HELP!!! Need help coding the following op report please
Post Operative Diagnosis: Coccyx sacral frature with painful nonunion
Procedure Performed: Sacral Osteotomy and coccygeal resection
Procedure:
The patient was placed prone. Using a paramedian incision the distal sacrum was exposed and the previous coccyx fracture identified. There was a posterior step-off of the distal sacral fracture. This was in a curvilinear fashion. The distal sacrum was resected subperiosteally with key elevators and bovie cautery technique. The sacral osteotomy was performed leveling the seating surface with a high speed bur. The anterior periosteum was cauterized. The wound irrigated with normal saline. Hemostasis achieved. Wound closed in layers. Dry sterile dressing appiled.
Post Operative Diagnosis: Coccyx sacral frature with painful nonunion
Procedure Performed: Sacral Osteotomy and coccygeal resection
Procedure:
The patient was placed prone. Using a paramedian incision the distal sacrum was exposed and the previous coccyx fracture identified. There was a posterior step-off of the distal sacral fracture. This was in a curvilinear fashion. The distal sacrum was resected subperiosteally with key elevators and bovie cautery technique. The sacral osteotomy was performed leveling the seating surface with a high speed bur. The anterior periosteum was cauterized. The wound irrigated with normal saline. Hemostasis achieved. Wound closed in layers. Dry sterile dressing appiled.