sxcoder05
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Need help with the following op note. Need CPT Code: confused:
PREOPERATIVE DIAGNOSES: Broken syndesmosis screw, left ankle
status post open reduction and internal fixation with
syndesmosis widening.
POSTOPERATIVE DIAGNOSES: Broken syndesmosis screw, left ankle
status post open reduction and internal fixation with
syndesmosis widening.
PROCEDURES: Revision open reduction and internal fixation left
ankle with insertion of two additional syndesmosis screws for
reduction of syndesmosis widening.
ANESTHESIA: MAC with left lower extremity block for pain
management and subsequent local anesthesia
Excised single broken screw and another short
cortical screw from the left ankle.
OPERATION & FINDINGS: While in the supine position, the patient
was placed under MAC and the left lower extremity ankle block
accomplished. A pneumatic tourniquet was applied high on the
patient's left upper thigh and the left lower extremity prepped
and draped free in the usual sterile orthopedic fashion. After
exsanguination of the left lower extremity, the pneumatic
tourniquet was elevated to 300 mmHg. A subcutaneous tissue
incisional area laterally over the lateral aspect of the ankle
was infiltrated with 0.25% Marcaine plain. A longitudinal
incision was made through the previous surgical scar inline with
the broken screw and the screw above, which I intended to
replace with a long syndesmosis screw. The incision was carrieddown sharply through subcutaneous tissue and hemostasis achieved
using electrocautery. Sharp dissection was carried out and
elevator used to expose the two screws that we needed to
replace. The broken screw was removed without difficulty as was
the shorter screw above. A drill was used to drill a hole
through four cortices through those two plate holes. A 50-mm
screw was placed in the top hole and a 55-mm 4.0 fully-threaded
cancellous screw below. Each screw was tightened against one
another so we achieved a good compression and AP and lateral Carm
x-ray confirmed anatomic reduction of the ankle mortis. The
patient could dorsiflex her ankle to neutral without difficulty.
Once both screws were equally tightened, the wound was irrigated
with sterile saline and closure achieved using interrupted 0
Vicryl for fascial closure and 2-0 Vicryl for subcutaneous
closure. Skin was closed with a running 4-0 nylon. The
incision was dressed with Owens silk, 4x4 gauze, over which a
sterile Sof-Rol was applied and an Ace bandage. The patient's
short-leg walking boot was applied. The pneumatic tourniquet
was let down with total tourniquet time being 30 minutes. Upon
completion of procedure, the toes of the left foot appeared pink
and warm.
PREOPERATIVE DIAGNOSES: Broken syndesmosis screw, left ankle
status post open reduction and internal fixation with
syndesmosis widening.
POSTOPERATIVE DIAGNOSES: Broken syndesmosis screw, left ankle
status post open reduction and internal fixation with
syndesmosis widening.
PROCEDURES: Revision open reduction and internal fixation left
ankle with insertion of two additional syndesmosis screws for
reduction of syndesmosis widening.
ANESTHESIA: MAC with left lower extremity block for pain
management and subsequent local anesthesia
Excised single broken screw and another short
cortical screw from the left ankle.
OPERATION & FINDINGS: While in the supine position, the patient
was placed under MAC and the left lower extremity ankle block
accomplished. A pneumatic tourniquet was applied high on the
patient's left upper thigh and the left lower extremity prepped
and draped free in the usual sterile orthopedic fashion. After
exsanguination of the left lower extremity, the pneumatic
tourniquet was elevated to 300 mmHg. A subcutaneous tissue
incisional area laterally over the lateral aspect of the ankle
was infiltrated with 0.25% Marcaine plain. A longitudinal
incision was made through the previous surgical scar inline with
the broken screw and the screw above, which I intended to
replace with a long syndesmosis screw. The incision was carrieddown sharply through subcutaneous tissue and hemostasis achieved
using electrocautery. Sharp dissection was carried out and
elevator used to expose the two screws that we needed to
replace. The broken screw was removed without difficulty as was
the shorter screw above. A drill was used to drill a hole
through four cortices through those two plate holes. A 50-mm
screw was placed in the top hole and a 55-mm 4.0 fully-threaded
cancellous screw below. Each screw was tightened against one
another so we achieved a good compression and AP and lateral Carm
x-ray confirmed anatomic reduction of the ankle mortis. The
patient could dorsiflex her ankle to neutral without difficulty.
Once both screws were equally tightened, the wound was irrigated
with sterile saline and closure achieved using interrupted 0
Vicryl for fascial closure and 2-0 Vicryl for subcutaneous
closure. Skin was closed with a running 4-0 nylon. The
incision was dressed with Owens silk, 4x4 gauze, over which a
sterile Sof-Rol was applied and an Ace bandage. The patient's
short-leg walking boot was applied. The pneumatic tourniquet
was let down with total tourniquet time being 30 minutes. Upon
completion of procedure, the toes of the left foot appeared pink
and warm.