Need help with the following op note. Is this a revision of total knee arthroplasty CPT 27486. Are there any other procedures that can be coded?
PREOPERATIVE DIAGNOSES:
1. Right knee, status post history of total knee arthroplasty.
2. Right knee, ambulatory instability.
PROCEDURE: Open exploration, right total knee arthroplasty, release of deepened superficial fibers of the MCL and polyethylene exchange to a more constrained polyethylene.
DESCRIPTION OF PROCEDURE: The patient was brought in the operating room, given preoperative antibiotics appropriately, given spinal anesthetic and femoral nerve block, correct knee was identified by its preoperative mark. Prep and drape was done in sterile fashion. Timeout was done per protocol. Again, the knee just had slight increased laxity at flexion, but definitely within acceptable, but may be not for his size. At that point, exsanguination was done, tourniquet was raised. I reincised his midline incision, created medial and lateral subcutaneous flaps and did a medial parapatellar arthrotomy. I did a complete synovectomy of the knee and removed scar tissue, released the subperiosteal dissection medial tibial flap and released the MCL. There was some scar tissue around his old meniscus, I excised this and sequentially released deepen and superficial fibers of the MCL. I did excise some of the synovium around that had developed around the patella to avoid any possible clunk, but he has a CR knee and I did a partial lateral facetectomy of the patella just to make sure there was no overgrowth there. I then after releasing continuing to do segmental release of the MCL even pie crusted the MCL with a 11 blade And developed a more symmetric ligamentous tension, there was a large osteophyte that had grown along the medial tibial plateau which I removed as well. Now, I tested the knee with a 10 mm polyethylene that was still in there. He still had about 5 degrees lacking full extension which is an improvement over what he had from his first preop. He has flexion to 125 degrees. At 90 degrees, he did have increased laxity anteriorly, still again within acceptable. I then trialed a 10 mm anterior stabilized, this did not change the extension gap, which was symmetric at 0 and 30 degrees with both gapping opening a few millimeters medially and laterally, but did significantly improve his flexion stability both 60, 90, and 120 degrees with very minimal anterior translation. We trialed the 12 and the 12 was too tight, he had loss of extension and loss of flexion and 0 translation at 90 degrees, I felt this was too tight. Lavage of the knee was done and we implanted a 10 mm deep dish constrained AS E- poly bearing with increased stability in flexion. Copious lavage was done. The capsular block was done with 0.5% Marcaine with epinephrine and morphine and the parapatellar arthrotomy was repaired with #2 Quill, and #1 Vicryls. subcutaneous tissues in layers with 2-0 Vicryl, skin was sewn with subcuticular Dermabond, Steri-Strips, Xeroform, and occlusive dressings, and a knee wrap was applied.
PREOPERATIVE DIAGNOSES:
1. Right knee, status post history of total knee arthroplasty.
2. Right knee, ambulatory instability.
PROCEDURE: Open exploration, right total knee arthroplasty, release of deepened superficial fibers of the MCL and polyethylene exchange to a more constrained polyethylene.
DESCRIPTION OF PROCEDURE: The patient was brought in the operating room, given preoperative antibiotics appropriately, given spinal anesthetic and femoral nerve block, correct knee was identified by its preoperative mark. Prep and drape was done in sterile fashion. Timeout was done per protocol. Again, the knee just had slight increased laxity at flexion, but definitely within acceptable, but may be not for his size. At that point, exsanguination was done, tourniquet was raised. I reincised his midline incision, created medial and lateral subcutaneous flaps and did a medial parapatellar arthrotomy. I did a complete synovectomy of the knee and removed scar tissue, released the subperiosteal dissection medial tibial flap and released the MCL. There was some scar tissue around his old meniscus, I excised this and sequentially released deepen and superficial fibers of the MCL. I did excise some of the synovium around that had developed around the patella to avoid any possible clunk, but he has a CR knee and I did a partial lateral facetectomy of the patella just to make sure there was no overgrowth there. I then after releasing continuing to do segmental release of the MCL even pie crusted the MCL with a 11 blade And developed a more symmetric ligamentous tension, there was a large osteophyte that had grown along the medial tibial plateau which I removed as well. Now, I tested the knee with a 10 mm polyethylene that was still in there. He still had about 5 degrees lacking full extension which is an improvement over what he had from his first preop. He has flexion to 125 degrees. At 90 degrees, he did have increased laxity anteriorly, still again within acceptable. I then trialed a 10 mm anterior stabilized, this did not change the extension gap, which was symmetric at 0 and 30 degrees with both gapping opening a few millimeters medially and laterally, but did significantly improve his flexion stability both 60, 90, and 120 degrees with very minimal anterior translation. We trialed the 12 and the 12 was too tight, he had loss of extension and loss of flexion and 0 translation at 90 degrees, I felt this was too tight. Lavage of the knee was done and we implanted a 10 mm deep dish constrained AS E- poly bearing with increased stability in flexion. Copious lavage was done. The capsular block was done with 0.5% Marcaine with epinephrine and morphine and the parapatellar arthrotomy was repaired with #2 Quill, and #1 Vicryls. subcutaneous tissues in layers with 2-0 Vicryl, skin was sewn with subcuticular Dermabond, Steri-Strips, Xeroform, and occlusive dressings, and a knee wrap was applied.