DButcher
Contributor
Could anyone help with this. I'm having a problem with the tendon transfers. Looking at 25310 for brachioradialis tendon transfer but not sure. For the side by side flexor transfer I see nothing, thinking maybe a repair code?? Any input is appreciated.
PREOPERATIVE DIAGNOSES:
1.* Median nerve palsy, left upper extremity with loss of flexor pollicis
longus and flexor digitorum profundus index function.
2.* Arthritis and deformity of left thumb metacarpophalangeal joint.
POSTOPERATIVE DIAGNOSIS:
Same.
OPERATION:
1.* Left thumb metacarpophalangeal joint arthrodesis.
2.* Brachioradialis tendon transfer to flexor pollicis longus tendon, left
thumb.
3.* Side to side index finger flexor digitorum profundus tendon transfer to
long finger flexor digitorum profundus tendon.
COMPLICATIONS:* None.
INDICATIONS:* This is a 68-year-old man who developed a median nerve palsy
after undergoing shoulder surgery resulting in weakness in his left hand.* He
had poor pinch and grip function and overall poor use of the hand.* His
symptoms were recalcitrant to nonoperative management and therefore surgery
was recommended.* After explaining the risks and benefits of the procedure in
detail with him, he elected to proceed.
OPERATIVE PROCEDURE:* The patient was taken to the operating room, placed on
the table in supine position.* The Anesthesia Department induced regional
block anesthesia without complication.* A tourniquet was applied to the left
arm and used for the case.* Left upper extremity was then prepared with
ChloraPrep solution, was draped in the usual sterile fashion.
A #15 scalpel was used to make a longitudinal incision over the dorsal aspect
of the left thumb MP joint.* Blunt dissection continued down where the
extensor tendon was released radially and retracted.* The MP joint was
identified and the joint capsule was opened.* There was significant arthrosis
noted at the MP joints at the metacarpal head and at the proximal phalanx
base.* The rongeur was then used to contour the metacarpal head into a cone
shape.* Similarly, a rongeur was used to contour the proximal phalanx base
into a cup shape.* Next, bone chips were obtained dorsally from the dorsal
prominence and were then used as bone graft in between the head and the
proximal phalanx base.* Compression was applied and then a 0.035 K-wire was
used to hold the position.* An attempt was made to use two compression
staples, but due to the tendon transfer additional surgery, I was concerned
that the constant pressure on the thumb might not allow this construct to be
strong enough and therefore I chose to remove the staples and go ahead and
secure the MP joint with a dorsal plate.* A 2.0 mm locking screw plate system
was then contoured to the dorsal aspect and then secured in approximately
40-45 degrees of flexion.* An excellent secure fixation was felt to have been
achieved.* The position of the hardware and the joint were felt to be
excellent and printouts were made and placed in the patient's office chart at
this time.
The extensor mechanism was secured using FiberWire in interrupted and
figure-of-eight fashion.* Subcutaneous tissue was approximated with Vicryl,
the skin with Monocryl and then skin glue was applied.
Attention was then moved to the volar aspect of the wrist where a longitudinal
incision was made just proximal to the radiocarpal joint.* Blunt dissection
continued down where the FCR was identified and retracted as was the radial
artery.* It was protected throughout the case.* The FPL and the median nerve
were identified.* The FPL had muscle that appeared grayish consistent with
poor function.* This was similarly seen for the index FDP tendon.* The FPL
was noted to have good passive motion.* It was retracted medially to protect
the median nerve.* Attention was then moved to the radius where the insertion
of the brachioradialis was identified and exposed.* The brachioradialis was
sharply elevated off of the radius.* It was tagged with a suture to be later
used for muscle transfer.* The excursion was felt to be acceptable and the
muscle had good bounce to it.* Next, the FPL was released proximally and then
adequate tension was applied and then a weave technique for Pulvertaft type
technique was used to secure the tendons together using 4-0 FiberWire in
figure-of-eight fashion x2 for each pass.* The tension on the thumb FPL was
felt to be excellent with tenodesis effect noted with flexion and extension of
the wrist.
With respect to the index finger, once the long finger flexor profundus tendon
was identified, the index finger profundus tendon was released proximally and
then passed through the long finger profundus tendon 3 times, each time
securing the tendon using figure-of-eight 4 FiberWire.* The tension set for
the index was identical to that of the long, ring and little fingers for
normal equal cascade of each of the 4 fingers.
The wound was irrigated with normal saline.* Subcutaneous tissue was then
approximated with Vicryl, the skin with Monocryl then skin glue was applied. *
A sterile compressive bandage was then applied followed by a fiberglass dorsal
splint holding the MP joints in full flexion and holding the thumb in flexion
as well.* An arm sling was then applied.* The patient was then transferred to
the recovery room in stable condition.
