Can someone help me code this note, I am studying to take the podiatry certification and trying to code some sample reports. Any help would be great, thanks in advance.
1. First metatarsal osteotomy with insertion of first
metatarsophalangeal total implant, right foot.
2. Injection of bone graft into bone cyst proximal phalanx
of right hallux.
3. Fifth metatarsal osteotomy with internal fixation, right
foot.
4. Implantation of bone graft, fifth metatarsal right
foot.
TECHNIQUE: The patient was brought into the operating room and placed on the operative table in the supine position. The right foot was marked in the preoperative area. Pneumatic ankle tourniquet was applied to the patient's right ankle. A time-out was performed. At this time, approximately 20 mL of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was injected in the patient's right foot in a Mayo nerve block fashion, as well as a reverse Mayo nerve block fashion. The
right foot was then prepped, scrubbed, and draped in typical aseptic technique. An Esmarch was applied and pneumatic ankle tourniquet was inflated to 250 mmHg.
First metatarsal osteotomy with insertion of first metatarsophalangeal joint total implant, right foot: Attention was then directed to the dorsomedial aspect of the
first metatarsophalangeal joint region where a linear skin incision was made across the dorsomedial aspect approximately 6 cm in length. Incision was then deepened through subcutaneous tissue using sharp and blunt dissection techniques. Care was taken to identify and retract all neurovascular structures. All bleeders were cauterized as necessary. Upon deep dissection of the subcutaneous tissue, the capsule of the first metatarsophalangeal joint was identified. A capsulotomy was subsequently created in a linear type fashion. The head of the first metatarsal was then freed of all soft tissue attachments both dorsally, plantarly, medially, and laterally with visible sesamoid apparatus noted. Soft tissue structures were also resected from the base of the proximal phalanx of the right hallux in
order to expose the base of the phalanx. Upon deep dissection, there appeared to be significant degenerative articular changes to the head of the first metatarsal, as
well as a bone cyst in the base of the proximal phalanx approximately 2 cm in diameter and 1 cm in depth. Next, utilizing Integra bone reamers, the head of the first
metatarsal was subsequently re-reamed to remove all articular cartilage of the head of the first metatarsal and to allow for proper placement of the head component of the total joint replacement. Upon resection of all denuded cartilage, a trial implant was subsequently placed on the first metatarsal head. Intraoperative x-rays were subsequently taken in order to adequately assess the appropriate size of the first metatarsal spacer in both AP and lateral views. The first metatarsophalangeal joint was then put through range of motion to ensure proper placement. Injection of bone graft into bone cyst proximal phalanx of the right hallux: Attention was then directed to the base of the proximal phalanx of the right hallux where a bone cyst was previously identified. Calcium phosphate injectable bone graft was then subsequently created according to manufacturer's techniques and injected into bones into the base of the proximal phalanx and allowed to harden for approximately 20 minutes in order to adequately drill to place the phalangeal component of the total first metatarsophalangeal joint implant. Upon hardening of the injectable bone graft, the base of the proximal phalanx of the right hallux was subsequently resected utilizing reamers in order to adequately resect all articular cartilage and ensure proper placement of the distal component of the first metatarsophalangeal joint total implant. Upon complete resection of the cartilage, a trial spacer of the base of the proximal phalanx total implant was placed into the proximal phalanx. The positioning and appropriate size of the implant was subsequently assessed utilizing intraoperative fluoroscopy in both AP and lateral views. Upon completion of assessment, the first metatarsophalangeal joint was put through range of motion with both the temporary implant in both the head of the first metatarsal and base of proximal phalanx. The first metatarsophalangeal joint appeared to be in normal range of motion with no clicking, catching, or cracking noted. The incision was then irrigated with copious amounts of sterile saline. The total joint implant was subsequently
