jdibble
True Blue
Can anyone help with what code(s) they would use for the following OP note:
PREOPERATIVE DIAGNOSIS: Fracture of the distal left tibia with disruption of the ankle joint.
POSTOPERATIVE DIAGNOSIS: Fracture of the distal left tibia with disruption of the ankle joint.
ANESTHESIA: General, administered
SURGEON:
PROCEDURE: Open reduction and internal fixation and syndesmotic screw to the left ankle.
PROCEDURE WAS AS FOLLOWS: After the patient was anesthetized, her left lower extremity was prepped and draped in usual sterile fashion. A tourniquet had been applied, but was not elevated until after time-out which verified patient's laterality and the procedures to be done. At this time, the tourniquet was elevated to 350 mmHg and subsequently was released after it had been on for 90 minutes to 120 minutes and left off. At this time, after identifying the medial malleolus and lateral malleolus and evaluating under x-ray control, it became evident that the fracture was not reduced in which she had a shift of the ankle mortise with probable tears medially and laterally. This being the situation, a curved incision was made starting along the medial malleolus and extending it proximally in the straight line just medial to the anterior tibialis tendon. This was taken down subcutaneously looking for the saphenous vein and nerve distally. This was identified and tried to protect throughout the procedure. At this time, the incision was taken down around to the fracture site. With little finessing, it was reducible. There was some comminution which made it little bit more difficult to reduce, but once it was reduced, x-ray showing good alignment, an interfragmentary screw was put anterior to posterior to hold it in position. At this time, an 8-hole locking plate, low profile medial malleolar plate was used. Once it was attached to the tibia and under x-ray control in good alignment, the appropriate screws were done in both locking and nonlocking starting with more distal and then going proximally and back-and-forth until it was pretty well locked in. Of the 8 screws, approximately I believe I put in 5. The total number was not put in as it was not necessary and she had about 5 locking and cancellous distally. Once this was carried out, it became evident that the fibula was very, very loose. This being the situation, a small incision was made laterally through which the fibula was grabbed with a large tenaculum to hold the ankle together. A single screw was placed between the other screws with some degree of difficulty because of some of the screws being put in medially. However, one was able to be put in and it did close up the joint nicely with foot held in dorsiflexion. This being the situation, the wounds were copiously irrigated and closed using 0-Vicryl for deep on the medial side, 2-0 subcutaneously both medially and laterally and a skin gun for the skin. After cleansing the wound, a sterile bulky dressing was applied as was a sugar-tong splint. Anesthesia at this time was reversed. Patient was taken to recovery room having tolerated the procedure well. Estimated blood loss was about 100 cc.
Thanks for the assistance.
PREOPERATIVE DIAGNOSIS: Fracture of the distal left tibia with disruption of the ankle joint.
POSTOPERATIVE DIAGNOSIS: Fracture of the distal left tibia with disruption of the ankle joint.
ANESTHESIA: General, administered
SURGEON:
PROCEDURE: Open reduction and internal fixation and syndesmotic screw to the left ankle.
PROCEDURE WAS AS FOLLOWS: After the patient was anesthetized, her left lower extremity was prepped and draped in usual sterile fashion. A tourniquet had been applied, but was not elevated until after time-out which verified patient's laterality and the procedures to be done. At this time, the tourniquet was elevated to 350 mmHg and subsequently was released after it had been on for 90 minutes to 120 minutes and left off. At this time, after identifying the medial malleolus and lateral malleolus and evaluating under x-ray control, it became evident that the fracture was not reduced in which she had a shift of the ankle mortise with probable tears medially and laterally. This being the situation, a curved incision was made starting along the medial malleolus and extending it proximally in the straight line just medial to the anterior tibialis tendon. This was taken down subcutaneously looking for the saphenous vein and nerve distally. This was identified and tried to protect throughout the procedure. At this time, the incision was taken down around to the fracture site. With little finessing, it was reducible. There was some comminution which made it little bit more difficult to reduce, but once it was reduced, x-ray showing good alignment, an interfragmentary screw was put anterior to posterior to hold it in position. At this time, an 8-hole locking plate, low profile medial malleolar plate was used. Once it was attached to the tibia and under x-ray control in good alignment, the appropriate screws were done in both locking and nonlocking starting with more distal and then going proximally and back-and-forth until it was pretty well locked in. Of the 8 screws, approximately I believe I put in 5. The total number was not put in as it was not necessary and she had about 5 locking and cancellous distally. Once this was carried out, it became evident that the fibula was very, very loose. This being the situation, a small incision was made laterally through which the fibula was grabbed with a large tenaculum to hold the ankle together. A single screw was placed between the other screws with some degree of difficulty because of some of the screws being put in medially. However, one was able to be put in and it did close up the joint nicely with foot held in dorsiflexion. This being the situation, the wounds were copiously irrigated and closed using 0-Vicryl for deep on the medial side, 2-0 subcutaneously both medially and laterally and a skin gun for the skin. After cleansing the wound, a sterile bulky dressing was applied as was a sugar-tong splint. Anesthesia at this time was reversed. Patient was taken to recovery room having tolerated the procedure well. Estimated blood loss was about 100 cc.
Thanks for the assistance.
