Certificate of Attendance
Transcription
Certificate of Attendance
Certificate of Attendance Advanced Clinic: Hand Surgery CPT Coding May 13, 2004 _____________________________________ NAME Lolita M. Jones, RHIA, CCS Presenter The American Health Information Management Association (AHIMA) has approved this program for two (2) continuing education clock hours in the Clinical Data Management content area. Retain this certificate as evidence of participation. Advanced Clinic Hand Surgery Advanced Clinic: Hand Surgery CPT Coding Author: Lolita M. Jones, RHIA, CCS Lolita M. Jones Consulting Services 1921 Taylor Avenue Fort Washington, MD 20744 (V) 301-292-8027 (FAX) 301-292-8244 Coding Training: www.hcprofessor.com E-mail: [email protected] Distributed by HCPro 1 Advanced Clinic Hand Surgery Table of Contents – Disclaimer 1 About Lolita M. Jones Consulting Services 2 Objective 7 Clinical Coder: Tendon Surgery 8 Hand and Finger Tendons 8 CPT Coding Tips and Traps 11 Clinical Coders: Anatomy of the Hand 19 CPT Coding Guidelines 35 Exercises 36 Answer Key 96 i Advanced Clinic Hand Surgery 1 Disclaimer Advanced Clinic: Hand Surgery is designed to provide accurate and authoritative information in regard to the subject covered. Every reasonable effort has been made to ensure the accuracy of the information within these pages. However, the ultimate responsibility lies with the user. Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express or implied, that this compilation is error-free or that the use of this publication will prevent differences of opinion or disputes with Medicare or other thirdparty payers, and will bear no responsibility or liability for the results or consequences of its use. Physician’s Current Procedural Terminology, Fourth Edition (CPT-4) is a copyrighted coding system owned and maintained by the American Medical Association. Please contact Lolita M. Jones, RHIA, CCS at: (V) 301-292-8027 (Fax) 301-292-8244 Coding Training: www.hcprofessor.com E-mail: [email protected] © 2004 Lolita M. Jones Consulting Services All five-digit number Physician’s Current Procedural Terminology, Fourth Edition (CPT) codes, service description, instructions and/or guidelines are © 2003 American Medical Association. All rights reserved. All rights reserved. The author grants permission for photocopying for limited personal use or internal use of the original purchaser. This consent does not extend to other kinds of copying, such as for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale. • HAND Advanced Clinic Hand Surgery 2 About Lolita M. Jones Consulting Services HOSPITAL TRAINING PROGRAMS Coding Training: www.hcprofessor.com (V) 301-292-8027 (FAX) 301-292-8244 E-mail: [email protected] BIOGRAPHY: Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospital outpatient and ambulatory surgery center coding, billing, reimbursement, and operations. Ms. Jones recently launched her web-based coding program at www.EZMedEd.com. She has over 15 years of experience in publishing, training, and auditing for the hospital outpatient and freestanding ambulatory surgery center (ASC) markets. Ms. Jones has earned both the Registered Health Information Administrator and Certified Coding Specialist credentials from the American Health Information Management Association (AHIMA) in Chicago, IL. Ms. Jones resides in Fort Washington, Maryland, and she has developed six (6) specialty manuals for freestanding ambulatory surgery centers (ASCs) as well as comprehensive manuals for the following ambulatory payment classification (APC) training programs: Basic CPT Outpatient Coding Clinic: This 6.5 hour program is designed for (Future/Beginning/Current) Coding Specialists, Coding Managers, Reimbursement Specialists, Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospital staff responsible for outpatient coding including emergency room, ancillary department and hospital-based clinic staff. The contents include general guidelines, steps for coding, and official CPT guidelines for surgical procedures that are commonly performed in the hospital outpatient setting. Exercises based on actual ambulatory surgery operative reports will be used to strengthen the attendees’ understanding of the guidelines presented. APC Institute: Impact on Emergency Services: This 3 hour program is designed for Emergency Department: Directors, Managers, Supervisors, and Nurses; Registration Staff, Health Information Managers, Coding Specialists, and Cast Room Technicians. The contents include APC Grouping Logic, Mapping Logic for ED Medical Visits, APCs for Emergency Department Services, Modifiers –25 and –27, Emergency Screening without Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound Closure, and Documentation Guidelines. Advanced Clinic Hand Surgery 3 APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program is designed for Compliance Department Staff (Corporate Officers, Directors, Managers, Analysts, Auditors); Health Information Management Staff (Directors, Coding Managers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators, Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors, Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsible for facility component outpatient coding in: Registration, Hospital-Based Clinics, Ancillary Departments, and the Emergency Department. The contents include: Brief Overview of APCs; CPT Surgery Coding Compliance; and APC Compliance Issues: siteof-service billing, reason for visits, discontinued surgery, medical visits, “limited followup services,” colorectal cancer screening, observation stay without recovery, critical care, interventional radiology, modifiers, unlisted procedure codes, units of service, UB92 claims data, and higher level APC groups. APC Institute: Clinical Documentation Strategies: This 6.5 hour program is designed for nursing, utilization management, case management, and other health care professionals responsible for health records documentation. The contents include ambulatory payment classification (APC)-related clinical documentation requirements and management tips for the following sites of service: Emergency Room, Observation Beds/Unit, Ambulatory Surgery, Hospital-Based Outpatient Departments/Clinics, Pain Management Clinic, Series/Recurring Services, Partial Hospitalization Program, Cast Room, Ancillary Testing Areas, and Utilization Management. APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designed for all technical, clinical and managerial staff responsible for facility component outpatient coding that will directly impact ambulatory payment classification (APC) payments. The contents include: Ambulatory Surgery Reimbursement under APCs, APC Data Reporting Requirements, Medicare Hospital Outpatient Edits, Outpatient Billing Procedures and Guidelines, Ambulatory Claims Rejection Monitors, Peer Review Ambulatory Surgery Review, Coding System Reviews, How to Use ICD-9-CM, How to Use CPT, and CPT Coding Guidelines By Body System (Integumentary, Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic, Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital, Endocrine, Nervous, Eye and Ocular Adnexa, Auditory). Advanced Clinic Hand Surgery 4 Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed for coding, reimbursement, compliance, billing, database management, ancillary, and clinic staff responsible for modifier programming, reporting, billing, and auditing. The contents include: Modifier Reporting Requirements, Official Medicare Guidelines, Recommended Hospital Front-End Modifier Edits, Electronic/On-Line UB-92 Reporting of Modifiers, Coding and Billing Aborted/Discontinued Procedures, ICD-9-CM vs. Medicare Coding Guidelines, Unsuccessful vs. Aborted/Discontinued Procedures, Documentation of Reduced/Discontinued Procedures, Testing Potential Coders, Software Encoder Modifier Edits, Interventional Radiology Procedures, Information System Upgrades, Data Quality Review, Radiology Modifier Reporting Issues, Ancillary Department Modifier Reporting for Hospitals, and Exercises/Case Studies. APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program is designed for hospital executives, directors, chargemaster coordinators, coding/reimbursement staff, and information system/database managers who will implement ambulatory payment classifications (APCs). The contents include: General Overview of APCs, APC Data Reporting Requirements, APC Policy Issues, Developing a Plan of Action, Conducting Hospital-Wide APC Education, and Assessing Current Outpatient Operations for: Overall Hospital, Management Information Systems, Business Office/Patient Accounts, Health Information Management, Ancillary Departments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-Owned Satellite Facilities, Hospital-Based Physician Coding and Billing, and Utilization Management. APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designed for Chief Financial Officers, Vice Presidents of Finance, Controllers, Chargemaster Coordinators, Database Managers, Software Vendor Product Managers, Coding Managers, Reimbursement Specialists, Director of Patient Accounts/Business Office, Outpatient Billing Supervisor/Coordinator, Outpatient Billing Specialists. The contents include: Durable Medical Equipment and Prosthetics, Pre-operative Registration, Outpatient Service “Red Flags,” Chargemaster/Charge Entry, Claims Preparation, Claims Payment, Tracking and Reviewing Medicare Billing Guidelines. Advanced Clinic Hand Surgery 5 Lolita M. Jones Consulting Services FREESTANDING AMBUALTORY SURGERY CENTER TRAINING PROGRAMS ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed for Freestanding ambulatory surgery center (ASC) Managers (Business, Nurse, Reimbursement), Directors, Administrators, Coding Supervisors, Coding Specialists, and Billers. The contents include: Current Freestanding ASC Structure, Proposed Freestanding ASC Structure, Medicare Coding Requirements, Medicare Billing Requirements, Coding Ambulatory Surgery, How To Use CPT When Coding Ambulatory Surgery, and CPT Coding Guidelines By Body System (Integumentary, Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic, Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital, Endocrine, Nervous, Eye and Ocular Adnexa, Auditory). ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: tissue expander, pedicle flap, pressure ulcer, skin grafts, nail avulsion and excision, scar revision, burn treatment, lesion excisions, wound repair, adjacent tissue transfer/rearrangement, breast surgery, free flaps with microvascular anastomosis. ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: cataracts. intraocular lens, keratoplasty, trabeculectomy, strabismus surgery, punctum plugs, tarsorrhaphy, trichiasis correction, retinal detachment repair, vitrectomy. Advanced Clinic Hand Surgery 6 ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: hernia repair, nasogastric intubation, percutaneous gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage, dental procedures, covered and noncovered colorectal cancer screening, gastrointestinal endoscopy, esophageal dilation. ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: ganglion cyst, joint injections, decompression fasciotomy, treatment of fractures/dislocations, skeletal anatomy of the hand and foot, surgical knee arthroscopy, bunionectomy, toe-to-hand transfer with microvascular anastomosis. ASC Clinic: Urology Procedures - This 6.5 hour program is designed for all technical, clinical and managerial staff responsible for facility component freestanding ASC coding and billing. The contents include: exercises based on actual outpatient operative reports; and CPT coding guidelines for topics such as: retrograde pyelogram, ureter vs. urethra, urethral dilation, ureteral stent, urethral stent, Burch Procedure, vesicourethropexy/urethropexy, urodynamics, chemotherapy. Advanced Clinic Hand Surgery OBJECTIVE: This program will first provide a detailed review of the hand surgery CPT coding guidelines to assist the participants in their understanding of the numerous techniques that are performed. “Real life” operative report case studies will also be presented for many of the hand surgery techniques that are discussed. 7 Advanced Clinic Hand Surgery Clinical Coder: Tendon Surgery Orthopaedics staff often find that selecting the appropriate CPT code for the repair of a lacerated or ruptured tendon of the hand or finger can be as complex as the surgery itself. Tendon repairs of the hand or finger are classified to code range 26350–26504 in the CPT manual. Code selection depends on the type of tendon and procedure performed, and the anatomic site. Understanding what the code narrative describes helps you translate the procedure statement into accurate codes, the key to appropriate reimbursement. This tool explains the medical terminology surgeons often use in the operative report and details what each tendon repair code describes. Before you review the information in the grid, you need to understand some basic tendon anatomy, described below. a. Hand and Finger Tendons Tendons are fibrous connective tissues that attach muscles to bones, as well as to other tissues. The type of tendon is classified according to the movement of the associated muscle. That is, tendons associated with the muscle that causes a part of the body, such as the hand or finger, to bend are called flexors. Those that extend a part of the body are called extensors. Tendons that are near the surface are described as “superficialis,” and those that are deep seated are termed “profundus.” When hand or finger tendons are lacerated or ruptured, the surgeon may perform a primary or secondary repair. In the primary repair, the tendon is sutured or reconstructed immediately after the injury. In the secondary repair, the suturing or reconstruction is delayed to allow the tendon or sheath to heal before it is repaired. Secondary repairs may require a tendon grafting, which may include induction of a sheath using silastic rods. 8 Advanced Clinic Clinical Coder: Tendon Surgery – continued FLEXOR TENDONS – HAND/FINGERS flexor pollicis longus tendon palmaris longus tendon index finger flexor digitorum superificialis middle finger flexor digitorum superficialis ring finger flexor digitorum superficilias little finger flexor digitorum superficialis index finger flexor digitorum profundus middle finger flexor digitorum profundus ring finger flexor digitorum profundus little finger flexor digitorum profundus flexor pollicis longus flexor carpi radialis flexor carpi ulnaris palmaris longus pronator teres EXTENSOR TENDONS WRIST/FOREARM extensor origin brachioradialis tendon supinator tendon abductor pollicis longus tendon extensor pollicis longus tendon extensor pollicis brevis tendon extensor indicis proprius tendon extensor digitorum communis tendon of the index finger extensor digitorum communis tendon of the middle finger extensor digitorum communis tendon of the ring finger extensor digitorum communis tendon of the little finger extensor digiti minimi tendon extensor carpi radialis longus tendon extensor carpi radialis brevis tendon extensor carpi ulnaris tendon extensor pollicis brevis muscle extensor carpi radialis longus muscle extensor carpi radialis brevis muscle extensor pollicis longus muscle extensor indicis proprius muscle extensor digiti minimi muscle extensor carpi ulnaris muscle Hand Surgery 9 Advanced Clinic Clinical Coder: Tendon Surgery – continued EXTENSOR TENDONS – DIGIT extensor tendon of the index finger extensor tendon of the middle finger extensor tendon of the ring finger extensor tendon of the littler finger extensor mechanism of the index finger extensor mechanism of the middle finger extensor mechanism of the ring finger extensor mechanism of the little finger radial sagittal band of the index finger radial sagittal band of the middle finger radial sagittal band of the ring finger radial sagittal band of the little finger ulnar sagittal band of the index finger ulnar sagittal band of the middle finger ulnar sagittal band of the ring finger ulnar sagittal band of the little finger central slip of the index finger central slip of the middle finger central slip of the ring finger central slip of the little finger radial lateral band of the index finger radial lateral band of the middle finger radial lateral band of the ring finger radial lateral band of the little finger ulnar lateral band of the index finger ulnar lateral band of the middle finger ulnar lateral band of the ring finger ulnar lateral band of the little finger terminal extensor tendon of the index finger terminal extensor tendon of the middle finger terminal extensor tendon of the ring finger terminal extensor tendon of the little finger Hand Surgery 10 Advanced Clinic b. Hand Surgery 11 CPT Coding Tips and Traps Although knowing the ins and outs of tendon repairs is essential to coding them correctly, it’s also important to follow a couple of reporting guidelines, which are often overlooked by coders. Read parenthetical notes: The note “includes obtaining graft” means that the harvesting of a tendon graft, even from a distant site (code 20924) is an integral part of the repair procedure and should not be coded separately. Other notes, such as “boutonniere deformity,” describe the reason for the procedure. Closely reviewing the code description for such diagnostic terms will ensure accurate code assignment. Code all repairs: Another point to keep in mind is that each code describes surgery performed on one tendon. Not reporting all tendons repaired could mean lost dollars for the facility. If you are unsure of the number of tendons repaired, seek the surgeon’s assistance. Finally, keep in mind that not all third-party payers follow the same reporting and reimbursement guidelines for tendon repairs. It is important to check with the payer in question for its coding and reimbursement policies. Advanced Clinic Hand Surgery 12 Clinical Coder: Tendon Surgery—continued CPT Code Procedure Description Diagnostic Implications 26350 Simple suturing, or advancing and suturing of superficial or deep (profundus) tendon proximal or distal to tendon sheath Lacerations of palmar surface of hand, forearm or finger with tendon involvement This code describes repairs or advancements in areas of the hand proximal to the midpalm crease or distal to the middle third of the middle finger (not “no man’s land”). 26352 Secondary reconstruction with flexor tendon grafting of flexor superficial or deep (profundus) tendon proximal or distal to tendon sheath Inability to perform a primary repair because of treatment delay or primary repair failure Harvesting of free tendon graft, locally or from a distance, is included in this procedure and should not be coded separately. 26356 Suturing, or advancing and suturing of superficial or deep (profundus) in “no man’s land” Injury in tendon sheath “No man’s land” refers to the critical area from the midpalm crease to the distal interphalangeal (DIP) joint. Comments Many times, the diagnosis is missed in the emergency room, and the patient is not evaluated early in the course of the disease. A portion of tendon may still be intact and then rupture a few days later, delaying the repair. 26357 Repair of flexor tendon in sheath after scar tissue has begun to form around damaged tendon or sheath Sometimes called “delayed primary repair.” Can be performed if the tendon has not retracted and the sheath has few adhesions—often seen after clean lacerations The term “delayed primary repair” varies among surgeons to mean three to 21 days or more. continued Advanced Clinic Hand Surgery 13 Clinical Coder: Tendon Surgery—continued CPT Code Procedure Description Diagnostic Implications 26358 Replacement of damaged tendon in tendon sheath after reaction of injury has subsided Tendon has retracted too far to make simple repair Comments This code describes onestage grafting without prior creation of a sheath by silicone rod. For twostage grafting, see codes 26390 and 26392. Harvesting of a free tendon graft, locally or from a distance, is included in this procedure and should not be coded separately. 