placed and once again assessed utilizing intraoperative fluoroscopy in order to assess the AP and lateral views and proper position of the joint. The capsular structures were then closed and reapproximated utilizing 3-0 Vicryl in simple interrupted suture technique. The subcutaneous tissues were closed and reapproximated using 3-0 Monocryl in a running suture type technique. The skin edges were then closed and reapproximated utilizing 4-0 Monocryl in a subcuticular running suture technique. Steri-Strips were applied. The pneumatic ankle tourniquet then was subsequently deflated at 2 hours.Fifth metatarsal osteotomy with internal fixation, right foot: Attention was then directed to the dorsolateral aspect of the fifth metatarsophalangeal region where a skin incision was made approximately 3 cm in length. The incision was deepened through subcutaneous tissue using sharp and blunt dissection techniques. Care was taken to identify and retract all neurovascular structures. All bleeders were cauterized as necessary. Upon dissection of the subcutaneous tissue, capsular structure was identified. Linear capsulotomy was subsequently performed over the fifth metatarsophalangeal joint. The head of the fifth metatarsal and base of the proximal phalanx were then subsequently freed of all soft tissue attachments dorsally, plantarly, medially, and aterally. Upon a complete capsulotomy, a V-type chevron osteotomy was created in the neck and shaft of the fifth metatarsal with a long plantar arm noted in both AP and lateral views. Upon completion of the osteotomy, the capital fragment of the fifth metatarsal head was then translated medially in order to reduce the IM angle of the fourth and fifth metatarsals. A temporary fixation was utilized, utilizing a 0.045 K-wire. The appropriate position of the fifth metatarsal and reduction of the IM angle was then subsequently assessed in both AP and lateral views. Next, the osteotomy was then fixated with two 2.0 screws approximately 18 mm and 20 mm in length. The position of the osteotomy was then identified and assessed in both AP and lateral views and noted to be
adequate with reduction of the IM angle. A subsequent bone cyst was found in the fifth metatarsal osteotomy and matrix bone HydroSet putty 3 mm in total were
then subsequently manufactured according to manufacturer's instructions and placed on the osteotomy site of the fifth metatarsal. Once again, the osteotomy was assessed utilizing intraoperative fluoroscopy in both AP and lateral views. The incision was then irrigated with copious amounts of sterile saline. The capsular structures were then closed and reapproximated utilizing 3-0 Monocryl in simple interrupted suture technique. The skin edges were closed and reapproximated with 4-0 Monocryl in subcuticular running suture technique. Steri-Strips were applied and the incision was dressed with 4 x 4s, Webril, and Ace. The patient tolerated the procedure well, had no complications, and was transferred to the PACU with vital signs stable and vascular status intact to the right foot.
1. First metatarsal osteotomy with insertion of first
metatarsophalangeal total implant, right foot.
2. Injection of bone graft into bone cyst proximal phalanx
of right hallux.
3. Fifth metatarsal osteotomy with internal fixation, right
foot.
4. Implantation of bone graft, fifth metatarsal right
foot.
TECHNIQUE: The patient was brought into the operating room and placed on the operative table in the supine position. The right foot was marked in the preoperative area. Pneumatic ankle tourniquet was applied to the patient's right ankle. A time-out was performed. At this time, approximately 20 mL of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was injected in the patient's right foot in a Mayo nerve block fashion, as well as a reverse Mayo nerve block fashion. The
right foot was then prepped, scrubbed, and draped in typical aseptic technique. An Esmarch was applied and pneumatic ankle tourniquet was inflated to 250 mmHg.
