Assign appropriate CPT and ICD-10-CM codes and modifiers
3. PREOPERATIVE DIAGNOSIS: Left tibial tubercleavulsion fracture.
POSTOPERATIVE DIAGNOSIS: Comminuted left distalend of the tibia
PROCEDURE: Open reduction and internal fixation ofleft tibia.
ANESTHESIA: General. The patient received 10 ml of0.5% Marcaine local anesthetic.
TOURNIQUET TIME: 80 minutes.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: One JP drain was placed.
COMPLICATIONS: No intraoperative complications orspecimens. Hardware consisted of two 4-5 K-wires, One 6.5, 60 mmpartially threaded cancellous screw and one 45, 60 mm partiallythreaded cortical screw and 2 washers.
HISTORY AND PHYSICAL: The patient is a 14-year-oldmale who reported having knee pain for 1 month. Apparently while hewas playing basketball on 12/22/2007 when he had gone up for ajump, he felt a pop in his knee. The patient was seen at an outsidefacility where he was splinted and subsequently referred toChildren's for definitive care. Radiographs confirmed comminutedtibial tubercle avulsion fracture with patella alta. Surgery isrecommended to the grandmother and subsequently to the father byphone. Surgery would consist of open reduction and internalfixation with subsequent need for later hardware removal. Risks ofsurgery include the risks of anesthesia, infection, bleeding,changes on sensation in most of the extremity, hardware failure,need for later hardware removal, failure to restore extensormechanism tension, and need for postoperative rehab. All questionswere answered, and father and grandmother agreed to the aboveplan.
PROCEDURE: The patient was taken to the operatingand placed supine on the operating table. General anesthesia wasthen administered. The patient was given Ancef preoperatively. Anonsterile tourniquet was placed on the upper aspect of thepatient's left thigh. The patient's extremity was then prepped anddraped in the standard surgical fashion. Midline incision wasmarked on the skin extending from the tibial tubercle proximallyand extremities wrapped in Esmarch. Finally, the patient hadtourniquet that turned in 75 mmHg. Esmarch was then removed. Theincision was then made. The patient had significant tearing of theposterior retinaculum medially with proximal migration of thetibial tubercle which was located in the joint there was asignificant comminution and intraarticular involvement. We wereable to see the underside of the anterior horn of both medial andlateral meniscus. The intraarticular cartilage was restored usingtwo 45 K-wires. Final position was checked via fluoroscopy and thecorners were buried in the cartilage. There was a large freefloating metaphyseal piece that included parts of proximal tibialphysis. This was placed back in an anatomic location and fixedusing a 45 cortical screw with a washer. The avulsed fragment withthe patellar tendon was then fixed distally to this area using a6.5, 60 mm cancellous screw with a washer. The cortical screw didnot provide good compression and fixation at this distal fragment.Retinaculum was repaired using 0 Vicryl suture as best as possible.The hematoma was evacuated at the beginning of the case as well asthe end. The knee was copiously irrigated with normal saline. Thesubcutaneous tissue was re-approximated using 2-0 Vicryl and theskin with 4-0 Monocryl. The wound was cleaned, dried, and dressedwith Steri-Strips, Xeroform, and 4 x4s. Tourniquet was released at80 minutes. JP drain was placed on the medium gutter. The extremitywas then wrapped in Ace wrap from the proximal thigh down to thetoes. The patient was then placed in a knee mobilizer. The patienttolerated the procedure well. Subsequently extubated and taken tothe recovery in stable condition.
POSTOP PLAN: The patient hospitalized overnight todecrease swelling and as well as manage his pain. He may weightbearas tolerated using knee mobilizer. Postoperative findings relayedto the grandmother. The patient will need subsequent hardwareremoval. The patient also was given local anesthetic at the end ofthe case.
