
for his reconstruction, and the patient did choose allograft for the
reconstruction. I did choose 2 posterior tibial tendons and placed #2
FiberWires in a whipstitch manner at both ends and then measured the
tendons. The one tendon was a 9.5 mm in diameter tendon looped upon
itself. The other tendon was a 9-mm tendon looped upon itself. I
initially did the exposure to the posterolateral corner. I took an
Esmarch bandage and exsanguinated the extremity. We inflated the
tourniquet to 350 mmHg.
A lateral incision was made staying on the posterior aspect of the
iliotibial band proximally, and the incision was turned distally to
around the posterior aspect of the proximal fibular head. The skin was
incised with a scalpel. Blunt retractor was placed in the wound. All
hemostasis obtained throughout the case with Bovie. Blunt dissection
was taken with tenotomies and scissors down to the deep fascia. The
patient had significant scarring from the injury. It was difficult to
identify the structures. The iliotibial band could be identified. The
biceps femoris was scarred in. The head of the fibula was scarred in
too. I did dissect around posteriorly and did find the peroneal nerve.
This was tagged and kept out of harm's way throughout the case. The
biceps femoris was split anteriorly over the fibular head, and the
fibular head was dissected out subperiosteally. Retractors were placed
around the fibular head. Once this could be fully seen, the fibular
collateral ligament and the popliteal fibular ligament were obviously
torn and scarred in. The patient's knee was very grossly unstable.
Once the fibular head was exposed, retractors were placed around this,
and a guide pin was placed from anterior to posterior in the fibular
head. A 5-mm reamer was taken with care to protecting the peroneal
nerve posteriorly. Once this was completed, I split the iliotibial band
over the lateral epicondyle proximally. Blunt dissection was taken down
to the lateral epicondyle of the femur. The popliteus tendon could be
seen and was avulsed off the femur. This was tagged with a #2
FiberWire. This would be later repaired.
I exposed the lateral epicondyle, and at this point with my exposure, I
went to arthroscopy. I made 2 standard incisions inferomedial and
inferolateral on the knee through the skin with a scalpel. Blunt trocar
and cannula were placed in the inferolateral portal, and suprapatellar
pouch was entered. Upon initial inspection, a significant amount of
synovitis and scarring. A shaver was placed in the inferomedial portal,
and a synovectomy was completed of the suprapatellar pouch, medial and
lateral compartments. This allowed better visualization.
Patellofemoral joint could be seen. There was some articular cartilage
injury to the patellofemoral joint. There was some mild chondromalacia.
A chondroplasty was completed on this with a shaver to a stable border
when probed. There was just some mild flaking cartilage, but this was
not significant. The medial and lateral gutters were inspected, and
there were no loose bodies. Femoral notch was inspected, and the ACL
stump could be seen and this was almost completely avulsed. PCL was
intact. The medial compartment was entered, and the articular cartilage
and meniscus were without injury.
Lateral compartment was entered. The articular cartilage and meniscus
were without injury. The popliteus tendon could be seen and was
avulsed. There was a significant amount of hemorrhagic tissue and
scarring from prior injury. I then removed the ACL stump with a shaver.
I cleared the lateral wall of the femur with thermal wand by ArthroCare.
I used a bur and completed a notchplasty as well. I placed the tibial
guide by Arthrex through the inferomedial portal on the footprint of the
ACL. This was placed anterior to the posterior cruciate ligament and
beside the anterior horn of the lateral meniscus. The pin was placed up
to the skin, and a small incision was made, and blunt dissection was
taken down to the bone medially. This was done medially to the tibial
I used a bur and completed a notchplasty as well. I placed the tibial
guide by Arthrex through the inferomedial portal on the footprint of the
ACL. This was placed anterior to the posterior cruciate ligament and
beside the anterior horn of the lateral meniscus. The pin was placed up
to the skin, and a small incision was made, and blunt dissection was
taken down to the bone medially. This was done medially to the tibial
tubercle. A pin was placed up through the tibia into the footprint.
The guide was removed. This had excellent position.
I did again size the graft to 9.5 mm. This was the posterior tibial
tendon allograft. I reamed over the wire up into the tibia 9.5 mm in
diameter. Care was taken to protect the PCL while doing this. Once
this was done, the pin and reamer were removed. The shaver was placed
back into the joint, and the debris was excised. This had excellent
position in front of the PCL and beside the anterior horn of the lateral
meniscus. The over-the-top guide was placed to the tibial tunnel on the
posterior wall of the femur. This was placed in a slightly more
horizontal position at approximately the 1:30 to 2 o'clock position.
The guide pin was placed up through the femur. A 9.5 mm reamer was
taken to a depth of 40 mm over the guide pin into the femur. Care was
taken to protect the PCL with probe. This was removed, and the debris
was removed with a shaver. This had excellent position of the tunnel.