First metatarsal osteotomy with insertion of first metatarsophalangeal joint total implant, right foot: Attention was then directed to the dorsomedial aspect of the
first metatarsophalangeal joint region where a linear skin incision was made across the dorsomedial aspect approximately 6 cm in length. Incision was then deepened through subcutaneous tissue using sharp and blunt dissection techniques. Care was taken to identify and retract all neurovascular structures. All bleeders were cauterized as necessary. Upon deep dissection of the subcutaneous tissue, the capsule of the first metatarsophalangeal joint was identified. A capsulotomy was subsequently created in a linear type fashion. The head of the first metatarsal was then freed of all soft tissue attachments both dorsally, plantarly, medially, and laterally with visible sesamoid apparatus noted. Soft tissue structures were also resected from the base of the proximal phalanx of the right hallux in
order to expose the base of the phalanx. Upon deep dissection, there appeared to be significant degenerative articular changes to the head of the first metatarsal, as
well as a bone cyst in the base of the proximal phalanx approximately 2 cm in diameter and 1 cm in depth. Next, utilizing Integra bone reamers, the head of the first
metatarsal was subsequently re-reamed to remove all articular cartilage of the head of the first metatarsal and to allow for proper placement of the head component of the total joint replacement. Upon resection of all denuded cartilage, a trial implant was subsequently placed on the first metatarsal head. Intraoperative x-rays were subsequently taken in order to adequately assess the appropriate size of the first metatarsal spacer in both AP and lateral views. The first metatarsophalangeal joint was then put through range of motion to ensure proper placement. Injection of bone graft into bone cyst proximal phalanx of the right hallux: Attention was then directed to the base of the proximal phalanx of the right hallux where a bone cyst was previously identified. Calcium phosphate injectable bone graft was then subsequently created according to manufacturer's techniques and injected into bones into the base of the proximal phalanx and allowed to harden for approximately 20 minutes in order to adequately drill to place the phalangeal component of the total first metatarsophalangeal joint implant. Upon hardening of the injectable bone graft, the base of the proximal phalanx of the right hallux was subsequently resected utilizing reamers in order to adequately resect all articular cartilage and ensure proper placement of the distal component of the first metatarsophalangeal joint total implant. Upon complete resection of the cartilage, a trial spacer of the base of the proximal phalanx total implant was placed into the proximal phalanx. The positioning and appropriate size of the implant was subsequently assessed utilizing intraoperative fluoroscopy in both AP and lateral views. Upon completion of assessment, the first metatarsophalangeal joint was put through range of motion with both the temporary implant in both the head of the first metatarsal and base of proximal phalanx. The first metatarsophalangeal joint appeared to be in normal range of motion with no clicking, catching, or cracking noted. The incision was then irrigated with copious amounts of sterile saline. The total joint implant was subsequently
placed and once again assessed utilizing intraoperative fluoroscopy in order to assess the AP and lateral views and proper position of the joint. The capsular structures were then closed and reapproximated utilizing 3-0 Vicryl in simple interrupted suture technique. The subcutaneous tissues were closed and reapproximated using 3-0 Monocryl in a running suture type technique. The skin edges were then closed and reapproximated utilizing 4-0 Monocryl in a subcuticular running suture technique. Steri-Strips were applied. The pneumatic ankle tourniquet then was subsequently deflated at 2 hours.Fifth metatarsal osteotomy with internal fixation, right foot: Attention was then directed to the dorsolateral aspect of the fifth metatarsophalangeal region where a skin incision was made approximately 3 cm in length. The incision was deepened through subcutaneous tissue using sharp and blunt dissection techniques. Care was taken to identify and retract all neurovascular structures. All bleeders were cauterized as necessary. Upon dissection of the subcutaneous tissue, capsular structure was identified. Linear capsulotomy was subsequently performed over the fifth metatarsophalangeal joint. The head of the fifth metatarsal and base of the proximal phalanx were then subsequently freed of all soft tissue attachments dorsally, plantarly, medially, and aterally. Upon a complete capsulotomy, a V-type chevron osteotomy was created in the neck and shaft of the fifth metatarsal with a long plantar arm noted in both AP and lateral views. Upon completion of the osteotomy, the capital fragment of the fifth metatarsal head was then translated medially in order to reduce the IM angle of the fourth and fifth metatarsals. A temporary fixation was utilized, utilizing a 0.045 K-wire. The appropriate position of the fifth metatarsal and reduction of the IM angle was then subsequently assessed in both AP and lateral views. Next, the osteotomy was then fixated with two 2.0 screws approximately 18 mm and 20 mm in length. The position of the osteotomy was then identified and assessed in both AP and lateral views and noted to be
adequate with reduction of the IM angle. A subsequent bone cyst was found in the fifth metatarsal osteotomy and matrix bone HydroSet putty 3 mm in total were
then subsequently manufactured according to manufacturer's instructions and placed on the osteotomy site of the fifth metatarsal. Once again, the osteotomy was assessed utilizing intraoperative fluoroscopy in both AP and lateral views. The incision was then irrigated with copious amounts of sterile saline. The capsular structures were then closed and reapproximated utilizing 3-0 Monocryl in simple interrupted suture technique. The skin edges were closed and reapproximated with 4-0 Monocryl in subcuticular running suture technique. Steri-Strips were applied and the incision was dressed with 4 x 4s, Webril, and Ace. The patient tolerated the procedure well, had no complications, and was transferred to the PACU with vital signs stable and vascular status intact to the right foot.