tdesher
Networker
I am so torn between 4 codes for this and getting mixed information. Any help please
POSTOPERATIVE DIAGNOSES:
1. Left knee patella fracture.
2. Left knee patellar dislocation.
3. Left knee medial retinacular tear.
PROCEDURES PERFORMED:
1. Left knee arthroscopy with irrigation, debridement and major synovectomy.
2. Removal of loose body.
3. Open medial patellar retinacular reconstruction.
HARDWARE: Using the Arthrex system one BioComposite Triple Play anchor and one #2 FiberWire.
INDICATIONS FOR SURGERY: The patient is 16 years of age. He had suffered a left knee lateral patellar dislocation which required reduction while wrestling. He had x-rays which showed an obvious loose body within the joint. He had an MRI which showed an apparent loose body in the joint as well as an obvious medial retinacular rupture of the medial aspect of the patella. The meniscal tissues and ACL appeared to be intact. We discussed in detail with the patient and mother the findings and their options, both conservatively and surgical.
Once the patient was fully prepped and draped and time-out had been performed again as stated identifying the patient, the operative site and the surgical procedure with the staff in the room, the preoperative antibiotics were given at the appropriate prior to the procedure. Esmarch was placed from the toes to the thigh. Knee was bent to 90 degrees and the tourniquet was placed to 250 mmHg. Standard anterolateral portal created with an 11-blade knife. Blunt trocar was used to enter into the joint and a diagnostic arthroscopy was performed. The patient had significant hemarthrosis which was evacuated to the cannula and then through a shaver. In addition, meticulous care was taken to protect the articular cartilage surfaces. The ACL was visibly intact. The PCL was visibly intact. The medial and lateral meniscus visibly intact. Articular cartilage surfaces showed some scuffing on the lateral tibial plateau. There was not an apparent fracture along the lateral femoral condyle. However, under direct visualization, there was a fracture along the medial margin of the patella which did not appeared to include any articular cartilage. With meticulous shaving, popliteus recess was evaluated. The medial and lateral gutters were evaluated and with probing, the fragment was felt to be scarred into the retinacular tear which was identified arthroscopically of the superior half of the patella. Once all this was cleaned out, the fragment was loosened with a shaver. All hardware was then removed. An incision was then made running from the superior pole of the patella along the medial margin of the patella down to approximately two-thirds the distance of the patella. Soft tissues were incised. Hemostasis was obtained with electrocautery. General dissection was carried down through the soft tissues and then there was easily identification of the retinacular rupture area. This had initially had been identified with an 18-gauge spinal needle identifying this area directly arthroscopically and this corresponded with the obvious rupture area of the open procedure. Once this was done, the curette was used meticulously curette out the bone along the medial patella as well as remove any further blood clots. The knee was irrigated. The patellar fracture fragment which had been initially loosened arthroscopically was then fully loosened and removed. Again it was noted did not have any articular cartilage and by measurement it was approximately 1.5 cm x 2-3 mm width and it was felt that this did not require repair. In addition, this area would leave a very nice bony bed in the area where the retinaculum had to be repaired back. Once this was done, again all areas were meticulously cleansed.
The 4.0-mm drill bit was used to drill centrally into the open bed area on the patella.
This area was then tapped and then the BioComposite Triple Play anchor was placed and was noted to have very excellent holding power. Simple stitches were then placed superior, central and distal in the area of the right retinacular tear. The distal most torn area was woven with figure-of-eight type stitch and then the central and superior aspect were woven with simple stitches. These were then tied down sequentially and this gave an excellent secure fixation of the retinaculum against the patella. In addition, at this point now, the other patella was pulled centrally on the trochlear groove by palpation and then with checking at this point, the lateral excursion of the left patella now equal the lateral excursion of the right patella to pressure. Also of note, prior to making the open arthrotomy, the shaver was used meticulously irrigate out and perform a synovectomy and removed the blood clotting and scar tissue from the suprapatellar pouch, the medial and lateral gutters and anteriorly in the joint. Once the retinaculum was repaired, the area was again cleansed and dried. The soft tissue above this layer was then closed with #2 FiberWire running stitch. The subcutaneous tissue closed with 2-0 Vicryl simple interrupted suture and then the skin with 4-0 Monocryl running subcuticular stitch. The portal sites were closed with 3-0 nylon simple interrupted suture. All wounds were thoroughly cleansed and dry. Benzoin and Steri-Strips were applied over the arthrotomy. Sterile Xeroform placed over the portals. Sterile 4x4's, sterile ABD, and sterile Webril, and a sterile Ace was applied. Tourniquet let down for a total tourniquet time about 81 minutes at 250 mmHg pressure. Estimated blood loss was less than 50 mL. IV fluid 900 mL. Complications were none. Counts were correct. The patient was then placed in a brace locked in extension. All drips were then taken down. Dorsalis pedis pulse was intact. Brisk capillary refill on all toes. The patient was then awakened without difficulty, transferred onto his bed, and taken from the operating room to the recovery room in a stable condition.