**
PREOPERATIVE DIAGNOSES:
1.* Median nerve palsy, left upper extremity with loss of flexor pollicis
longus and flexor digitorum profundus index function.
2.* Arthritis and deformity of left thumb metacarpophalangeal joint.
POSTOPERATIVE DIAGNOSIS:
Same.
OPERATION:
1.* Left thumb metacarpophalangeal joint arthrodesis.
2.* Brachioradialis tendon transfer to flexor pollicis longus tendon, left
thumb.
3.* Side to side index finger flexor digitorum profundus tendon transfer to
long finger flexor digitorum profundus tendon.
COMPLICATIONS:* None.
INDICATIONS:* This is a 68-year-old man who developed a median nerve palsy
after undergoing shoulder surgery resulting in weakness in his left hand.* He
had poor pinch and grip function and overall poor use of the hand.* His
symptoms were recalcitrant to nonoperative management and therefore surgery
was recommended.* After explaining the risks and benefits of the procedure in
detail with him, he elected to proceed.
OPERATIVE PROCEDURE:* The patient was taken to the operating room, placed on
the table in supine position.* The Anesthesia Department induced regional
block anesthesia without complication.* A tourniquet was applied to the left
arm and used for the case.* Left upper extremity was then prepared with
ChloraPrep solution, was draped in the usual sterile fashion.
A #15 scalpel was used to make a longitudinal incision over the dorsal aspect
of the left thumb MP joint.* Blunt dissection continued down where the
extensor tendon was released radially and retracted.* The MP joint was
identified and the joint capsule was opened.* There was significant arthrosis
noted at the MP joints at the metacarpal head and at the proximal phalanx
base.* The rongeur was then used to contour the metacarpal head into a cone
shape.* Similarly, a rongeur was used to contour the proximal phalanx base
into a cup shape.* Next, bone chips were obtained dorsally from the dorsal
prominence and were then used as bone graft in between the head and the
proximal phalanx base.* Compression was applied and then a 0.035 K-wire was
used to hold the position.* An attempt was made to use two compression
staples, but due to the tendon transfer additional surgery, I was concerned
that the constant pressure on the thumb might not allow this construct to be
strong enough and therefore I chose to remove the staples and go ahead and
secure the MP joint with a dorsal plate.* A 2.0 mm locking screw plate system
was then contoured to the dorsal aspect and then secured in approximately
40-45 degrees of flexion.* An excellent secure fixation was felt to have been
achieved.* The position of the hardware and the joint were felt to be
excellent and printouts were made and placed in the patient's office chart at
this time.
The extensor mechanism was secured using FiberWire in interrupted and
figure-of-eight fashion.* Subcutaneous tissue was approximated with Vicryl,
the skin with Monocryl and then skin glue was applied.
Attention was then moved to the volar aspect of the wrist where a longitudinal
incision was made just proximal to the radiocarpal joint.* Blunt dissection
continued down where the FCR was identified and retracted as was the radial
artery.* It was protected throughout the case.* The FPL and the median nerve
were identified.* The FPL had muscle that appeared grayish consistent with
poor function.* This was similarly seen for the index FDP tendon.* The FPL
was noted to have good passive motion.* It was retracted medially to protect
the median nerve.* Attention was then moved to the radius where the insertion
of the brachioradialis was identified and exposed.* The brachioradialis was
sharply elevated off of the radius.* It was tagged with a suture to be later
used for muscle transfer.* The excursion was felt to be acceptable and the
muscle had good bounce to it.* Next, the FPL was released proximally and then
adequate tension was applied and then a weave technique for Pulvertaft type
technique was used to secure the tendons together using 4-0 FiberWire in
figure-of-eight fashion x2 for each pass.* The tension on the thumb FPL was
felt to be excellent with tenodesis effect noted with flexion and extension of
the wrist.
With respect to the index finger, once the long finger flexor profundus tendon
was identified, the index finger profundus tendon was released proximally and
then passed through the long finger profundus tendon 3 times, each time
securing the tendon using figure-of-eight 4 FiberWire.* The tension set for
the index was identical to that of the long, ring and little fingers for
normal equal cascade of each of the 4 fingers.
The wound was irrigated with normal saline.* Subcutaneous tissue was then
approximated with Vicryl, the skin with Monocryl then skin glue was applied. *
A sterile compressive bandage was then applied followed by a fiberglass dorsal
splint holding the MP joints in full flexion and holding the thumb in flexion
as well.* An arm sling was then applied.* The patient was then transferred to
the recovery room in stable condition.
**