valerieeanderson
Networker
Would you guys code CPT 25210 X2 for the removal of the carpals? The provider insists that we should bill this separately because they were not removed initially for the graft but b/c they were unable to be fused and then decided to use them as a graft. I would appreciate any thoughts/ resources. We have CPT 25810, 64772.
OP NOTE:
Patient identity consent and the correct operative extremity were verified in the preoperative holding area. Patient received a regional anesthetic block by the anesthesia team. brought back to the operative theater and placed supine on the operative
table. All bony prominences were well-padded. After induction of general anesthesia a tourniquet was placed high in the right upper extremity. Right upper extremity was then prepped and draped in sterile fashion. Preoperative antibiotics consisted 2 g of Ancef was administered. A preoperative timeout was then observed by all members of the surgical team to verify patient identity consent and the correct operative extremity. After Esmarch exsanguination the tourniquet was inflated to 250 mmHg.
A longitudinal incision was carried out overlying the dorsal aspect of the distal radius extending from the mid aspect of the third metacarpal and extending proximally to the distal portion of the distal radius. Full-thickness skin flaps were raised and adequate hemostasis were achieved using bipolar electrocautery. The extensor retinaculum was opened along the third extensor compartment and the EPL tendon was retracted in a radial direction. The fourth extensor compartment was entered along its
radial margin and the contents of the fourth extensor compartment were retracted in an ulnar direction. On the floor of the fourth extensor compartment the posterior interosseous nerve was identified and a posterior interosseous nerve neurectomy performed using bipolar cautery to reduce any postoperative pain. A ligament sparing approach was utilized for the capsulotomy portion of the procedure but I then extended the capsular flaps both radially and ulnarly off of the proximal aspect of the distal radius to gain exposure of the radiocarpal joint. There was significant diastases of the scapholunate interval with proximal migration of the proximal pole of the capitate. I elected to go ahead and excise the lunate and the triquetrum to utilize as bone graft for the procedure. I was able to remove both bones in its entirety using a McGlamry elevator. The bones were kept on the back table. Wound was then thoroughly irrigated with normal saline. I used a high-speed bur to remove the chondral surfaces off of the distal radius, capitate, hamate, and scaphoid. The wound was thoroughly irrigated to remove any bony debris.
I then placed a Medartis CMC sparing short wrist fusion plate on the dorsal aspect of the distal radius. I did remove Lister's tubercle in order for the plate to sit flush with the dorsal aspect of the distal radius. This was provisionally pinned in place. X-rays
were taken which confirmed good position of the plate. I placed a cortical screw in the most distal and ulnar portion of the plate to help bring the plate flush to the carpus. I reinforce fixation with a locking screw in the most distal and radial hole. I then placed a cortical screw into the oblong hole on the proximal portion of the plate to help compress through the fusion site. X-rays were taken which confirmed good position of the plate as well as the carpus relative to the radius. I drilled and filled locking screws in the remaining holes of the proximal portion of the plate. I then utilized bone graft from the lunate and the triquetrum and impacted this into the radiocarpal space using a bone tamp. This was done after thoroughly irrigating out the wrist joint. After there was sufficient bone graft in place I reinforce fixation of the distal holes with distal locking screws. X-rays were taken which confirm plate placement screw purchase and good position of the fusion site all of which are deemed to be acceptable. Wounds were then thoroughly irrigated with normal saline.
The capsule was then repaired using a 3-0 Vicryl suture in an interrupted fashion. The extensor retinaculum was then repaired using a 3-0 Vicryl suture in an interrupted fashion keeping the EPL tendon subcutaneous. The skin incision was then
closed with a 4-0 nylon suture in an interrupted horizontal mattress fashion. Xeroform dressing followed by sterile dressings were applied. The tourniquet was deflated and the fingers to be perfused. The patient was placed into a well-padded long-arm sugar-tong plaster splint. He was awakened from general anesthesia and brought back to PACU in stable condition. The needle thread and sponge counts were correct at the end of the procedure. Greater than 3 fluoroscopic images were obtained of the right wrist to assess for plate placement, screw purchase and good compression to the fusion site all of which are deemed to be acceptable.
