I am on the newer side of Ortho coding and my docs tend to do a few of these. I'm not sure how to code this once as there is not a lot of research on how to code these out there. Any help would be greatly appreciated. Please see the op note included.
op note
I began the nerve transfer procedures of the left lower extremity. I identified the sural nerve, tibial nerve, superficial and deep peroneal nerves. The saphenous nerve was not amenable to transfer due to the traumatic condition and length. I then identified 4 motor branches including the motor branch to the medial head gastrocnemius, EDL, Peroneus Longus, and the soleus muscles. The EDL and Peroneus longus motor branches were identified through a separate lateral incision. I performed nerve transfer for the sural nerve to the motor branch medial head gastrocnemius muscle. I performed nerve transfer for the superficial peroneal nerve to the motor branch peroneus longus muscle. I performed nerve transfer of the deep peroneal nerve to the EDL motor branch. I performed nerve transfer for the tibial nerve to the motor branch of the soleus muscle. The nerve repairs were done with loop magnification and 8-0 nylon suture. The wound was irrigated with normal saline. Hemostasis was obtained with bipolar cautery.
I then proceeded with the gastrocnemius flap for the left proximal knee skin loss. I began by making an access incision from the medial amputation wound extending it distally to expose the medial head gastrocnemius muscle. Blunt dissection was made down to the deep fascia. I excised the atrophic skin at the margins of anterior knee wound. I performed debridement of the wound with a combination of scalpel, tenotomy scissors, curette of the skin, subcutaneous tissue, fascia, and bone. The wound was irrigated with 3 L normal saline. Hemostasis was obtained with bipolar cautery. The wound was clean with no purulence or foreign debris.
An incision was then made in the deep fascia exposing the medial head of the gastrocnemius muscle. Perforators were identified and hemostasis was obtained with bipolar cautery. The midline raphae between the medial and lateral heads was identified. I then incised the tendon is portion distally elevating the medial head from the lateral head and the Achilles tendon. Hemostasis was obtained with bipolar cautery. The muscle was then scored on the superficial and deep fascia surfaces to increase the length as well as the width of this muscle flap. I rotated the gastroc flap. I did not find the flap covered the entire wound at the margins which I thought would benefit from additional Integra dermal substitute. I would then complete the split thickness skin grafting after the Integra dermal substitute was fully incorporated.
The inset was then performed. The tendinous portion was sewed to the periosteum with 2-0 PDS suture. The margins of the flaps were sewn with interrupted 3-0 Monocryl suture. A round blake drain was placed. The skin margins adjacent to the flap inferiorly was sewn with 2-0 Nylon sutures. The subcutaneous layer was sewn with interrupted 3-0 Monocryl suture. The skin was sewn with interrupted 4-0 nylon suture. The Integra dermal substitute was soaked in saline. I cut the Integra dermal substitute to fit. The size of the Integra placement was 10 cm x 12 cm. The Integra dermal substitute was sewn to the surface of the wound with interrupted 4-0 Monocryl suture.
I then began work on the left upper extremity for the targeted muscle re-innervation. My portion of the procedure consisted of targeted muscle reinnervation nerve transfers to the left upper extremity.