26370 Suturing, or advancing and suturing of deep (profundus) flexor tendon in flexor sheath distal to intact flexor digitorum superficialis Performed if shortening is less than 1 cm and extreme flexion of finger is not necessary to take tension off repair Occasionally, the profundus tendon is cut after it passes through the superficialis tendon decussation distal to the proximal interphalangeal (PIP) flexion crease. If the profundus (deep) tendon has been avulsed or enough of the end is damaged to require resection of a small amount, the tendon can be advanced up to 1 cm and be reattached directly to the distal phalanx. If the tendon is sharply lacerated, an end-to-end repair can be performed. continued Advanced Clinic Hand Surgery 14 Clinical Coder: Tendon Surgery—continued CPT Code Procedure Description 26372 Replacement of damaged deep (profundus) tendon in flexor sheath distal to intact flexor digitorum superficialis Diagnostic Implications Comments This procedure code describes delayed repair with a free tendon graft. For delayed repair without grafting, see code 26373. Harvesting of a graft is included in this code and should not be coded separately. 26373 Suturing, or advancing and suturing of damaged deep (profundus) tendon in flexor sheath distal to intact flexor digitorum superficialis 26390 Excision of flexor tendon and surrounding scar tissue with insertion of plastic (Hunter) rod or tube to establish a flexor sheath for subsequent tendon grafting This procedure does not include tendon grafting. See code 26372. Excessive scarring of tendon bed, and joint stiffness This procedure is the first stage of a two-stage delayed tendon grafting. In the first stage, a silicone rod may be used to create a tendon sheath. In the second stage, tendon grafting is performed. Delayed flexor tendon grafting without rods to create tendon channels is classified as CPT codes 26352, 26358 and 26372. continued Advanced Clinic Hand Surgery 15 Clinical Coder: Tendon Surgery—continued CPT Code Procedure Description Diagnostic Implications 26392 Delayed flexor tendon grafting after creating channels for tendon sliding This procedure includes harvesting of a tendon graft. 26410 Suturing, or advancing and suturing of an extensor tendon on back of hand Use code 26418 or 26420 to report the repair of tendon dorsum of the finger. 26412 Suturing, or advancing and suturing of an extensor tendon on back of hand with tendon graft This procedure includes harvesting of a tendon graft. 26415 Insertion of plastic tube or rod to create tendon channel prior to tendon grafting 26416 Delayed extensor tendon grafting of hand or finger Heavy scarring on back of hand Comments A plastic tube or rod is inserted, allowing the body to create a new sheath into which a tendon graft or transfer can be placed for extension of the fingers. This is the second stage of a delayed extensor tendon grafting in which the implanted rod or tube is removed and a tendon is grafted or transferred. continued Advanced Clinic Hand Surgery 16 Clinical Coder: Tendon Surgery—continued CPT Code Procedure Description Diagnostic Implications 26418 Suturing, or advancing and suturing of extensor tendon on back of finger Laceration or rupture of extensor tendon, finger A simple laceration can often be managed with simple cleansing of a wound and direct suture or merely positioning adjacent joints in full extension for six weeks to allow proper healing. If treatment is delayed, Mallet finger or boutonniere deformity may develop and require more extensive surgery or a graft. 26420 Repair of extensor tendon by tendon graft to replace portion of tendon lost or shortened due to delay in treatment Inability to straighten finger A graft can be required if the tendon is shortened due to a delay in treatment of an injury or if some tendon was lost due to an injury. Normal balance of the finger does not tolerate a discrepancy in length. 26426 Repair of extensor tendon lost or shortened due to delay in treatment Boutonniere deformity (deformity of the finger characterized by flexion of PIP joint and hyperextension of distal joint) If the injury is old, some readjustments of local tissue may provide adequate extension. If tissue is just shortened and not lost, this rearrangement may be adequate. If tissue is lost, a graft will be necessary. 26428 Repair of extensor tendon by tendon graft to replace portion of tendon lost or shortened due to delay in treatment Comments Harvesting of the graft is included and should not be coded separately. continued Advanced Clinic Hand Surgery 17 Clinical Coder: Tendon Surgery—continued CPT Code Procedure Description Diagnostic Implications 26432 Closed treatment of extensor tendon, laceration or rupture of the distal insertion, with or without fracture of dorsal lip of distal phalanx Mallet finger (an avulsion of the insertion of the extensor tendon at the base of the distal phalanx). A fragment of bone may be avulsed along with the tendon. 26433 Open reattachment of extensor tendon, laceration or rupture of the distal insertion, using local tissues only 26434 Open reattachment of extensor tendon, insertion laceration or rupture, with tendon graft Comments If there is no fracture, the patient usually needs to have the DIP joint splinted in extension for six or more weeks. If there is a fracture, percutaneous pinning— placing a pin through the fracture site or across the DIP joint under x-ray guidance—may be used to stabilize the joint without splinting. This procedure is performed rarely. Shortening of tendon caused by loss of tendon or delay in treatment Repair may include pinning of the fracture or joint to maintain extension. Advanced Clinic Hand Surgery This Page Was Left Blank Intentionally. 18 Advanced Clinic Hand Surgery Clinical Coders: Anatomy of the Hand Source: Melloni, June L. et al. Melloni’s Illustrated Review of Human Anatomy. Philadelphia: J.B. Lippincott Co., 1988. 19 Advanced Clinic Hand Surgery Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994. 20 Advanced Clinic Hand Surgery Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994. 21 Advanced Clinic Hand Surgery Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994. 22 Advanced Clinic Hand Surgery Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994. 23 Advanced Clinic Hand Surgery Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994. 24 Advanced Clinic Hand Surgery Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994. 25 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 26 Advanced Clinic Hand Surgery 27 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 28 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 29 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 30 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 31 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 32 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 33 Advanced Clinic Hand Surgery Source: Surgical Exposures in Orthopaedics, The Anatomic Approach, Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott Company, Philadelphia, PA. 34 Advanced Clinic Hand Surgery 35 CPT Coding Guidelines See codes 20920 and 20922 (fascia lata graft) for application of an anchovy. This term is used in microsurgery and hand surgery and refers to a rolled up piece of fascia lata (that looks like an anchovy). Carpometacarpal Joint Interposition Arthroplasty: Per the article “First Carpometacarpal Joint Arthritis,” by Nathaniel P. Cohen, MD and Melvin Rosenwasser, MD: “Carroll and Fromison have described excisional arthroplasty combined with a rolled tendon interposition graft, the “anchovy procedure.” In this, a strip of tendon from the flexor Carpi radialis or from the palmaris longus is rolled into a ball and placed into the space created by the excision of the trapezium.” Code 25447 classifies a carpometacarpal joint interposition arthroplasty. An additional CPT code should also be assigned for the tendon transfer. Sublimis or profundus flexor tendon transposition: assign 25310 (forearm/wrist tendon transplantation or transfer) for sublimis or profundus flexor tendon transposition. Source: June 2002 CPT Assistant newsletter, AMA. Tenolysis and capsulotomy on the flexor tendon in the interphalangeal (IP) joint: report both codes 26440, Tenolysis, flexor tendon; palm OR finger, each tendon, and code 28272–59, Capsulotomy; interphalangeal joint, each joint (separate procedure). A capsulotomy is performed on the joint in an attempt to increase the range of motion of the joint and/or release a contracture. A tenolysis releases scar tissue, which binds a tendon to surrounding structures, allowing for improved motion of the tendon. Capsulotomy and tenolysis are distinct procedures, which can be performed independently, or in some cases, together. Source: December 2002 CPT Assistant newsletter, AMA. Code 26440, Tenolysis, flexor tendon; palm or finger; each tendon, includes capsulectomy of the interphalangeal joint when performed. Source: April 2002 CPT Assistant newsletter, AMA. Advanced Clinic Exercises Hand Surgery 36 Advanced Clinic Hand Surgery 37 Exercise 1. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT SURGEON: ASSISTANT: None. PREOPERATIVE DIAGNOSIS: Right wrist ganglion cyst and left wrist ganglion cyst. POSTOPERATIVE DIAGNOSIS: Right wrist ganglion cyst and left wrist ganglion cyst. OPERATION: Right wrist excision of dorsal ganglion. Left wrist aspiration of dorsal ganglion. ANESTHESIA: Intravenous sedation. INDICATIONS: This is a 39-year-old female who has had bilateral painful mass on the wrists. Her right wrist has recurred multiple times after aspiration. The left wrist has recently grown to about 2.5 cm and we had aspirated this today under local anesthetic and sterile prep. PROCEDURE/FINDINGS: The patient as placed in the supine position on the operating room table. After adequate intravenous sedation was given, she had a block of 0.25% Marcaine into the right wrist. She was prepped and draped in the usual sterile fashion. The arm was elevated and tourniquet inflated to 250 mm Hg. Then a transverse incision was made overlying the mass and carried down through the skin. The subcutaneous tissue was carefully dissected. The sensory nerves were retracted medially and laterally. The extensor mechanism was opened. I opened the retinaculum and the extensor tendons were retracted medially and laterally. We then found the ganglion cyst. It was approximately 3-cm in diameter and had a tract both radially and ulnarly. We dissected around the cyst completely with the surrounding fibrofatty tissue and followed this down to its origin in the dorsal wrist capsule at the region of the scaphoradial joint. We excised it with a portion of the capsule and its serpiginous tail. We also excised a portion of the posterior interosseous nerve, which was lying in direct contact with this mass. We then copiously irrigated the wound. We obtained hemostasis and cauterized the area of cyst excision. We closed this with a running 3-0 Prolene subcuticular suture. Benzoin and Steri-Strips, 4 by 4’s, bulky dressing and plaster splint were applied. The patient tolerated the procedure well and was discharged to the recovery room in satisfactory condition. Advanced Clinic Hand Surgery 38 Exercise 1 - continued PATHOLOGY REPORT Age/Sex: 39/F PREOPERATIVGE DIAGNOSIS: RIGHT WRIST GANGLION, BILATERAL OPERATION PERFORMED: RIGHT-EXCISION GANGLION WRIST; ASPIRATION CYST; REMOVAL RIGHT WRIST, LEFT WRIST ASPIRATION GANGLION. TISSUE REMOVED: A. GANGLION RT WRIST GROSS DESCRIPTION: RECEIVED LABELED GANGLION RT WRIST. THE SPECIMEN CONSISTS OF A RUBBERY FIRM PINK-TAN TISSUE MEASURING 1.5 X 0.5 X 0.3 CM. THE SPECIMEN IS SERIALLY SECTIONED ON THE SHORT AXIS DIRECTION REVEALING A RUBBERY FIRM PINK-TAN CUT SURFACE. ALL BLOCKED. PATH PROCEDURES: PROCEDURES: PATH DSM, A1 BLK FINAL DIAGNOSIS: SOFT TISSUE, RIGHT WRIST, EXCISION: FIBROADISPOSE TISSUE WITH FOCAL MYXOID CHANGES PRESENT, CONSISTENT WITH GANGLION CYST. Signed ____________________ Advanced Clinic Hand Surgery 39 Exercise 2. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT Operation: Release of long and ringer trigger fingers bilaterally. Anesthesia: Local 2% Xylocaine median and ulnar nerve blocks bilaterally. Preoperative diagnosis: Long and ring trigger fingers bilaterally. Postoperative diagnosis: Long and ring trigger fingers bilaterally. Operative Indications: The 49-year-old patient developed triggering of the long and ring fingers of both hands. Conservative treatment was unsuccessful. He had a closed percutaneous release of the left ring trigger finger which was unsuccessful. Operative Findings: There was some superficial fraying of the superficialis tendon of the right long finger. There were some adhesions between the two flexor tendons in each of the fingers. There was marked fraying of the superficialis and moderate fraying of the profundus tendon in the left ring finger. The Al pulley was very tight. There was some tenosynovitis proximal to the Al pulley. The Al pulley had been partially divided at its proximal end. After the releases, the patient was able to fully flex and extend his fingers without any catching or locking. Operative Procedure: The right hand was done first. A transverse incision was made between the proximal and distal palmar creases at the bases of the long and ring fingers. The flexor sheaths were exposed. The Al pulleys were divided. The tendons were inspected. The fraying of the superficialis tendon of the long finger was minimally debrided. The skin was closed with #4-0 nylon sutures. A dry, sterile, bulky, compressive type dressing was applied. The pneumatic tourniquet was released. The left hand was then done. A transverse incision was made between the proximal and distal palmar creases at the bases of the long and ring fingers. The flexor sheaths were exposed. The Al pulley of the long finger was divided. A Transverse incision was made in the proximal flexor crease of the ring finger to further expose the flexor sheath and the tendon. The frayed edges of the tendons were debrided. Localized tenosynovectomy was carried out. The patient was then able to fully flex and extend his fingers without any catching or locking. The skin was closed with #4-0 nylon sutures. A moist, bulky, compressive type dressing was applied. The pneumatic tourniquet was released. Advanced Clinic Hand Surgery 40 Exercise 2 - continued The patient tolerated the procedure well and was sent to the recovery room in satisfactory condition. Drains: None. Complications: None. Estimated Blood Loss: None. I was present during the entire operation. Advanced Clinic Hand Surgery 41 Exercise 3. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSES: 1. Trigger finger, left ring. 2. Trigger finger, left little. 3. Trigger finger, right ring. POSTOPERATIVE DIAGNOSES: Same. OPERATIVE PROCEDURES: 1. Release of trigger finger, left fourth finger. 2. Release of trigger finger, left fifth finger. 3. Injection of Kenalog 40 into tendon sheath of right ring finger. INDICATIONS FOR OPERATION: The patient is a 62-year-old man with stenosing tenosynovitis of the flexor tendons of his right and left hands. He has had severe triggering of his left ring and little fingers. He has moderate triggering of the right ring finger. Careful discussion has been undertaken over the surgical procedures of releasing of the A-1 pulley of the flexor tendons to alleviate triggering. He understands that there is a small possibility of complications because of injury to the adjacent neurovascular bundles and that the injection has no guarantee of success. Because he has symptoms of both right and left hands, injections will be performed on the right hand and release will be performed on the left. The following procedure was performed. DESCRIPTION OF PROCEDURE: The patient was placed on the operating room table in the supine position. Adequate intravenous sedation was given to allow for anesthetization of the right and left palmar area with 0.5% Marcaine plain. A pneumatic tourniquet was then placed on the left upper arm. The left arm and hand were then prepped with Hibiclens solution and draped with sterile technique. The left arm and hand were then exsanguinated with an Esmarch bandage and the pneumatic tourniquet was elevated to 280 mmHg pressure. A transverse skin crease incision was made overlying the metacarpal phalangeal joint on the palmar aspect of the left hand between the fourth and fifth fingers. The skin and subcutaneous tissues were incised. The palmar aponeurosis was divided in the direction of its fibers. The flexor tendon was then bluntly exposed allowing the neurovascular bundles to deviate to the sides. The A-1 pulley of the left ring finger was then divided longitudinally and the flexor tendon was retracted to make sure that it was completely mobile within the canal. The same technique was then used on the left fifth finger flexor tendon to divide the A-1 pulley and to make sure that it was completely released. Advanced Clinic Hand Surgery 42 Exercise 3 - continued The pneumatic tourniquet was then released with a total tourniquet time of 5 minutes. The patient was asked to flex and extend his hand and was found to have no triggering of the ring or little finger. Hemostasis was then obtained with pressure, elevation, and the electrocautery. The wound was then closed with interrupted horizontal mattress and continuous simple sutures of 5-0 nylon. Sterile dressings of Xeroform gauze and a volar splint of 3 inch fiberglass were applied. On the right palm, the anesthetization had been obtained with 0.5% Marcaine over the metacarpal phalangeal joint of the right ring finger. A 25-gauze needle with a 3 cc syringe and 0.5% Kenalog 40 were then used to inject into the flexor tendon sheath of the right ring finger. The finger was then placed through a range of motion. The wound was left undressed. The patient was awakened and taken from the operating room in satisfactory condition having tolerated the procedures well. Estimated blood loss was minimal. Sponge and instrument counts were correct at the end of the operation. Advanced Clinic Hand Surgery 43 Exercise 4 . Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Extensive adhesions left index finger flexor digitorum profundus and flexor digitorum superficialis tendon, nine months status post flexor tendon repair tendon repair in zone 2. POSTOPERATIVE DIAGNOSIS: Extensive adhesions left index finger flexor digitorum profundus and flexor digitorum superficialis tendon, nine months status post flexor tendon repair in zone 2. OPERATION: Tenolysis left index finger flexor digitorum profundus and flexor digitorum superficialis tendons. ANESTHESIA: Bier block. TOTAL TOURNIQUET TIME: 105 minutes at 250 mmHg. BLOOD LOSS: Minimal. INDICATIONS: The patient is a 59-year-old right hand dominant retired who has become well known to me over the past nine months. She initially presented on January 23, 2003 after sustaining a laceration to the palmar aspect of the left index finger which resulted in lacerations of both the FDP and FDS tendons and both digital nerves to the index finger. Her tendons and nerves were repaired the same day. She initially did well for the first five weeks postoperatively and motion was impressive. Unfortunately, at that point, she went on vacation for a week and, despite having continued with exercises, developed marked adhesions between weeks five and six. We have spent a great deal of time performing therapy in the interim in order to try to free these adhesions. It ultimately became clear that these were fixed and additional time was allowed for scar to soften up. She has clearly plateaued in terms of therapy and in terms of scar remodeling and is prepared at this time to undergo tenolysis. She understands that tenolysis is designed to free the flexor tendons from the scar that has formed between them and the adjoining structures. This will allow freer gliding of the tendons. In order to maintain this motion, active therapy immediately following the release is necessary. This is made possible by the fact that the tendons are now strong and can withstand this stress. Without such early motion, adhesions will reform and may in fact be worse. Advanced Clinic Hand Surgery 44 Exercise 4 - continued She understands this. She understands that all surgery is attended by