OP NOTE:
Patient identity consent and the correct operative extremity were verified in the preoperative holding area. Patient received a regional anesthetic block by the anesthesia team. brought back to the operative theater and placed supine on the operative
table. All bony prominences were well-padded. After induction of general anesthesia a tourniquet was placed high in the right upper extremity. Right upper extremity was then prepped and draped in sterile fashion. Preoperative antibiotics consisted 2 g of Ancef was administered. A preoperative timeout was then observed by all members of the surgical team to verify patient identity consent and the correct operative extremity. After Esmarch exsanguination the tourniquet was inflated to 250 mmHg.
A longitudinal incision was carried out overlying the dorsal aspect of the distal radius extending from the mid aspect of the third metacarpal and extending proximally to the distal portion of the distal radius. Full-thickness skin flaps were raised and adequate hemostasis were achieved using bipolar electrocautery. The extensor retinaculum was opened along the third extensor compartment and the EPL tendon was retracted in a radial direction. The fourth extensor compartment was entered along its
radial margin and the contents of the fourth extensor compartment were retracted in an ulnar direction. On the floor of the fourth extensor compartment the posterior interosseous nerve was identified and a posterior interosseous nerve neurectomy performed using bipolar cautery to reduce any postoperative pain. A ligament sparing approach was utilized for the capsulotomy portion of the procedure but I then extended the capsular flaps both radially and ulnarly off of the proximal aspect of the distal radius to gain exposure of the radiocarpal joint. There was significant diastases of the scapholunate interval with proximal migration of the proximal pole of the capitate. I elected to go ahead and excise the lunate and the triquetrum to utilize as bone graft for the procedure. I was able to remove both bones in its entirety using a McGlamry elevator. The bones were kept on the back table. Wound was then thoroughly irrigated with normal saline. I used a high-speed bur to remove the chondral surfaces off of the distal radius, capitate, hamate, and scaphoid. The wound was thoroughly irrigated to remove any bony debris.
I then placed a Medartis CMC sparing short wrist fusion plate on the dorsal aspect of the distal radius. I did remove Lister's tubercle in order for the plate to sit flush with the dorsal aspect of the distal radius. This was provisionally pinned in place. X-rays
were taken which confirmed good position of the plate. I placed a cortical screw in the most distal and ulnar portion of the plate to help bring the plate flush to the carpus. I reinforce fixation with a locking screw in the most distal and radial hole. I then placed a cortical screw into the oblong hole on the proximal portion of the plate to help compress through the fusion site. X-rays were taken which confirmed good position of the plate as well as the carpus relative to the radius. I drilled and filled locking screws in the remaining holes of the proximal portion of the plate. I then utilized bone graft from the lunate and the triquetrum and impacted this into the radiocarpal space using a bone tamp. This was done after thoroughly irrigating out the wrist joint. After there was sufficient bone graft in place I reinforce fixation of the distal holes with distal locking screws. X-rays were taken which confirm plate placement screw purchase and good position of the fusion site all of which are deemed to be acceptable. Wounds were then thoroughly irrigated with normal saline.
The capsule was then repaired using a 3-0 Vicryl suture in an interrupted fashion. The extensor retinaculum was then repaired using a 3-0 Vicryl suture in an interrupted fashion keeping the EPL tendon subcutaneous. The skin incision was then
closed with a 4-0 nylon suture in an interrupted horizontal mattress fashion. Xeroform dressing followed by sterile dressings were applied. The tourniquet was deflated and the fingers to be perfused. The patient was placed into a well-padded long-arm sugar-tong plaster splint. He was awakened from general anesthesia and brought back to PACU in stable condition. The needle thread and sponge counts were correct at the end of the procedure. Greater than 3 fluoroscopic images were obtained of the right wrist to assess for plate placement, screw purchase and good compression to the fusion site all of which are deemed to be acceptable.
