Hi list,
Need some input here, I don't agree with 29879 as he doesn't mention microfracture/bleeding bone, which is why I selected 29877. Other opinions, please.
M,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Left knee synovitis, patellofemoral chondromalacia.
POSTOPERATIVE DIAGNOSIS:
Left knee synovitis, patellofemoral chondromalacia.
PROCEDURE:
Arthroscopic examination with synovectomy of the suprapatellar
area in the medial joint with abrasion chondroplasty of the
patellofemoral joint.
SURGEON:
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 45-year-old female with history of injury to her
left knee at work several months ago. She had pain and
soreness of the knee. She had evaluation that showed possible
stress fracture and injury to the knee joint. She had
continued trouble despite conservative care. She noted to
have some possible chondromalacia changes of the
patellofemoral joint. The options of continued conservative
care versus surgery were discussed with her at length. She
understood and agreed to proceed with arthroscopic examination
treatment of her left knee.
PROCEDURE IN DETAIL:
After taking informed consent, the patient was brought to the
operating room, placed on operating room table in supine
position. After administration of general LMA anesthesia, the
tourniquet was placed on left proximal thigh.
Time-out was then performed. The patient was identified.
Appropriate body site had been marked. She received
appropriate antibiotics. Next, the skin was prepped and 0.5%
lidocaine with epinephrine was placed into the knee joint.
The left leg was then sterilely prepped and draped in a
routine manner. An anterolateral arthroscopy portal was then
made and arthroscopic examination was performed. Examination
of the joint was admitted for the suprapatellar area. There
was a band of tissue noted just above the patella, tensed down
to the anterior distal femur. The patella showed 2 areas of
grade II chondromalacia, 1 in the midline, 1 on the medial
edge. The medial gutter showed inflamed synovium and a small
plica. The medial joint with some synovial impingement noted.
The medial meniscus was examined and no obvious tears were
noted. The articular surface was normal in appearance. An
anteromedial portal was made with aid of spinal needle. The
medial meniscus was probed throughout its length and no
obvious tears were noted. The articular surface was normal in
appearance. The notch area was examined. The ACL, PCL, and
ligamentum mucosum was intact. The lateral compartment was
examined. There was some slight fraying of the insight edge
of meniscus, but no obvious tears were noted. This was probed
throughout its length and again noted to be stable. The
articular surfaces were normal in appearance. The lateral
gutter was normal in appearance. The frayed edge of meniscus
was debrided with a punch and shaver back to stable tissue.
Next, the cement was performed. The medial joint gutter and
suprapatellar area. The abrasion chondroplasty was done on
the patellofemoral area, debriding back to stable cartilage.
The remainder of the exam was otherwise unremarkable. Next,
the arthroscopy equipment was removed from the knee joint.
Steri-Strips used to approximate the skin edges of the
portals. The portals were infiltrated with 1% lidocaine. A
sterile dressing was applied and she was transferred to the
recovery in stable condition.
Need some input here, I don't agree with 29879 as he doesn't mention microfracture/bleeding bone, which is why I selected 29877. Other opinions, please.
M,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Left knee synovitis, patellofemoral chondromalacia.
POSTOPERATIVE DIAGNOSIS:
Left knee synovitis, patellofemoral chondromalacia.
PROCEDURE:
Arthroscopic examination with synovectomy of the suprapatellar
area in the medial joint with abrasion chondroplasty of the
patellofemoral joint.
SURGEON:
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 45-year-old female with history of injury to her
left knee at work several months ago. She had pain and
soreness of the knee. She had evaluation that showed possible
stress fracture and injury to the knee joint. She had
continued trouble despite conservative care. She noted to
have some possible chondromalacia changes of the
patellofemoral joint. The options of continued conservative
care versus surgery were discussed with her at length. She
understood and agreed to proceed with arthroscopic examination
treatment of her left knee.
PROCEDURE IN DETAIL:
After taking informed consent, the patient was brought to the
operating room, placed on operating room table in supine
position. After administration of general LMA anesthesia, the
tourniquet was placed on left proximal thigh.
Time-out was then performed. The patient was identified.
Appropriate body site had been marked. She received
appropriate antibiotics. Next, the skin was prepped and 0.5%
lidocaine with epinephrine was placed into the knee joint.
The left leg was then sterilely prepped and draped in a
routine manner. An anterolateral arthroscopy portal was then
made and arthroscopic examination was performed. Examination
of the joint was admitted for the suprapatellar area. There
was a band of tissue noted just above the patella, tensed down
to the anterior distal femur. The patella showed 2 areas of
grade II chondromalacia, 1 in the midline, 1 on the medial
edge. The medial gutter showed inflamed synovium and a small
plica. The medial joint with some synovial impingement noted.
The medial meniscus was examined and no obvious tears were
noted. The articular surface was normal in appearance. An
anteromedial portal was made with aid of spinal needle. The
medial meniscus was probed throughout its length and no
obvious tears were noted. The articular surface was normal in
appearance. The notch area was examined. The ACL, PCL, and
ligamentum mucosum was intact. The lateral compartment was
examined. There was some slight fraying of the insight edge
of meniscus, but no obvious tears were noted. This was probed
throughout its length and again noted to be stable. The
articular surfaces were normal in appearance. The lateral
gutter was normal in appearance. The frayed edge of meniscus
was debrided with a punch and shaver back to stable tissue.
Next, the cement was performed. The medial joint gutter and
suprapatellar area. The abrasion chondroplasty was done on
the patellofemoral area, debriding back to stable cartilage.
The remainder of the exam was otherwise unremarkable. Next,
the arthroscopy equipment was removed from the knee joint.
Steri-Strips used to approximate the skin edges of the
portals. The portals were infiltrated with 1% lidocaine. A
sterile dressing was applied and she was transferred to the
recovery in stable condition.