risk including the risks of infection, wound healing difficulties, injury to the tendons themselves or to adjacent nerves, the potential for rupture at or following the surgery, the potential for the reformation of adhesions, and the certainty of a less than ideal result should she not participate in postoperative rehabilitation aggressively. She understands and accepts these risks and, after having all of her questions answered to her satisfaction, has signed the appropriate consent forms in witness there of. DESCRIPTION OF PROCEDURE: The patient was identified in the preoperative holding area where an intravenous line was placed in her affected left hand by the anesthesiologist. She was then transferred to the operating room where she was placed supine on the operating table. At that point, her anesthesiologist, the doctor performed a Bier block with my assistance. With this done, the intravenous line in the left hand was removed and her left upper extremity was prepped and draped in the usual sterile fashion with a Betadine scrub and paint from the fingertips to the tourniquet. The case was performed under 2.5 x loupe magnification. I began by making a 2 cm long incision in the distal palmar crease at the Al pulley level. The skin was incised sharply and the subcutaneous tissue dissected bluntly to reveal the underlying flexor digitorum profundus and flexor digitorum superficialis tendons. After isolating these, traction was applied in an effort to effect a traction tenolysis. This was completely ineffective at this level. It was clear that I was not going to be able to pull through the dense scar over the proximal phalangeal level. At this point, I proceeded to expose the palmar aspect of the finger. This was done through a curved incision making every effort to avoid cutting across the palmar surface of the finger as much as possible. Transverse limbs were placed in the flexion creases at the MP, PIP and DIP joint and the longitudinal segments were kept as laterally as possible. The skin was incised sharply here and careful blunt dissection was carried out to divide the skin from the underlying scar. This was an arduous process as the scar was quite dense and quite thick. With the skin flaps raised, care was then taken to identify the radial and ulnar digital nerves. These were traced from the level of the MP flexion crease out to the DIP flexion crease and were noted to be intact and healthy appearing. With the nerves isolated, I began to address the scar overlying the flexor tendons. The scar was debrided to reveal the A1 and A4 pulleys which were largely intact. The A3 pulley had been damaged in the initial injury. With the superficial scarring removed, I was able to use the A3 pulley window to bluntly divide scar deep to the flexor digitorum superficialis. Finally, with this done, I returned to the palmar wound where traction was applied and, at this point, having removed as much of the scar surgically, a traction tenolysis was effective in completing the release of the adherent tendons. Advanced Clinic Hand Surgery 45 Exercise 4 - continued At the completion of the procedure, I was able to bring the left index fingertip to within 7 mm of the distal palm via traction through the A1 pulley level. This was essentially the passive limit or her joint motion. She has a 36 degree flexion contracture at the PIP joint, but I decided that in the interest of allowing her the best chance at maintaining her flexion I would not do a significant release at the PIP joint, which would cause her more pain and likely inhibit her ability to perform active rehabilitation. We will do that at a later date if she desires. After cleaning up the remnants of the scar and assuring that both digital nerves remained intact, the wound was irrigated copiously with dilute Betadine saline solution. The skin over the finger was closed and again traction was placed at the palmar wound. The fingertip actually came slightly closer to the palm approximately 6 mm from the distal palm. Satisfied with the release, the finger closure was completed with interrupted sutures of #5-0 nylon and the palmar wound was closed with interrupted horizontal mattress sutures of #5-0 nylon. A soft dressing consisting of Xeroform over the incision and a Kling wrap was applied and secured with an Ace bandage. At the completion of the case, sponge, needle and instrument counts were correct. Total tourniquet time was 105 minutes at 250 mmHg. There were no complications. At the completion of the case, the patient was accompanied to the PACU awake and in stable condition. COMPLICATIONS: Advanced Clinic Hand Surgery 46 Exercise 5. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE RECORD PREOPERATIVE DIAGNOSIS: Dupuytren disease, left palm. POSTOPERATIVE DIAGNOSIS: Dupuytren disease, left palm, pathology pending. OPERATION: Palmar fasciectomy, left palm. ANESTHESIA: Local. INDICATIONS: This is a 66-year-old female with a painful pretendinous band in the left palm who presents for definitive treatment. PROCEDURE: The patient was taken to the operating room and placed in the supine position. A tourniquet was placed high on the left upper extremity, and the left upper extremity was prepped and draped in the usual sterile fashion. Infiltration with 0.5% Marcaine with epinephrine was performed for anesthesia using a field block. Next, the arm was elevated and exsanguinated. The tourniquet inflated to 250 mmHg. The total tourniquet time was less than 2 hours. Using a chevron-shaped incision, the skin was incised. The skin was sharply taken down off of the underlying diseased fascia. The pretendinous band was exposed. The proximal extent of it was identified and cut. The mass was excised incorporating normal superficial palmar fascia. The mass was sent to pathology for appropriate study after releasing it from its most distal end in the palm. The wound was copiously irrigated. Hemostasis obtained with electrocautery. The skin was gently approximated with 5-0 nylon. Xeroform and a bulky dressing were applied and held with Kerlix and an Ace wrap. Estimated blood loss was minimal. The IV fluid replaced was none. Drains and packs were none. Complications were none. The patient tolerated the procedure well and was taken to the recovery room in a good postoperative condition. Advanced Clinic Hand Surgery Exercise 5 - continued SURGICAL PATHOLOGY REPORT Age: 1/17/37 Sex: F CLINICAL DIAGNOSIS: Deep Mass Left Palm TISSUE SUBMITTED: Mass Left Palm IMPORTANT CLINICAL DATA: GROSS: MASS LEFT PALM. The specimen is received in formalin and consists of a shaggy, partially cystic structure measuring 1.3 x 0.6 x 0.5 cm. The specimen will be bisected and submitted in toto. DIAGNOSIS: TISSUE FROM LEFT PALM: FIBROTENDINOUS TISSUE SHOWING FIBROBLASTIC PROLIFERATION, COMPATIBLE WITH PALMAR FIBROMATOSIS. 47 Advanced Clinic Hand Surgery 48 Exercise 6. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT OPERATION: Left little finger palmar and digital fasciectomies for Dupuytren’s. ANESTHESIA: Axillary block. PREOPERATIVE DIAGNOSIS: Moderate to severe left little finger Dupuytren’s. POSTOPERATIVE DIAGNOSIS: Moderate to severe left little finger Dupuytren’s. OPERATIVE INDICATIONS: The patient is a 74-year-old male who has left little finger Dupuytren’s primarily of the proximal interphalangeal and distal interphalangeal joints. He has significant contracture across both of these joints. OPERATIVE FINDINGS: Moderate severe palmar disease and severe proximal interphalangeal and distal interphalangeal joint disease involving the left little finger. OPERATIVE PROCEDURE: With consent from the patient, he was taken to the operating room. In the supine position, an axillary block was placed by anesthesia. Anesthesia administered intravenous sedation. Anesthesia monitored the patient continuously during the procedure. The extremity was prepared with Betadine and draped out. With adequate anesthesia, the preoperative markings were marked out. The extremity was exsanguinated. The incision was made with a #15 Bard-Parker. Carefully and delicately, the dermis was dissected off the overlying diseased fascia. The ulnar and radial neurovascular bundles were identified out distally. These were dissected out carefully with a Beaver blade and Stevens’ scissors. The ulnar and radial neurovascular bundles were then dissected back proximally exposing them along their length of the finger to the palm. In doing this, the diseased fascia was carefully dissected aware from the surrounding dermis and soft tissue. The diseased fascia was also dissected away from the flexor sheath. Ulnarly, the disease inserted beyond the distal interphalangeal joint into the flexor sheath. Significant insertions of the diseased fascia were dissected off the distal interphalangeal joint and proximal interphalangeal joint areas. Additionally, proximally the diseased fascia was dissected off the musculotendinous origin of the abductor digiti minimi. Bleeding was controlled with bipolar cautery. Advanced Clinic Hand Surgery 49 Exercise 6 - continued The tourniquet was released. The little finger remained well perfused. The wound was irrigated out. Bleeding was controlled with bipolar cautery. A Z-plasty was performed across the metacarpophalangeal crease. The skin edges were reapproximated with #50 nylon. The wound was dressed with Xeroform, fluffs, Webril and ulnar gutter splints with the wrist extended 20 degrees, metacarpophalangeal joint at 70 degrees and interphalangeal joint at 0. SPECIMEN: Bacteriological: None. Pathological: The palmar and digital diseased fascia was submitted. PROSTHETIC DEVICE OR IMPLANT: None. ESTIMATED BLOOD LOSS: Less than 10 milliliters/blood given, none. FLUIDS: Crystalloid. SPONGE COUNT: Correct. POSTOPERATIVE CONDITION: Fair, stable. Advanced Clinic Hand Surgery 50 Exercise 6 - continued SURGICAL PATHOLOGY FINAL DIAGNOSIS: LITTLE FINGER (EXCISION) - FIBROMATOSIS (DUPUYTRENS CONTRACTURE) ************************************************************************ ***** SPECIMEN(S) SUBMITTED: LEFT LITTLE FINGER DUPUYTRENS CLINICAL DATA: Left little finger contracture GROSS DESCRIPTION: A. Received fresh are two pieces of soft irregular shaped white fibrous tissue with attached fibroadipose tissue which measure in aggregate 5 x 1 x 0.5 cm. Specimens are serially sectioned and representative sections are submitted. (Age: 74) M Advanced Clinic Hand Surgery 51 Exercise 7. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Recurrent Dupuytren’s contracture of the left little finger with significant proximal interphalangeal joint contracture of 80 degrees. POSTOPERATIVE DIAGNOSIS: Recurrent Dupuytren’s contracture of the left little finger with significant proximal interphalangeal joint contracture of 80 degrees. OPERATION: 1. Excision of digital palmar fascia with skin grafting from the ulnar border of the hand to the proximal interphalangeal joint level. 2. Release of volar plate and joint contracture of the proximal interphalangeal joint. INDICATIONS: This is a 64-year-old female who had had excision of digital palmar fascia several years ago on left little finger. She was noncompliant with the brace and rehab protocol initially postop, and she had progressed down from approximately 35- to 40- degree contracture when she was last seen to almost 80 degrees at this point in time. To try to stop any bridging fascial cords, it was elected that we would skin graft at the PIP joint with this release. PROCEDURE: The patient was placed in the supine position on the operating table. After adequate intravenous sedation was given, she had a block of the ulnar nerve at the wrist with 0.25% Marcaine and 2% Xylocaine plain. She was prepped and draped in the usual sterile fashion. The arm was elevated, and the tourniquet was inflated to 250 mmHg. Then a Bruner zigzag incision was made overlying the finger and was carried down to the skin, carefully dissecting the subcutaneous tissue and lifting a flap. We exposed and protected the neurovascular bundles and excised the diseased cords. Then we opened the tendon sheath and excised a portion of the volar plate and released the accessory and collateral ligaments to the finger at the PIP joint. We obtained full extension intraoperatively. We measured the size for the proposed skin graft and removed a 2.5 x 1.5 cm skin graft from the lateral margin of the hand. The skin was carefully dissected, and a full-thickness graft was obtained. The flaps were elevated. Advanced Clinic Hand Surgery 52 Exercise 7 - continued Hemostasis was achieved, and the graft site was closed primarily with 5-0 Prolene sutures. The finger was closed with 5-0 Prolene sutures as the graft was interposed at the PIP joint level. Once this was completed, we applied Xeroform, soft bulky dressing, and a plaster splint to keep the finger in full extension. The patient tolerated the procedure well and was discharged to the recovery room in satisfactory condition. Advanced Clinic Hand Surgery 53 Exercise 8. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Dupuytren disease, right hand. POSTOPERATIVE DIAGNOSIS: Dupuytren disease, right hand. OPERATION: Excision of Dupuytren disease, right hand from right thumb, right middle finger, and right palm. ANESTHESIA: General. INDICATIONS: This is a 56-year-old female with painful and large Dupuytren nodules at the aspect of the first webbed space by the thumb also at the PIP joint of the middle finger with approximately 30% contracture and at the A1 pulley area in line with the ring finger. She desires definitive treatment and presents for excision. PROCEDURE: The patient was taken to the operating room and placed in the supine position. After general anesthesia was obtained, a tourniquet was placed high on the right upper extremity, and the right upper extremity was prepped and draped in the usual sterile fashion. First, the arm was exsanguinated and the tourniquet inflated to 250 mmHg. The total tourniquet time was less than 2 hours. Infiltration was 0.5% Marcaine was performed at each of the sites where the Dupuytren disease was present for postoperative anesthesia. First, attention was directed to the palmar area in line with the ring finger. A transverse incision was made at the distal/palmar crease where the disease was present. The skin was sharply dissected away from the disease. Circumferential dissection of the disease was completed. It was cut distally and dissected proximally. Careful attention paid to protect the underlying neurovascular bundles and flexor tendon. The disease was completely excised and sent to Pathology. The wound was copiously irrigated. Hemostasis was obtained with electrocautery. The skin gently approximated with 5-0 nylon. Next, attention was paid to the PIP joint of the middle finger, where again a transverse incision was made at the PIP crease. Circumferential dissection was carried out around the ulnar aspect of the digit. The ulnar neurovascular bundle was first identified and then dissection carried out and completed around the disease. It was also released proximally and dissected distally. It was taken off of the middle phalanx, and this helped correct the 30% contracture of the PIP joint. Advanced Clinic Hand Surgery 54 Exercise 8 - continued Next, attention was paid to the first webbed space just below the thumb. A transverse incision was made over longitudinal disease. And again, circumferential dissection was carried out around the disease protecting underlying neurovascular structures. The disease was able to be excised in toto. This wound was also gently approximated with 5-0 nylon after copious irrigation, and hemostasis being obtained with electrocautery. All wounds were dressed with Xeroform and dressing sponges. This was held with Kerlix and then an Ace wrap. Estimated blood loss was minimal. The IV fluids replaced was less than 2000 cc of crystalloid. Drains and packs were none. Complications were none. The patient tolerated the procedure well and was taken to the recovery room in a good postoperative condition. Advanced Clinic Hand Surgery 55 Exercise 8 - continued SURGICAL PATHOLOGY REPORT Age 6/04/46 Sex: F CLINICAL DIAGNOSIS: Dupuytren’s Disease Right Thumb, Middle and Ring Finger TISSUE SUBMITTED: Fascia Right Thumb, Middle and Ring Fingers IMPORTANT CLINICAL DATEA: GROSS: FASCIA RIGHT THUMB, MIDDLE RING FINGER. The specimen is received in formalin and consists of three fragments of firm, rubbery whitish yellow partially friable tissue, ranging in size from 1.0 x 0.8 x 0.5 cm up to 1.5 x 1.0 x 1.0 cm. Representative sections will be submitted in one cassette. DIAGNOSIS: TISSUE FROM RIGHT HAND: FRAGMENTS OF ADIPOSE TISSUE WITH FIBROVASCULAR TISSUE AND FIBROTENDINOUS COMPONENTS SHOWING FIBROBLASTIC CELLULAR PROLIFERATIVE CHANGES COMPATIBLE WITH A FIBROMATOSIS OF DUPUTYREN’S CONTRACTURE. Advanced Clinic Hand Surgery 56 Exercise 9. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. PROCEDURE NOTE PREOPERATIVE DIAGNOSIS: Extensor tendon injury zone 5, right index finger. POSTOPERATIVE DIAGNOSIS: Same. OPERATIVE PROCEDURE: Repair of right index finger extensor tendon zone 5. ANESTHESIA: Marcaine 0.25% and sedation. DRAINS: None. COMPLICATIONS: None. INDICATION FOR PROCEDURE: This patient has a history of an extensor tendon injury to his right index finger over zone 5. It was felt best amenable to operative intervention. DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite and 1 gram of Ancef was administered. The right upper extremity was prepped and draped in a normal sterile fashion. Marcaine 0.25% had been infiltrated about the proposed incision. The arm was exsanguinated of blood and tourniquet was inflated to 250 mmHg. There was noted to be an oblique laceration over zone 5 of the right index finger of 1 cm. This was extended distally and proximally in a Brunner type fashion. Skin flaps were elevated and retracted with 4-0 silk. The wound was copiously irrigated. The extensor mechanism was completely transected including the ulnar sagittal bands. A running 6-0 nylon epitendinous suture was applied to coapt the tendon. We then placed 3-0 Ethibond suture of Kessler type configuration as a core suture. Excellent coaptation of the tendon was achieved. When we flexed the finger, there was no gaping at the tendon juncture. The wound was irrigated and closed with 4-0 nylon. A sterile dressing and splint were applied with the wrist in extension and the MP at 0 degrees. The IP joints were left free. The patient was transferred to the recovery room in good condition. Advanced Clinic Hand Surgery 57 Exercise 10. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: 1. Laceration left index finger at proximal phalanx dorsally. 2. Extensor tendon laceration left index finger. 3. Laceration left index finger to bone. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: 1. Irrigation, debridement, exploration of left index finger laceration including violation of cortical bone. 2. Repair of extensor tendon laceration. Total length of repaired laceration is 3.5 centimeters. ANESTHESIA: Monitored anesthesia care. FLUIDS DELIVERED INTRAOPERATIVELY: 300 CC Ringer’s Lactate. ESTIMATED BLOOD LOSS: Minimal. TOTAL TOURNIQUET TIME OF THE CASE: 7 minutes at 250 mmHg. COMPLICATIONS: None. INDICATIONS: The patient is a 50-year-old right-handed dominant female who sustained a laceration to her left index finger a couple of days ago as a result of a knife wound, self-infected while cutting or slicing turkey. She was seen in the emergency room at General Hospital where the extensor tendon was seen in the wound and noticed to be lacerated. The patient is being taken to the operating room to undergo formal evaluation, irrigation, debridement and repair of structures as indicated at the left index finger laceration site at the dorsal radial aspect of the proximal phalanx. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the OR table in the supine position under IV sedation, augmented with local digital block anesthesia using a 50/50 mix of 0.5% Marcaine and 2% Xylocaine. Advanced Clinic Hand Surgery 58 Exercise 10 - continued The extremity was prepped and draped in the usual fashion for surgery. A tourniquet was applied to the arm. The extremity was exsanguinated with an Esmarch bandage. The tourniquet was inflated to 250 mmHg. The total tourniquet time for the case is 7 minutes. The total tourniquet time for the case is 7 minutes. The procedure was begun by extending the excision proximally and distally in a gentle S shape. The original incision is approximately 1.5 centimeters in length, it is roughly transverse at the dorsal radial portion of the proximal phalanx at about its halfway mark. The total incision length is 3.5 centimeters. The entire surgical procedure was performed under 3.5 power loupe magnification. The flaps were elevated. The extensor tendon mechanism is evaluated. There is a 1-centimeter transverse incision in the extensor tendon hood. The palmar most edge of the radial lateral band remains intact. There is approximately 4 millimeters distanced from that edge to the beginning of the incision. The incision then carried over ulnad to about the mid portion of the extensor hood. The periosteum is evaluated deep to the tendon. The lacerate had gone to bone. This area of exposed bone is then debrided with a curet and thoroughly irrigated with antibiotic irrigation. The tendon laceration is repaired using 3-0 Ethibond suture with multiple figure-of-eight stitches. The tourniquet is released. Hemostasis is obtained by direct pressures and elevation, followed by bipolar electrocautery Bovie. The skin is closed with 5-0 nylon sutures. Xeroform and sterile gauze dressing is applied. A finger extension splint is applied and held in place with an Ace wrap. The dressing includes the wrist and distal forearm. The patient is returned to the recovery area in good condition. there were no preoperative, intraoperative or postoperative complications. Advanced Clinic Hand Surgery 59 Exercise 11. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE RECORD PREOPERATIVE DIAGNOSIS: Radial collateral ligament injury, right thumb. POSTOPERATIVE DIAGNOSIS: Radial collateral ligament injury, right thumb. OPERATION: Radial collateral ligament reconstruction with advancement of abductor tendon. ANESTHESIA: General. INDICATIONS: This 28-year-old police officer was injured in an altercation. He has done well with conservative treatment and by physical examination and x-ray has complete rupture of his radial collateral ligament. He presents for definitive treatment. PROCEDURE: The patient was taken to the operating room and placed in the supine position. After general anesthesia was obtained, a tourniquet was placed high on the right upper extremity. The right upper extremity was prepped and draped in the usual sterile fashion. An incision was made along the radial side of the MIP joint at the thumb. In the subcutaneous tissues, the dorsal central branch radial nerve was identified and protected. The extensor mechanism was also gently retracted ulnar ward. An incision was made along the radial side of the joint. There was obvious complete rupture of the ligament. A remnant ligament was fortunately still present. Using a ronguer, bony troughs were made on the radial side of the proximal phalanx and the radial side of the metacarpal head. Bone anchors were applied to each area. The joint was reduced. The remnant ligaments were sewn into our bony troughs on either end. The sutures from the bone anchors were then used to advance the abductor into the radial side of the joint for added stability. With this completely sewn in then, radial stability was once again restored to the joint with the ulnar deviation. There was no gapping of the joint on the radial side. Passive flexion-extension was attacked as well. The wound was copiously irrigated. Hemostasis obtained with bipolar electrocautery. The skin was gently approximated with 5-0 nylon. The area was infiltrated with 0.5% Marcaine with epinephrine for postoperative anesthesia. Xeroform and a bulky dressing were applied and held with Kerlix. A radial thumb spica splint was applied and held with Kerlix. A radial thumb spica splint was applied and held with Kerlix and an Ace wrap. Advanced Clinic Hand Surgery Exercise 11 - continued The estimated blood loss: Minimal. The IV fluid replaced: Less than 3000 cc of crystalloid. Drains and packs: None. Complications: None. The patient tolerated the procedure well and was taken to the recovery room in good postoperative condition. 60 Advanced Clinic Hand Surgery 61 Exercise 12. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Right hook of hamate nonunion. POSTOPERATIVE DIAGNOSIS: Right hook of hamate nonunion. OPERATION: Excision right hoot of hamate. ANESTHESIA: General endotracheal. INDICATIONS: The patient is a 34-year-old gentleman with trauma to his right hand sustained a hook of hamate fracture, which has developed a nonunion. Given persistent discomfort, the patient is brought for hook of hamate excision. PROCEDURE/FINDINGS The patient was brought to the operating room and after successful induction of general anesthesia with endotracheal intubation, the patient was positioned supinely on the operating room table. The tourniquet was placed around the right upper extremity and the limb prepped and draped in a sterile fashion. After exsanguination with elevation, the tourniquet was inflated to 250 mmHg. A curvilinear incision based in the right palmar overlying Guyon canal was made with a #15-blade scalpel. Subcutaneous tissue was divided bluntly with Stevens tenotomy scissors. The ulnar nerve vascular bundle was identified and retracted ulnarly and the tip of the hamate were palpated. The fascia was split longitudinally and dissected subperiosteally around the hook of the hamate. At its base there was a nonunion with gross motion. The hook was removed and the base was smoothed with a rongeur and small rasp. Bone was placed over the cancellous portion. The flexor tendons were visualized showing no evidence of fraying or irritation. The tourniquet was then deflated. Hemostasis was assured with bipolar cautery and the wound irrigated with normal saline. The wound edges re-approximated with 4-0 nylon suture. Xeroform followed by sterile dressing was applied. Prior to dressing the wound area was infiltrated with 0.25% Marcaine plain for postoperative pain relief. A short arm splint was ultimately applied. Estimated blood loss 5 cc. Tourniquet time 17 minutes. Drains: none. Complications: none. DISPOSITION: The patient tolerated the procedure well and was taken to the recovery room in good condition. Advanced Clinic Hand Surgery 62 Exercise 13. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE RECORD PREOPERATIVE DIAGNOSIS: Right thumb, metacarpophalangeal joint arthritis. POSTOPERATIVE DIAGNOSSI: Right thumb, metacarpophalangeal joint arthritis. OPERATION: graft. Right thumb metacarpophalangeal joint arthrodesis with local bone ANESTHESIA: General. INDICATIONS: This 50-year-old female has been followed with MP joint arthrosis of her thumb for some time. She has failed conservative treatment including splinting and presents for definitive treatment. PROCEDURE: The patient was taken to the operating room and placed in a supine position. After general anesthesia was obtained, a tourniquet was placed high on the right upper extremity. The right upper extremity was prepped and draped in the usual sterile fashion. Using a radially based flap semi-curved incision over the MP joint, the skin was incised. The dorsal central branch of the radial nerve was protected. The EPL was identified and, at the level of the MP joint, the joint was entered between the EPL and other extensor tendons. The collateral ligaments were taken down. There were large osteophytes present on both medial and lateral side. These were debrided with a rongeur. There was a complete loss of cartilage down to denuded bone on the metacarpal side of the MTP joint as well as on the proximal phalanx side. Next, using a Conex reamer, the green reamer was used to prepare both the metacarpal head and the proximal portion of the proximal phalanx. This was taken down to good bleeding cancellous bone and local bone was harvested for graft. Next, using bold screws over a K-wire, a K-wire was placed holding the joint in about 25 degrees flex. Our graft was packed into the joint site, and a 32-mm screw was measured the appropriate size. A 32-mm screw was placed giving excellent compression of our fusion site. This was supplemented with an anti-rotational K-wire. The hardware positions were checked on AP, lateral and oblique views of the C-arm, and excellent position noted. Good apposition of the bony ends was obtained. Advanced Clinic Hand Surgery 63 Exercise 13 - continued The K-wire was cut off at the level of the bone. A 3-0 undyed Vicryl was used to repair the capsule, and the retinaculum over the extensor tendons was also repaired with a 3-0 undyed Vicryl. The skin was approximated with 5-0 nylon. The area was infiltrated with 0.5% Marcaine for post-op anesthesia. Xeroform and a bulky dressing were applied and held with Kerlix. A radial thumb spica splint was applied and held with Kerlix and an Ace wrap. The estimated blood loss was minimal. The IV fluid replaced was less than 2000 cc of crystalloid. Drains and packs were none. Complications were none. The patient tolerated the procedure well and she was taken to the recovery room in a good postoperative condition. Advanced Clinic Hand Surgery 64 Exercise 14. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE RECORD PREOPERATIVE DIAGNOSIS: 1. Chronic painful mallet deformity, left little finger. 