I proceeded with the targeted muscle reinnervation portion of the procedure. This portion of the procedure was performed without tourniquet. I began to identify the nerve stumps which were tagged with a Prolene suture (median nerve, ulnar nerve, medial antebrachial cutaneous nerve, lateral antebrachial cutaneous nerve, radial nerve). Careful subcutaneous dissection was performed with tenotomy scissors down to the level of the fascia which was incised longitudinally between the biceps short and long heads. Blunt dissection between the 2 heads of the biceps was performed until we identified the musculocutaneous nerve as well as its motor branches. Small bridging vessels were identified and cauterized with bipolar cautery. Proximally, we identified a large motor branch exiting from the musculocutaneous nerve laterally to supply the long head of biceps. We also identified a large motor branch exiting medially to the short head of biceps. We also identified a large motor branch exiting deeper and medial to the brachialis more distally. Each of these branches was stimulated with a nerve stimulator to confirm the innervated muscles. The brachialis muscle had significant crush injury and the motor branch did not stimulate as strongly as the other motor branches. The previously identified and tagged median nerve, ulnar nerve and medial antebrachial cutaneous nerve stumps were dissected out and then brought in through the wound and positioned for nerve transfer. The ulnar nerve and medial antebrachial cutaneous nerve were shuttled underneath the bicep for more direct route. We also dissected out the lateral antebrachial cutaneous nerve (the distal extent of the musculocutaneous nerve). This was also brought back into the volar exposure in preparation for nerve transfer. Each donor nerve stump was cut sharply with a 15 blade or straight iris scissors, exposing healthy bulging fascicles. We also ensured that each donor nerve stump was sufficiently long to prevent tension at the nerve coaptations. Recipient motor nerve branches were cut near their muscle targets with straight microscissors. We then proceeded with nerve transfers under loupe magnification. The first nerve transfers consisted of median nerve and medial antebrachial cutaneous nerve transfer to the musculocutaneous nerve motor branch to the short head of biceps. This was performed using 8-0 nylon sutures to perform an epineural nerve repair of both donor nerves to the recipient short head of biceps motor branch. We then proceeded with nerve transfer of the ulnar nerve and lateral antebrachial cutaneous nerve to the musculocutaneous nerve motor branch to the brachialis, again using 8-0 nylon epineural sutures. This completed the volar targeted muscle reinnervation transfers.
I then dissected out the radial nerve. Careful subcutaneous dissection was performed down to the muscle layer with the fascia incised longitudinally, identifying the plane between the lateral and long head of triceps. We bluntly dissected through this plane, identifying the radial nerve as well as a large branch to the lateral head of triceps. The branch of the long heads of triceps was likely proximal to our exposure. We dissected out the radial nerve stump as well as the posterior brachial cutaneous nerve stump distally and brought it into the posterior exposure between the heads of the triceps for targeted muscle reinnervation nerve transfer. The radial nerve stumps were cut with straight iris scissors to expose bulging fascicles and to ensure sufficient length for a tension-free repair to the recipient motor branch. The motor branch of the lateral head of triceps was cut near the insertion to the muscle, and the radial nerve was then coapted to it using 8-0 nylon interrupted epineural sutures under loupe magnification. This completed the right upper arm nerve transfers after transhumeral amputation. All wounds were copiously irrigated with saline.
op note
I began the nerve transfer procedures of the left lower extremity. I identified the sural nerve, tibial nerve, superficial and deep peroneal nerves. The saphenous nerve was not amenable to transfer due to the traumatic condition and length. I then identified 4 motor branches including the motor branch to the medial head gastrocnemius, EDL, Peroneus Longus, and the soleus muscles. The EDL and Peroneus longus motor branches were identified through a separate lateral incision. I performed nerve transfer for the sural nerve to the motor branch medial head gastrocnemius muscle. I performed nerve transfer for the superficial peroneal nerve to the motor branch peroneus longus muscle. I performed nerve transfer of the deep peroneal nerve to the EDL motor branch. I performed nerve transfer for the tibial nerve to the motor branch of the soleus muscle. The nerve repairs were done with loop magnification and 8-0 nylon suture. The wound was irrigated with normal saline. Hemostasis was obtained with bipolar cautery.
I then proceeded with the gastrocnemius flap for the left proximal knee skin loss. I began by making an access incision from the medial amputation wound extending it distally to expose the medial head gastrocnemius muscle. Blunt dissection was made down to the deep fascia. I excised the atrophic skin at the margins of anterior knee wound. I performed debridement of the wound with a combination of scalpel, tenotomy scissors, curette of the skin, subcutaneous tissue, fascia, and bone. The wound was irrigated with 3 L normal saline. Hemostasis was obtained with bipolar cautery. The wound was clean with no purulence or foreign debris.
An incision was then made in the deep fascia exposing the medial head of the gastrocnemius muscle. Perforators were identified and hemostasis was obtained with bipolar cautery. The midline raphae between the medial and lateral heads was identified. I then incised the tendon is portion distally elevating the medial head from the lateral head and the Achilles tendon. Hemostasis was obtained with bipolar cautery. The muscle was then scored on the superficial and deep fascia surfaces to increase the length as well as the width of this muscle flap. I rotated the gastroc flap. I did not find the flap covered the entire wound at the margins which I thought would benefit from additional Integra dermal substitute. I would then complete the split thickness skin grafting after the Integra dermal substitute was fully incorporated.
