A sterile marking pen was then utilized to mark out a curvilinear incision overlying the ulnar
border of the thumb MCP joint. An Esmarch was utilized to exsanguinate the upper extremity
and the tourniquet was inflated to 250 mmHg. A #15 blade was used to incise the skin.
Meticulous hemostasis was obtained in subcutaneous plane with bipolar cautery. Several
superficial branches of the radial sensory nerve were identified and protected throughout the
procedure. The sagittal band was then released off of the ulnar border of the extensor pollicis
longus leaving a 2mm cuff of the band attached to EPL for later repair. A longitudinal
capsulotomy of the MCP joint was performed along the ulnar border of the joint line. This
allowed for excellent exposure of the underlying ulnar collateral ligament injury and the
proximal phalanx fracture. The patient had a complete avulsion of the ulnar collateral ligament
off of the proximal phalanx with an associated bony avulsion fracture. The proximal phalanx
fragment was very small and multi-fragmented. As such, the proximal phalanx fragments were
carefully excised. The ulnar collateral ligament was then carefully unfolded and brought back
out to length. The ulnar corner of the proximal phalanx was completely devoid of cortical bone
at the native footprint for the collateral ligament. As such, two Keith needles were advanced
from the ulnar corner of the proximal phalanx in an anterograde and radial direction to exit along
the radial border of the thumb proximal phalanx.
Two 2-0 prolene sutures were then passed through the ulnar collateral ligament in a running,
non-locking fashion. The prolene suture tails were then passed through the Keith needles and the
Keith needles were pulled through the proximal phalanx to shuttle the suture tails through the
bone. The suture tails were then passed through a layer of Xeroform and gauze followed by a
polypropylene button along the radial border of the proximal phalanx. The thumb MCP joint
was then carefully reduced and held in a semi-flexed posture while each set of suture tails were
sequentially tightened and tied to reduce the ulnar collateral ligament down to the proximal
phalanx.
Tensioning of the repair was then checked with the MCP joint in both full extension as well as
30 degrees of flexion. All testing demonstrated excellent restraint against apex ulnar deviation
stress at the level of the thumb MCP joint. The repair was then further reinforced by retensioning
the ulnar MCP joint capsule with 3-0 vicryl sutures (capsulodesis). The ulnar sagittal
band and the adductor aponeurosis were then repaired with 3-0 vicryl sutures to re-centralize the
EPL tendon.
He feels that CPTs: 26540, 26437, 26235 and 26516 are all warranted..
I believe that 26540 and 26437 are the only CPTs that should be billed.
Just was wondering if a diferent set of eyes could help!
Thanks
Heather