Primary delayed closure of knee disarticulation

Hello, I would appreciate some help with coding this op report please.  I added a modifier 52 to the disarticulation code since there wasn't a closure.

PREOPERATIVE DIAGNOSES:  Status post emergent left knee disarticulation amputation for setting of a grade 3C open proximal tibia fracture with significant contamination.


POSTOPERATIVE DIAGNOSES:  Status post emergent left knee disarticulation amputation for setting of a grade 3C open proximal tibia fracture with significant contamination.


NAME OF PROCEDURE:  Repeat irrigation and debridement of left knee disarticulation, revision knee dysarticulation with primary complex skin closure.

HISTORY:  The patient is a 66-year-old gentleman who is now 3 days out status post emergent knee disarticulation with debridement of muscle, tendon, skin and bone.  He has returned to the operating room for repeat debridement and primary closure versus VAC exchange.  Consent obtained by a family member.  Discussed risks and benefits of the procedure preoperatively.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and his left lower extremity was prepped and draped in the usual sterile fashion using Betadine paint and scrub.  Prior to incision, a formal timeout was obtained where we confirmed the correct patient, procedure, side, site, use of appropriate antibiotic, DVT prophylaxis as well as the presence of appropriate preoperative imaging and equipment.  After the timeout, I performed a repeat debridement of muscle, skin and tendons.  We ensured all debris was removed from the wound.  The wound started quite clean, although I did find a small amount of dirt within the wound.  We then proceeded with over 9 liters of normal saline irrigation using cysto tubing.  After the thorough irrigation and debridement of any necrotic or damaged tissue, we then performed the tenodesis of the Hoffa fat pad to both the ACL and PCL within the notch.  This was done with full hip flexion in order to centralize the patellar tendon within the notch.  This will allow for a triangular stump and improve prosthesis fitting.  The remaining patellar tendon was then also tenodesed to the Hoffa fat pad for secondary fixation.  The patellar length prevented us from attaching it to the ACL, PCL stump.  Overall, I was happy with the stability of the patella within the notch.  After this was completed, we then tenodesed the hamstring tendons to the anterior medial joint capsule.  We then performed a closure of both the medial and lateral gastroc heads to the anterior joint capsule.  This allowed for excellent coverage of the femoral condyles.  Overall, this tissue was quite healthy and further muscle debridement was not required.  We used interrupted 0 PDS sutures for this closure.  He had a significant amount of edge skin necrosis, particularly laterally.  The necrotic skin edge was excised with a #15 blade.  We then had to undermine the skin small amount in order to perform a primary closure.  Closure was well over 20 cm2 in length.  This included continuation of the closure along the lateral distal thigh secondary to the initial injury.  Overall, I was quite happy with the closure.  There was a corner anterolaterally that had mild amount of tension on it, but overall we had excellent coverage and minimal tension at the skin edges.  It should be noted that a Hemovac drain was placed within the intra-articular space underneath the gastroc closure.  It was exited out the anteromedial aspect of the distal thigh.  This skin closure was performed with a combination of 3-0 Monocryl sutures and staples for skin.  Please see Dr. Kirkham's separate operative note for details on skin closure.  We then placed a meticulous dressing, which included combination of 4 x 4's, puffy Kling and Kerlix roll for the distal stump.  I used a significant amount of cast padding along the entire thigh including the distal stump.  A plaster stirrup was placed.  Plaster was then overwrapped with a bias-cut stockinette.  We ensured that the deep drain was not directly compressing the skin medially.  We fashioned the splint so that we could take out the drain through the splint.  Overall, I was very happy with the security of the thigh splint.  The patient was then transferred back to the CICU intubated.

Shana Qualey, CPC


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