POSTOPERATIVE DIAGNOSES:
1. Left knee patella fracture.
2. Left knee patellar dislocation.
3. Left knee medial retinacular tear.
PROCEDURES PERFORMED:
1. Left knee arthroscopy with irrigation, debridement and major synovectomy.
2. Removal of loose body.
3. Open medial patellar retinacular reconstruction.
HARDWARE: Using the Arthrex system one BioComposite Triple Play anchor and one #2 FiberWire.
INDICATIONS FOR SURGERY: The patient is 16 years of age. He had suffered a left knee lateral patellar dislocation which required reduction while wrestling. He had x-rays which showed an obvious loose body within the joint. He had an MRI which showed an apparent loose body in the joint as well as an obvious medial retinacular rupture of the medial aspect of the patella. The meniscal tissues and ACL appeared to be intact. We discussed in detail with the patient and mother the findings and their options, both conservatively and surgical.
Once the patient was fully prepped and draped and time-out had been performed again as stated identifying the patient, the operative site and the surgical procedure with the staff in the room, the preoperative antibiotics were given at the appropriate prior to the procedure. Esmarch was placed from the toes to the thigh. Knee was bent to 90 degrees and the tourniquet was placed to 250 mmHg. Standard anterolateral portal created with an 11-blade knife. Blunt trocar was used to enter into the joint and a diagnostic arthroscopy was performed. The patient had significant hemarthrosis which was evacuated to the cannula and then through a shaver. In addition, meticulous care was taken to protect the articular cartilage surfaces. The ACL was visibly intact. The PCL was visibly intact. The medial and lateral meniscus visibly intact. Articular cartilage surfaces showed some scuffing on the lateral tibial plateau. There was not an apparent fracture along the lateral femoral condyle. However, under direct visualization, there was a fracture along the medial margin of the patella which did not appeared to include any articular cartilage. With meticulous shaving, popliteus recess was evaluated. The medial and lateral gutters were evaluated and with probing, the fragment was felt to be scarred into the retinacular tear which was identified arthroscopically of the superior half of the patella. Once all this was cleaned out, the fragment was loosened with a shaver. All hardware was then removed. An incision was then made running from the superior pole of the patella along the medial margin of the patella down to approximately two-thirds the distance of the patella. Soft tissues were incised. Hemostasis was obtained with electrocautery. General dissection was carried down through the soft tissues and then there was easily identification of the retinacular rupture area. This had initially had been identified with an 18-gauge spinal needle identifying this area directly arthroscopically and this corresponded with the obvious rupture area of the open procedure. Once this was done, the curette was used meticulously curette out the bone along the medial patella as well as remove any further blood clots. The knee was irrigated. The patellar fracture fragment which had been initially loosened arthroscopically was then fully loosened and removed. Again it was noted did not have any articular cartilage and by measurement it was approximately 1.5 cm x 2-3 mm width and it was felt that this did not require repair. In addition, this area would leave a very nice bony bed in the area where the retinaculum had to be repaired back. Once this was done, again all areas were meticulously cleansed.
The 4.0-mm drill bit was used to drill centrally into the open bed area on the patella.
This area was then tapped and then the BioComposite Triple Play anchor was placed and was noted to have very excellent holding power. Simple stitches were then placed superior, central and distal in the area of the right retinacular tear. The distal most torn area was woven with figure-of-eight type stitch and then the central and superior aspect were woven with simple stitches. These were then tied down sequentially and this gave an excellent secure fixation of the retinaculum against the patella. In addition, at this point now, the other patella was pulled centrally on the trochlear groove by palpation and then with checking at this point, the lateral excursion of the left patella now equal the lateral excursion of the right patella to pressure. Also of note, prior to making the open arthrotomy, the shaver was used meticulously irrigate out and perform a synovectomy and removed the blood clotting and scar tissue from the suprapatellar pouch, the medial and lateral gutters and anteriorly in the joint. Once the retinaculum was repaired, the area was again cleansed and dried. The soft tissue above this layer was then closed with #2 FiberWire running stitch. The subcutaneous tissue closed with 2-0 Vicryl simple interrupted suture and then the skin with 4-0 Monocryl running subcuticular stitch. The portal sites were closed with 3-0 nylon simple interrupted suture. All wounds were thoroughly cleansed and dry. Benzoin and Steri-Strips were applied over the arthrotomy. Sterile Xeroform placed over the portals. Sterile 4x4's, sterile ABD, and sterile Webril, and a sterile Ace was applied. Tourniquet let down for a total tourniquet time about 81 minutes at 250 mmHg pressure. Estimated blood loss was less than 50 mL. IV fluid 900 mL. Complications were none. Counts were correct. The patient was then placed in a brace locked in extension. All drips were then taken down. Dorsalis pedis pulse was intact. Brisk capillary refill on all toes. The patient was then awakened without difficulty, transferred onto his bed, and taken from the operating room to the recovery room in a stable condition.