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Patella revision with poly exchange
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Patient had a revision of a patellafemoral resufacing to a total knee. The sulcus compontent was removed and replaced with a femoral and tibial component. The closest I can find is 27487-52?
Thank you in advance.
Any ideas on what to bill?
1. staged revision hip arthroplasty, left 2. placement of antibiotic cement hip spacer. 3. Irrigation and debridement bone, muscle 4. fluoroscopy 5. incisional wound VAC 6. Femoral Osteotomy
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Pre-Op Diagnosis Code: Pre-op Diagnosis
* Infection associated with internal left hip prosthesis, initial encounter (CMS/HCC) [T84.52XA]
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Post-Op Diagnosis Code: Post-op Diagnosis
* Infection associated with internal left hip prosthesis, initial encounter (CMS/HCC) [T84.52XA]
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Findings:
Purulent fluid around prosthesis and soft tissues.
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Indications: The patient is a 66-year-old woman who has a history of acute myeloid leukemia secondary to MDS. She is post bone marrow transplant and has relapsed. She has pancytopenia due to relapse of disease and recent chemotherapy requiring blood product support. She developed Klebsiella sepsis with growth from her blood, urine, and most recently from an aspiration of the left hip joint. Alternatives risks and benefits were discussed with the patient and with her hematology team and the recommendation was to proceed with surgery to remove her infected hip prosthesis and replace it with an antibiotic spacer in an attempt to eradicate her infection. She understood and wished to proceed with the surgery.
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Procedure Details
The patient was brought to the operating room and placed in a supine position on the operating table. General anesthetic was induced by the anesthesiologist. The patient was already on IV antibiotic therapy. She was rolled into a lateral position and secured with a hip positioner and axillary roll. The left hindquarter was prepped with DuraPrep and draped in the usual sterile fashion for arthroplasty. I first used the patient’s previous scar which was about 15 cm centered on the greater trochanter and I dissected down through dense fibrous scar tissue. I opened the gluteus maximus fascia and revealed dark brownish slightly purulent looking fluid which was consistent with the fluid that I had aspirated from her hip last week. The fluid was in the gluteus maximus and tracked up into the buttock and also was around the posterior aspect of the prosthesis as the posterior capsular and piriformis repair had torn and there was open communication with the hip joint in the space. I evacuated the fluid and cultured it. We dislocated the hip. I removed the metal femoral head. I then debrided the soft tissues sharply with a rongeur and excised yellowish fibrinous tissue from around the prosthesis and around the hip joint. The patient also had bone on the lesser trochanter that had disintegrated and I remove these areas of fragmented bone.
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Turned our attention to extraction of the femoral stem. He uses cement removal osteotomes and try to loosen the interval between the prosthesis and the native bone. She had a bone ingrowth stem in place. With multiple attempts I was unable to extract the femoral device with a slap hammer. Therefore I opted to perform a femoral osteotomy. I had to extend the incision proximally an additional 10 cm and distally an additional 16 cm down the thigh in order to perform the osteotomy. He is a C-arm image and performed an extended osteotomy including the greater trochanter and the lateral half of the femur for 15 centimeters. I remove the lateral half of the femur maintaining the abductor attachment on the greater trochanter. I then used osteotome to extract the press-fit stem from the anterior half of the femur and was able to finally extracted.
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We then turned our attention to the acetabular side. I remove the acetabular polyethylene liner with a osteotome. We removed 3 acetabular screws. I then replaced the acetabular liner and use the centralizing curved osteotome device to loosen the interface between the metal bone ingrowth shell and the patient’s native bone around the acetabulum circumferentially. I was then able to extract the acetabular shell.
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The entire proximal femur acetabulum and soft tissues were debrided excising infected tissue. I then copiously irrigated with pulsatile lavage 9 L of solution last 3 L containing bacitracin.
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After change of gloves and new drape we then proceeded with placement of a nonabsorbable drug delivery antibiotic spacer. Based on my preoperative discussions with infectious disease team and the pharmacist and the patient’s cultures with Klebsiella with sensitivities to amikacin, we selected amikacin. I placed 2 g of amikacin per package of cement and we created using the Biomet system for femoral antibiotic spacer a femoral cement spacer and a femoral head cement spacer. I placed the femoral stem cement spacer in position in the anterior half of the osteotomized femur. I then placed the lateral half of the osteotomy including greater trochanter over this and placed to Dall-Miles cables in position around the osteotomy and tensioned these and crimped them in position. I then placed the cement femoral head and reduce the hip into the acetabulum. I then packed into the bone defect and around the femoral neck some additional antibiotic cement in the proximal femur.