The inset was then performed. The tendinous portion was sewed to the periosteum with 2-0 PDS suture. The margins of the flaps were sewn with interrupted 3-0 Monocryl suture. A round blake drain was placed. The skin margins adjacent to the flap inferiorly was sewn with 2-0 Nylon sutures. The subcutaneous layer was sewn with interrupted 3-0 Monocryl suture. The skin was sewn with interrupted 4-0 nylon suture. The Integra dermal substitute was soaked in saline. I cut the Integra dermal substitute to fit. The size of the Integra placement was 10 cm x 12 cm. The Integra dermal substitute was sewn to the surface of the wound with interrupted 4-0 Monocryl suture.
I then began work on the left upper extremity for the targeted muscle re-innervation. My portion of the procedure consisted of targeted muscle reinnervation nerve transfers to the left upper extremity.
I proceeded with the targeted muscle reinnervation portion of the procedure. This portion of the procedure was performed without tourniquet. I began to identify the nerve stumps which were tagged with a Prolene suture (median nerve, ulnar nerve, medial antebrachial cutaneous nerve, lateral antebrachial cutaneous nerve, radial nerve). Careful subcutaneous dissection was performed with tenotomy scissors down to the level of the fascia which was incised longitudinally between the biceps short and long heads. Blunt dissection between the 2 heads of the biceps was performed until we identified the musculocutaneous nerve as well as its motor branches. Small bridging vessels were identified and cauterized with bipolar cautery. Proximally, we identified a large motor branch exiting from the musculocutaneous nerve laterally to supply the long head of biceps. We also identified a large motor branch exiting medially to the short head of biceps. We also identified a large motor branch exiting deeper and medial to the brachialis more distally. Each of these branches was stimulated with a nerve stimulator to confirm the innervated muscles. The brachialis muscle had significant crush injury and the motor branch did not stimulate as strongly as the other motor branches. The previously identified and tagged median nerve, ulnar nerve and medial antebrachial cutaneous nerve stumps were dissected out and then brought in through the wound and positioned for nerve transfer. The ulnar nerve and medial antebrachial cutaneous nerve were shuttled underneath the bicep for more direct route. We also dissected out the lateral antebrachial cutaneous nerve (the distal extent of the musculocutaneous nerve). This was also brought back into the volar exposure in preparation for nerve transfer. Each donor nerve stump was cut sharply with a 15 blade or straight iris scissors, exposing healthy bulging fascicles. We also ensured that each donor nerve stump was sufficiently long to prevent tension at the nerve coaptations. Recipient motor nerve branches were cut near their muscle targets with straight microscissors. We then proceeded with nerve transfers under loupe magnification. The first nerve transfers consisted of median nerve and medial antebrachial cutaneous nerve transfer to the musculocutaneous nerve motor branch to the short head of biceps. This was performed using 8-0 nylon sutures to perform an epineural nerve repair of both donor nerves to the recipient short head of biceps motor branch. We then proceeded with nerve transfer of the ulnar nerve and lateral antebrachial cutaneous nerve to the musculocutaneous nerve motor branch to the brachialis, again using 8-0 nylon epineural sutures. This completed the volar targeted muscle reinnervation transfers.
I then dissected out the radial nerve. Careful subcutaneous dissection was performed down to the muscle layer with the fascia incised longitudinally, identifying the plane between the lateral and long head of triceps. We bluntly dissected through this plane, identifying the radial nerve as well as a large branch to the lateral head of triceps. The branch of the long heads of triceps was likely proximal to our exposure. We dissected out the radial nerve stump as well as the posterior brachial cutaneous nerve stump distally and brought it into the posterior exposure between the heads of the triceps for targeted muscle reinnervation nerve transfer. The radial nerve stumps were cut with straight iris scissors to expose bulging fascicles and to ensure sufficient length for a tension-free repair to the recipient motor branch. The motor branch of the lateral head of triceps was cut near the insertion to the muscle, and the radial nerve was then coapted to it using 8-0 nylon interrupted epineural sutures under loupe magnification. This completed the right upper arm nerve transfers after transhumeral amputation. All wounds were copiously irrigated with saline.