AT2728
Expert
I'm at a complete loss on this one, from the correct diagnosis code to the correct procedure code. I would greatly appreciate any advice on this operative report!
Daignosis: Left ankle syndesmotic injury (maisonneuve injury)
Procedure performed: Closed Reduction, internal fixation left ankle
Operative Report: Tourniquet was placed proximally to the left lower extremity. It was then prepped and draped in a sterile manner and a time out was taken. At this point in time a stab incision was made on the medial and lateral condyle. A reduction clamp was used to reduce the syndesmosis. At this point in time a separate stab incision was made along the fibula. A guide wire was placed on the lateral aspect of the fibula and went through both cortices to the fibula and the tibia. A reamer was used to over ream the guide wire. The guide wire reamer was removed . An Arthrex tightrope was placed through the hole to the contralateral cortex of the tibia. The Arthrex button was then pulled tight along the tibia. The button on the fibula was then pulled down, holding the syndesmosis reduced. Once this was done the excess suture was then cut. The clamp was removed. X-rays were taken as well as a stress x-ray which showed no widening of the tibia. #3-0 Nylon suture was used to close the incision. 30 cc's 0.25% Marcaine plain was injected into the incision site. A sterile, soft, dressing with Xeroform, 4X4, web roll and short leg posterior splint was placed. The patient went to recovery in stable condition.
Daignosis: Left ankle syndesmotic injury (maisonneuve injury)
Procedure performed: Closed Reduction, internal fixation left ankle
Operative Report: Tourniquet was placed proximally to the left lower extremity. It was then prepped and draped in a sterile manner and a time out was taken. At this point in time a stab incision was made on the medial and lateral condyle. A reduction clamp was used to reduce the syndesmosis. At this point in time a separate stab incision was made along the fibula. A guide wire was placed on the lateral aspect of the fibula and went through both cortices to the fibula and the tibia. A reamer was used to over ream the guide wire. The guide wire reamer was removed . An Arthrex tightrope was placed through the hole to the contralateral cortex of the tibia. The Arthrex button was then pulled tight along the tibia. The button on the fibula was then pulled down, holding the syndesmosis reduced. Once this was done the excess suture was then cut. The clamp was removed. X-rays were taken as well as a stress x-ray which showed no widening of the tibia. #3-0 Nylon suture was used to close the incision. 30 cc's 0.25% Marcaine plain was injected into the incision site. A sterile, soft, dressing with Xeroform, 4X4, web roll and short leg posterior splint was placed. The patient went to recovery in stable condition.