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Fluoroscopy confirmed good position of the cement spacer and good fixation of the and reduction of the femoral osteotomy.
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I then attempted to close the posterior capsule with 0 PDS. I closed the vastus lateralis. I placed a deep 15 French drain and closed the IT band and gluteus maximus fascia over the drain. I closed the deep subcutaneous layers which are fibrosed with 0 PDS and subcutaneous layers with 2-0 PDS and skin was closed with staples.
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I then placed a customizable incisional wound VAC 41 cm onto the incision and attached the adhesive and suction tubing and confirmed good function of the wound VAC with no leak. I placed a sterile dressing over the Jackson-Pratt drain entry site. We placed an abduction pillow on the patient.
Patient’s right lower extremity was marked in the preop period. Patient was then brought back to the OR where she was given spinal followed by general anesthesia. A tourniquet was placed on the patient’s right thigh. Patient’s right lower extremity was prepped and draped in normal sterile fashion. A timeout was taken and was agreed upon by Lillie had the correct site and procedure and correct patient. Next a scalpel blade was used to make a transverse incision following the previous scar at the stump of the AKA. At this point the sinus tract of the abscess at the skin level was ellipsed out. Next the soft tissue abscess approximately 2 cm in diameter was excised from the subcutaneous layer at the apex of the stump. Next a longitudinal incision approximately 3 fingerbreadths in length were his made over the lateral aspect of the thigh over top of a firm area which represented a 2nd soft tissue abscess. The 2nd abscess approximately 3 cm in diameter was excised using electrocautery from the subcutaneous layer. Next using that lateral incision blunt finger dissection was used to free the cavity superficial to the fascia over the lateral aspect of the thigh. Deep cultures were taken at the distal incision. Next at the distal aspect of the stump the fascia was incised down to bone at the distal femur. No gross purulence or soft bone was noted. The content of the intramedullary canal was evacuated at the distal 1 cm. Next large Roger was used to remove approximately 2-3 cm off the distal aspect of the femur circumferentially. Next the distal and lateral wounds were irrigated out with pulse lavage approximately 3 L of saline. Next the subcutaneous layer was reapproximated using PDS in simple stitch fashion. Skin was reapproximated using 2-0 nylon in simple stitch fashion. Prior to wound closure 2 Hemovac drains were placed. The 1st Hemovac was placed adjacent to the distal femur exiting adjacent to the distal incision. The 2nd Hemovac drain was placed along the lateral aspect of the thigh superficial to the fascia. Next the tourniquet was deflated and patient recovered from anesthesia. Then transferred to PACU postoperatively in stable condition.
Procedures performed: Right knee open irrigation and debridement with polytheylene liner exchange of medial and lateral unicompartmental arthroplasties.
Description: A thorough debridement of the entire joint was then undertaken. A quarter-inch osteotome was then used to remove the medial and lateral polyethylenes. 3L of normal saline were then irrigated throughout the joint with pulse irrigation. This was then followed by 1L of saline with Bacitracin, another 3L of sterile saline and finally by 1L of dilute Betadine wash. The dilute Betadine was allowed to sit in the joint for approximately 3 minutes before being irrigated out. Next, new polyethylenes were inserted into the medial and lateral tibial base plates.
Would I bill the knee revision code for 27486: Revision of total knee arthroplasty, with or without allograft; 1 component ? Even though it is technically 2 components?
I would normally bill the 27486 with a 52 modifier for poly exchanges of a conventional total knee, but have never come across a bilateral uni poly exchange.
Thanks for all your help!
Heather
1. Left total hip arthroplasty revision, conversion to constrained liner (I believe this is CPT 27134?)
2. Left hip debridement and irrigation, down to and including removal of bone (CPT 11044? Is this bundled with the main procedure?)
3. Open advancement of hip abductor tendons (CPT 27299 matched to 27098? Again, is this considered incidental to the primary procedure?)
If an existing breast prosthesis is replaced, it may be reported separately, see 19340.