I then took the U-shaped guide for the bioabsorbable cross pin by
Arthrex up through the tunnels with the arm exiting laterally. The
guide pin was placed up to the bone. I placed the guide pin through the
femur from an inferolateral position to a superior medial position.
This was taken out through the other side. I then reamed the lateral
cortex over the guidewire with a reamer. I then placed a nitinol wire
in the eyelet laterally and took this through the knee using the guide
pin from lateral to medial. I put clamps on the nitinol wire. I then
pulled the guide down to the tibial tunnel, pulling down the nitinol
wire. The looped the posterior tibial tendon allograft onto the wire
and pulled this up into the tunnels. This had excellent position. The
wire slid nicely back-and-forth. The bioabsorbable cross pin was placed
through the nitinol wire laterally through the graft, tapping this into
place. This engaged very nicely. I pulled the graft, and this was very
secure.
Before fixing the graft on the tibial side, I went to the lateral side.
I placed a guide pin on the anterior portion of the lateral femoral
epicondyle. I placed a graft around this pin and took the knee through
range of motion. This appeared to be the isometric point. I then
reamed a 9-mm reamer at a depth of 25 mm into the femur over the pin. I
took the 9-mm graft and then passed it through the fibula using a Hewson
suture passer. The limbs were measured so that approximately 2 mm of
graft would fit in the tunnel. I did have to place two more #2
FiberWire whip stitches at both ends of the graft, cutting the excess
graft proximally. The nitinol wire was loaded with 1 of the sutures
through 1 of the limbs of the graft and then taken through the femur
from lateral to medial. I then made a separate hole, exiting lateral to
medial for the other #2 FiberWire for the other end of the graft so I
could tie this over the bony bridge medially. The graft fit nicely into
the femoral hole proximally. The graft was taken under the biceps
femoris and iliotibial band before passed into the femoral tunnel. This
was placed over the capsule as well. I tensioned this, pulling the
suture with the knee in 30 degrees of flexion, internally rotating and a
medial for the other #2 FiberWire for the other end of the graft so I
could tie this over the bony bridge medially. The graft fit nicely into
the femoral hole proximally. The graft was taken under the biceps
femoris and iliotibial band before passed into the femoral tunnel. This
was placed over the capsule as well. I tensioned this, pulling the
suture with the knee in 30 degrees of flexion, internally rotating and a
valgus stress. This was very tight.
I cycled the knee several times for equal tension of the ACL graft. I
placed the knee at 20 degrees of flexion and placed a nitinol wire over
the graft in the tibial tunnel for the ACL. I placed a 10 mm
biocomposite screw by Arthrex over the graft into the tunnel. This had
excellent position and was very tight. This seated very nicely. I
excised the remaining graft distally. I then secured the graft
laterally, reconstructing the fibular collateral ligament and
popliteofibular ligament. I made a small incision medially and then
took the sutures through the same incision and then tied these down over
a bony bridge. I then took a nitinol wire and placed this over the
graft through the distal femoral hole where the graft was inserting. I
placed a 9 mm bioabsorbable tenodesis screw by Arthrex over the graft in
the hole. This had excellent purchase and was very tight. Nitinol wire
was removed. I then repaired down the popliteus tendon to the graft as
well and the capsule on the distal femur. This was done with a #2
FiberWire. This had excellent repair. I then repaired the posterior lateral
capsule with a #1 Vicryl. I then repaired the split in the iliotibial band and
deep tissue with a running #2 FiberWire. I augmented this with a #1 Vicryl. I
closed the interval through the biceps femoris over the proximal fibula with #1
Vicryl as well.
Once that was complete, I placed the scope back into the knee. The ACL
was very tight in extension, slightly loosened in flexion. This had
excellent position with no impingement on the notch. The lateral
compartment was entered, and the popliteus tendon could be seen in its
normal anatomic position. The lateral compartment was much tighter than
it was prior. I did gently stress the knee in varus and 0 degrees and
30 degrees of flexion. This was very stable. The patient had a
negative anterior Lachman's. I irrigated out the wounds with normal
saline. On the lateral side, I closed the deep tissue with 0 Vicryl and
then placed 2-0 Vicryl to approximate the skin. Nylon was placed in a
horizontal mattress manner on the skin. Portals were closed with
suture. Medial incision was closed with 2-0 Vicryl, then nylon. Local
anesthetic was injected around the knee as well as into the joint. At
that point, sterile dressing was applied as well as a cold therapy pack
placed over the dressing, wrapped with an Ace wrap from the foot to the
thigh. The patient's knee was placed in an immobilizer. The tourniquet
was released.
The patient was then awoken from anesthesia without complication and
transferred to the postanesthesia care unit in stable condition.
