samyjm13
Guru
Hi all, I am having a trouble coding this procedure for a nonunuion patella repair. I was thiking 27524. Provider wants to code 27599-22, 20680. Can someone help
PROCEDURE PERFORMED
Right patellar nonunion repair with tibial bone graft and OP-1 and removal of previous patella button.
A midline incision is made over her knee through the
previous incision. There was significant amount of scar tissue. We first isolated the fascial layer which was once again difficult to drill over previous scar tissue. We then isolated the area at the proximal tibia bone on the medial side below the component using C-arm fluoroscopy. We made a small trapdoor window with 1/4 inch osteotome and then we obtained abone graft from this. Once we had an adequate amount of bone graft, approximately 8-10 mL we then placed Gelfoam and then we closed the trapdoor window after irrigating. We closed the fascia over this and the periosteum with 2-0 Vicryl.
Next we opened up the joint in a medial parapatellar approach. The previous Mersilene tape suture was seen and this was removed. Her knee was quite tight. We had to do a significant amount of mobilization around the patellar fragments and they also had a significant amount of fibrous scar tissue over the proximal and distal patella piece. We removed all the fibrous scar tissue as well as mobilized the patella tendon by making a lateral release and it freed it up proximally and distally on the anterior and posterior aspect of the quadriceps tendon as well as on the patellar tendon itself. We then used a
curette to remove the fibrous tissue from the end of the distal pole. There was not a significant amount of bone left. Next we addressed the proximal pole and unfortunately there was absolutely no bone but just cement at the fracture interface.
This is likely why the previous suture fixation failed. We began removing the cement carefully. The patellar button appeared to be slightly loose and we removed more cement to get to bone so the nonunion would heal. This did come off.
We removed all cement. We then used curettes as well as a bur to get this down to as much bleeding bone as possible. Once again it did not appear to be the healthiest bone due to the three previous surgeries. It was quite difficult to approximate these two ends. We did have to also cut the soft tissue of the medial and lateral aspect and then reapproximate this later. We were able to hold this with Kocher clamps and then a Weber clamp as we approximated as much as possible and then we placed 1.6 mm K-wires across this. The original plan was to place 4.0 cannulated screws, however the fragment of bone distally also had a vertical fracture and we did not feel like there was enough bone to hold the fracture. We then placed two 1.6 mm K-wires and once we were
happy of the position these on C-arm fluoroscopy we then passed an 18-gauge wire around the K-wires in a tension band type fashion, a tensioning band, making two twists. We cut the excess wire proximally and bent this. We did leave it long in the quadriceps and patella soft tissue as we could not bend it posteriorly due to it would scratch the femoral component. We left the K-wires long so that the 18-gauge wire would not flip over them. This gave us reasonable fixation before the final tightening was done. With the tension band we placed the bone graft and the OP-1 in the fracture site. This had been
mixed together. We then tensioned this down and we cut off the excess wire at approximately four twists. We tamped these down into bone and then we were able to irrigate. Before we did the OP-1 we irrigated the wound out. We dropped the
tourniquet because it was just over 2 hours and 5 minutes. Electrocautery was used to control bleeding. The #2 Quill suture was used to close the medial parapatellar approach. We did use a running 2-0 Vicryl Plus suture over the bone graft from the previous excess soft tissue in the prepatellar bursa.
Thanks
PROCEDURE PERFORMED
Right patellar nonunion repair with tibial bone graft and OP-1 and removal of previous patella button.
A midline incision is made over her knee through the
previous incision. There was significant amount of scar tissue. We first isolated the fascial layer which was once again difficult to drill over previous scar tissue. We then isolated the area at the proximal tibia bone on the medial side below the component using C-arm fluoroscopy. We made a small trapdoor window with 1/4 inch osteotome and then we obtained abone graft from this. Once we had an adequate amount of bone graft, approximately 8-10 mL we then placed Gelfoam and then we closed the trapdoor window after irrigating. We closed the fascia over this and the periosteum with 2-0 Vicryl.
Next we opened up the joint in a medial parapatellar approach. The previous Mersilene tape suture was seen and this was removed. Her knee was quite tight. We had to do a significant amount of mobilization around the patellar fragments and they also had a significant amount of fibrous scar tissue over the proximal and distal patella piece. We removed all the fibrous scar tissue as well as mobilized the patella tendon by making a lateral release and it freed it up proximally and distally on the anterior and posterior aspect of the quadriceps tendon as well as on the patellar tendon itself. We then used a
curette to remove the fibrous tissue from the end of the distal pole. There was not a significant amount of bone left. Next we addressed the proximal pole and unfortunately there was absolutely no bone but just cement at the fracture interface.
This is likely why the previous suture fixation failed. We began removing the cement carefully. The patellar button appeared to be slightly loose and we removed more cement to get to bone so the nonunion would heal. This did come off.
We removed all cement. We then used curettes as well as a bur to get this down to as much bleeding bone as possible. Once again it did not appear to be the healthiest bone due to the three previous surgeries. It was quite difficult to approximate these two ends. We did have to also cut the soft tissue of the medial and lateral aspect and then reapproximate this later. We were able to hold this with Kocher clamps and then a Weber clamp as we approximated as much as possible and then we placed 1.6 mm K-wires across this. The original plan was to place 4.0 cannulated screws, however the fragment of bone distally also had a vertical fracture and we did not feel like there was enough bone to hold the fracture. We then placed two 1.6 mm K-wires and once we were
happy of the position these on C-arm fluoroscopy we then passed an 18-gauge wire around the K-wires in a tension band type fashion, a tensioning band, making two twists. We cut the excess wire proximally and bent this. We did leave it long in the quadriceps and patella soft tissue as we could not bend it posteriorly due to it would scratch the femoral component. We left the K-wires long so that the 18-gauge wire would not flip over them. This gave us reasonable fixation before the final tightening was done. With the tension band we placed the bone graft and the OP-1 in the fracture site. This had been
mixed together. We then tensioned this down and we cut off the excess wire at approximately four twists. We tamped these down into bone and then we were able to irrigate. Before we did the OP-1 we irrigated the wound out. We dropped the
tourniquet because it was just over 2 hours and 5 minutes. Electrocautery was used to control bleeding. The #2 Quill suture was used to close the medial parapatellar approach. We did use a running 2-0 Vicryl Plus suture over the bone graft from the previous excess soft tissue in the prepatellar bursa.
Thanks