One of my surgeons wants to bill for the tendon transfer (26480) with 25448 because he says the tendon transfer performed was not for the arthroplasty but done for the MP joint hyperextension and says it would not be included in 25448 for that reason. He says it is not the same thing as performing a tendon transfer using FCR tendon or APL to FCR etc. What he did was the EPB to APL which he says was done for a different reason. I would love other's thoughts and opinions on this. Agree or disagree? The op report is below. Thank you.
Pre-operative Diagnosis: Left thumb carpometacarpal arthritis
Post-operative Diagnosis: same as preop diagnosis
Description of procedure:
Patient was brought to the operating room and positioned supine with a hand table. Patient underwent sedation by department of anesthesia after regional block was performed by anesthesiologist. 2 g of Ancef was administered for prophylactic antibiotic. The left upper extremity was prepped and draped in sterile fashion. Tourniquet placed high on the arm. Limb was exsanguinated with an Esmarch and tourniquet raised.
A longitudinal incision was made along the dorsum of the thumb CMC joint. Branches of the radial sensory nerve were identified and protected throughout the procedure. The tendon sheath of the EPB and APL were opened and first dorsal compartment completely released. The tendons were then retracted. The radial artery was identified and protected throughout the procedure. The branches of the radial artery were cauterized. A longitudinal incision through the capsule and periosteum over the trapezium extending to the base of the metacarpal and proximal to the scaphoid trapezium joint was made using a needle tip Bovie. The APL insertion was identified. A threaded Steinmann pin was inserted into the trapezium to use as a joystick. X-ray was taken at this time and correctly identified the trapezium with a Steinmann pin in place. The trapezium was mobilized by carefully elevating periosteum circumferentially around the bone with use of a 15 blade, Beaver blade, needle tip Bovie, and McGlamory elevator. Care was taken to protect underlying structures including volar flexor tendons and neurovascular structures. The trapezium was able to be resected en bloc. The FCR was found to be intact underneath. The STT joint was evaluated and it was noted to not have significant arthritis. The wound was then copiously irrigated. Suture tape, 1.3 mm Arthrex, was used to perform the suture suspensioplasty. Suture tape was brought up through the APL from deep to superficial right at the enthesis. It was placed back down through the APL at the end pieces again. The suture was then passed through the FCR at its insertion. The steps were repeated once again. The suture tape was then tied onto the base of the metacarpal with slight traction applied to the metacarpal. Excellent stability was achieved which was then confirmed using intraoperative fluoroscopy.
Next the EPB tendon transfer was performed. The EPB tendon was sewn to the periosteum of the first metacarpal distally using Vicryl suture. It was then released distal to the attachment to decrease the hyperextension moment at the MP joint and improved the abduction moment on the metacarpal. The wound was once again copiously irrigated.
The CMC joint capsule was copiously irrigated and then packed with thrombin Gelfoam. The capsule was then closed with 3-0 Vicryl suture. The wound was then closed with 3-0 Monocryl deep dermal sutures and followed by 4-0 Monocryl suture followed by Dermabond and Steri-Strips. Dry sterile dressing and a thumb spica splint were applied in the operating room.
The procedure was without complications and the patient was in satisfactory condition upon leaving the operating room.
Pre-operative Diagnosis: Left thumb carpometacarpal arthritis
Post-operative Diagnosis: same as preop diagnosis
- Left thumb CMC suspension arthroplasty
- Left EPB to APL tendon transfer
Description of procedure:
Patient was brought to the operating room and positioned supine with a hand table. Patient underwent sedation by department of anesthesia after regional block was performed by anesthesiologist. 2 g of Ancef was administered for prophylactic antibiotic. The left upper extremity was prepped and draped in sterile fashion. Tourniquet placed high on the arm. Limb was exsanguinated with an Esmarch and tourniquet raised.
A longitudinal incision was made along the dorsum of the thumb CMC joint. Branches of the radial sensory nerve were identified and protected throughout the procedure. The tendon sheath of the EPB and APL were opened and first dorsal compartment completely released. The tendons were then retracted. The radial artery was identified and protected throughout the procedure. The branches of the radial artery were cauterized. A longitudinal incision through the capsule and periosteum over the trapezium extending to the base of the metacarpal and proximal to the scaphoid trapezium joint was made using a needle tip Bovie. The APL insertion was identified. A threaded Steinmann pin was inserted into the trapezium to use as a joystick. X-ray was taken at this time and correctly identified the trapezium with a Steinmann pin in place. The trapezium was mobilized by carefully elevating periosteum circumferentially around the bone with use of a 15 blade, Beaver blade, needle tip Bovie, and McGlamory elevator. Care was taken to protect underlying structures including volar flexor tendons and neurovascular structures. The trapezium was able to be resected en bloc. The FCR was found to be intact underneath. The STT joint was evaluated and it was noted to not have significant arthritis. The wound was then copiously irrigated. Suture tape, 1.3 mm Arthrex, was used to perform the suture suspensioplasty. Suture tape was brought up through the APL from deep to superficial right at the enthesis. It was placed back down through the APL at the end pieces again. The suture was then passed through the FCR at its insertion. The steps were repeated once again. The suture tape was then tied onto the base of the metacarpal with slight traction applied to the metacarpal. Excellent stability was achieved which was then confirmed using intraoperative fluoroscopy.
Next the EPB tendon transfer was performed. The EPB tendon was sewn to the periosteum of the first metacarpal distally using Vicryl suture. It was then released distal to the attachment to decrease the hyperextension moment at the MP joint and improved the abduction moment on the metacarpal. The wound was once again copiously irrigated.
The CMC joint capsule was copiously irrigated and then packed with thrombin Gelfoam. The capsule was then closed with 3-0 Vicryl suture. The wound was then closed with 3-0 Monocryl deep dermal sutures and followed by 4-0 Monocryl suture followed by Dermabond and Steri-Strips. Dry sterile dressing and a thumb spica splint were applied in the operating room.
The procedure was without complications and the patient was in satisfactory condition upon leaving the operating room.