Hi, I was wondering if someone could help me with this. Is the medial plantar artery angiosome rotational flap part of the TMA surgery or is this a separate code for this? I have 28805 for the TMA, the wound matrix is 15275, but I need some guidance for this rotational flap. I am brand new to podiatry coding. Any feedback would help!
PROCEDURE PERFORMED: Transmetatarsal amputation with medial plantar
artery angiosome rotational flap, application of synthetic nanofiber
wound matrix and placement of wound vacuum assisted closure (VAC) device,
right foot.
SURGICAL INDICATIONS:
Attention was then directed to the right foot where a modified
transverse fishmouth incision was made and extended more distal
medially to the level of the first metatarsophalangeal joint. The
area of plantar forefoot eschar was excised in wedge-shaped fashion
with the apex proximal. The incision encompassed the area of dorsal
lateral necrotic eschar, which was also excised in full-thickness
fashion. The dissection was deepened to the dorsal and plantar
metatarsal periosteum which was incised in linear fashion and
reflected with a periosteal elevator and sharp dissection. There was
some surrounding liquefactive necrosis, but no sign of abscess or
osseous destructive change. Utilizing a small sagittal saw, the
metatarsals were transected, beveling the first and fifth metatarsal
osteotomy cuts appropriately to avoid medial and lateral prominences
and maintaining the metatarsal parabola. The resected metatarsals
were then freed from their remaining soft tissue attachments and the
forefoot excised and sent to pathology for gross and microscopic
evaluation.
Any remaining areas of liquefactive necrotic tissue were excised
sharply with a handheld rongeur. A thorough irrigation of the wound
was then undertaken with 3 liters of sterile saline via a pulsed lavage
system. Bone wax was applied to the raw cancellous surfaces of bone
to limit postoperative bleeding. Adequate bleeding of the wound bed
during the course of the procedure was noted. Hemostasis was obtained
with electrocautery. A medial plantar artery angiosome flap was then
rotated laterally and secured laterally with several interrupted 2-0
Prolene sutures. The entire dorsal portion of the wound was left
open, as well as a 3-4 cm area of the plantar medial wound given the
condition of the soft tissue. A 7.5 x 7.5 cm piece of Restrata
synthetic nanofiber wound matrix was then contoured to the wound
margins dorsally and plantarly and secured to the wound periphery with
surgical staples. A piece of Adaptic non-adherent gauze was similarly
contoured to the wound and secured overlying the wound matrix to the
wound periphery with surgical staples after fenestration of the wound
matrix with a scalpel. Wound VAC sponge was then placed overlying the
wound matrix and nonadherent gauze and secured with occlusive sterile
dressing. The wound VAC was then connected 125 mmHg continuous
suction with an excellent seal. At the end of the procedure, sterile
dressings consisting of 4 x 4, fluffs, Kerlix, and a light Ace wrap
were applied to the right foot. The patient tolerated the anesthesia
and procedure without complication, was extubated uneventfully on
the operating room table and returned to the recovery room in stable
condition to be readmitted to the hospital for adequate postoperative
analgesia, continued empiric intravenous antibiotics, local wound care
and maintenance of wound VAC therapy uninterrupted for the next 5 to 7
days, diabetic management, DVT prophylaxis and physical therapy
instruction to maintain protected non-weight bearing on the operative
extremity.
PROCEDURE PERFORMED: Transmetatarsal amputation with medial plantar
artery angiosome rotational flap, application of synthetic nanofiber
wound matrix and placement of wound vacuum assisted closure (VAC) device,
right foot.
SURGICAL INDICATIONS:
Attention was then directed to the right foot where a modified
transverse fishmouth incision was made and extended more distal
medially to the level of the first metatarsophalangeal joint. The
area of plantar forefoot eschar was excised in wedge-shaped fashion
with the apex proximal. The incision encompassed the area of dorsal
lateral necrotic eschar, which was also excised in full-thickness
fashion. The dissection was deepened to the dorsal and plantar
metatarsal periosteum which was incised in linear fashion and
reflected with a periosteal elevator and sharp dissection. There was
some surrounding liquefactive necrosis, but no sign of abscess or
osseous destructive change. Utilizing a small sagittal saw, the
metatarsals were transected, beveling the first and fifth metatarsal
osteotomy cuts appropriately to avoid medial and lateral prominences
and maintaining the metatarsal parabola. The resected metatarsals
were then freed from their remaining soft tissue attachments and the
forefoot excised and sent to pathology for gross and microscopic
evaluation.
Any remaining areas of liquefactive necrotic tissue were excised
sharply with a handheld rongeur. A thorough irrigation of the wound
was then undertaken with 3 liters of sterile saline via a pulsed lavage
system. Bone wax was applied to the raw cancellous surfaces of bone
to limit postoperative bleeding. Adequate bleeding of the wound bed
during the course of the procedure was noted. Hemostasis was obtained
with electrocautery. A medial plantar artery angiosome flap was then
rotated laterally and secured laterally with several interrupted 2-0
Prolene sutures. The entire dorsal portion of the wound was left
open, as well as a 3-4 cm area of the plantar medial wound given the
condition of the soft tissue. A 7.5 x 7.5 cm piece of Restrata
synthetic nanofiber wound matrix was then contoured to the wound
margins dorsally and plantarly and secured to the wound periphery with
surgical staples. A piece of Adaptic non-adherent gauze was similarly
contoured to the wound and secured overlying the wound matrix to the
wound periphery with surgical staples after fenestration of the wound
matrix with a scalpel. Wound VAC sponge was then placed overlying the
wound matrix and nonadherent gauze and secured with occlusive sterile
dressing. The wound VAC was then connected 125 mmHg continuous
suction with an excellent seal. At the end of the procedure, sterile
dressings consisting of 4 x 4, fluffs, Kerlix, and a light Ace wrap
were applied to the right foot. The patient tolerated the anesthesia
and procedure without complication, was extubated uneventfully on
the operating room table and returned to the recovery room in stable
condition to be readmitted to the hospital for adequate postoperative
analgesia, continued empiric intravenous antibiotics, local wound care
and maintenance of wound VAC therapy uninterrupted for the next 5 to 7
days, diabetic management, DVT prophylaxis and physical therapy
instruction to maintain protected non-weight bearing on the operative
extremity.