2. Distal interphalangeal joint arthritis, left little finger. POSTOPERATIVE DIAGNOSIS: OPERATION: Distal interphalangeal joint fusion, left little finger with autograft. ANESTHESIA: Local. INDICATIONS: This is a 46-year-old female who suffered an injury to her little finger DIP joint and has had pain, redness, and irritation in that joint since July of this year. On physical exam, she had a chronic mallet deformity, but on exam she also had pain at the DIP joint consistent with possible early osteoarthritis. She presented for definitive treatment. PROCEDURE: The patient was taken to the operating room and placed in the supine position. A digital block was performed with 0.5% Marcaine plain. A tourniquet was placed high on the left upper extremity. The left upper extremity was prepped and draped in the usual sterile fashion. The arm was exsanguinated. The tourniquet was inflated to 250 mmHg. The total tourniquet time was less than 2 hours. First, an S-shaped incision was made on the dorsum of the DIP joint, taken down to the level of the extensor mechanisms where flaps were raised. The previous disruption of the extensor mechanism was identified. The DIP joint was entered, and there was significant loss of cartilage off of the middle phalanx as well as the distal phalanx. Because of these findings, it was elected to perform a DIP joint fusion. Using a rongeur, a lot of bone was removed from the ends of the middle phalanx as well as from the proximal end of the distal tufts down to good cancellous bleeding bone. Local bone graft was also harvested from the middle phalanx. Next, using Acutrak fusion set, the distal phalanx and middle phalanx were prepared. A 24-mm screw was placed with our graft interposed between the 2 ends. Good compression of the distal tuft on the middle phalanx was noted. Good placement of the hardware and alignment of the digit were noted on AP and lateral views of the C-arm. Advanced Clinic Hand Surgery Exercise 14 - continued This being the case, the wound was copiously irrigated. Hemostasis obtained with bipolar electrocautery. Using vertical mattress sutures over the extensor mechanism using full-thickness sutures, the wound was repaired. This was supplemented with horizontal mattress sutures medially and laterally for the skin edges. The blood loss was minimal. The IV fluid replaced was none. Drains and packs were none. Complications were none. The patient tolerated the procedure well and was taken to the recovery room after Xeroform and a bulky dressing were placed and held with tube gauze. 65 Advanced Clinic Hand Surgery 66 Exercise 15. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT Age: 43 OPERATION: Right thumb CMC joint arthrodesis with internal fixation. ANESTHESIA: General endotracheal anesthesia. PREOPERATIVE DIAGNOSIS: Right thumb CMC arthritis. POSTOPERATIVE DIAGNOSIS: Right thumb CMC arthritis. OPERATIVE INDICATIONS: The patient has for some time had pain about the right basilar thumb region. History and physical examination as well as radiographic studies were all consistent with degenerative arthritis at that joint. Conservative treatment was attempted, however, the patient still had significant pain limiting daily activities. For that reason, the patient wished to pursue the surgical option. We discussed in detail the alternatives for treatment, the recommended surgical treatment and the risks and benefits associated with surgery. With full understanding, the patient wished to proceed with the operation as described below. OPERATIVE PROCEDURE: The patient was brought into operating room #4 at the ambulatory surgical center. He was placed supine on the operating room table and a right proximal arm tourniquet applied. It was isolated with a sterile drape. The right upper extremity was prepped with Betadine and draped in a free and sterile fashion after the patient was anesthetized by the anesthesia department. Also, the patient was given 1 gram of Ancef intravenously. The extremity was exsanguinated with an Esmarch bandage and the tourniquet inflated to 250 mmHg where it remained for less than two hours. A 3 cm longitudinal incision was made over the first extensor compartment beginning just distal to the radial styloid and proceeding over the dorsal surface of the thumb metacarpal base. Dissection was primarily sharp with a 15 blade. The capsule over the thumb CMC joint was incised. There was noted to be a significant amount of synovial fluid present. The joint was inspected and the cartilaginous surfaces were extremely worn. We also inspected the scaphotrapezial joint through a small arthrotomy and the cartilage surfaces seemed to be well maintained. It should be noted that during the initial dissection, the dorsal branch of the radial artery was isolated and protected throughout the case. Advanced Clinic Hand Surgery 67 Exercise 15 - continued At this point, we chose to proceed with arthrodesis of the thumb CMC joint as described. Using a curet and water cooled burs, a “cup and cone” tight fit was fashioned. We made certain that we had excellent apposition between cancellous surfaces at the base of the thumb metacarpal and the trapezium. We placed the thumb in approximately 40 degrees of palmar abduction and 20 degrees of extension. We utilized the flexed index finger as a guide making certain that the pulp of the thumb nicely met the index finger middle phalanx on its radial aspect. Once this was assured, we then compressed the arthrodesis site and two 0.062 smooth K-wires were introduced. Both Kwires gained excellent fixation in both bones. The K-wires were cut below the level of the skin. The position of the arthrodesis was assessed clinically as was radiolographically. Also, the reduction and stabilization was assessed. We were very happy with the position and the stability. The wound was thoroughly irrigated as it had been throughout the case and the capsule repaired with 3-0 Ethibond suture. The skin was then closed with 5-0 Prolene suture. Adaptic and sterile dressings were applied together with a thumb spica splint. The patient was given pain medications, instructions and a follow-up appointment. There were no operative complications. Advanced Clinic Hand Surgery 68 Exercise 16. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT Age: 75 OPERATION: Left index finger revision-amputation at the P3 level. Left middle finger distal interphalangeal arthrodesis with cortical cancellous distal radial bone graft. ANESTHESIA: Axillary block. PREOPERATIVE DIAGNOSIS: Left index finger snow blower injury, with non healing wounds. Left middle finger snow blower injury, with T3-distal interphalangeal non union. POSTOPERATIVE DIAGNOSIS: OPERATIVE PROCEDURE: With consent from the patient, he was taken to the Operating Room. In the supine position, anesthesia placed an axillary block. The extremity was prepared with Betadine and draped out. The extremity was exsanguinated. The tourniquet was inflated to 250 millimeters of mercury. Total tourniquet time was approximately 1 hour and 20 minutes. The left index finger was approached first. The necrotic soft tissue from the tip was debrided away. The underlying P-3 that was comminuted and non united was debrided away. The proximal most shaft of the P-3 was debrided down too. The bone was healthy at this point. This wound was irrigated out copiously with saline. The laterally based skin flap that was viable was debrided back to healthy tissue and preserved. This would provide coverage for the tip. Perpendicular incisions were made at the eponychial fold, and the nail bed was dissected out. The nail bed was then resected in its entirety. The wound was again irrigated out with saline. The lateral flap was brought around and trimmed to fit the index stump. The flap was sutured in place with simple interrupted Nylon sutures. Advanced Clinic Hand Surgery 69 Exercise 16 - continued The left middle finger P-3, distal interphalangeal non union was approached through a dorsal incision. The incision was made with a #15 Bard Parker. The extensor tendon was incised and lifted up from the distal P-2 area out distally. The comminuted, non united P3-distal interphalangeal was rongeured away. This was irrigated out with saline. The nail and soft tissue of the middle finger had healed well. A distal radial bone graft was harvested from beneath the third extensor compartment. Cortical cancellous bone was harvested. The harvest site was packed with Gelfoam. The periosteum here was reapproximated with simple interrupted Ticron. The skin here was reapproximated with simple interrupted #5-0 Nylon. The cortical cancellous bone was packed into the distal interphalangeal/P-3 fracture site. The cancellous bone was placed underneath the nail bed for support. Two 0.045 K pins were fired through the remnant P-3 and P-2 head. The distal interphalangeal was arthrodesed in 10 degrees of flexion. This would was irrigated out with saline. The tendon was repaired with simple interrupted #3-0 Ticron. The skin was repaired with simple interrupted #5-0 Nylon. The wounds were dressed with Xeroform fluffs, casting passing, and a protective plaster slab splint. ESTIMATED BLOOD LOSS: Less than 10 ml, no blood given. FLUIDS GIVEN: Crystalloid. SPONGE COUNT: Correct. POSTOPERATIVE CONDITION: Stable. SPECIMEN: Bacteriological-Soft tissue and bone, gram stain and bacterial cultures were submitted. Pathological-Skin, soft tissue and bone were submitted. PROSTETIC DEVICE OR IMPLANTS: 0.045 K pins x 2. Advanced Clinic Hand Surgery Exercise 16 - continued SURGICAL PATHOLOGY REPORT (Age: 75) M SPECIMEN(S) SUBMITTED: Part A: LEFT INDEX FINGER DEBRIDEMENT Part B: MIDDLE FINGER DEBRIDEMENT ***************************************************************** FINAL DIAGNOSIS 1. FINGER (DEBRIDEMENT, LEFT INDEX FINGER) - NECROSIS, ACUTE INFLAMMATION, CHRONIC INFLAMMATION, GRANULATION TISSUE AND FOCAL IMPACTION OF OSSEOUS SEGMENTS IN FIBROUS TISSUE. 2. BONE AND FIBROUS TISSUE (DEBRIDEMENT, LEFT MIDDLE FINGER, B) - GRANULATION TISSUE AND FIBROSIS. ****************************************************************** CLINICAL DATA: 1. Left middle and index finger snowblower injury. GROSS DESCRIPTION: A. Received in formalin are multiple fragments of red-tan-gray soft tissue and bone aggregating to 4.0 x 2.5 x 0.2 cm. A fingernail is present with the specimen. Representative sections are submitted in formalin. B. Received in formalin are multiple minute fragments of gray-white soft tissue and bone aggregating to 0.2 x 0.1 x 0.1 cm. The specimen is entirely submitted in formalin. 70 Advanced Clinic Hand Surgery 71 Exercise 17. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSES: Rheumatoid arthritis—severe of the right hand with subluxation and dislocations of all of her MP joints and instability. POSTOPERATIVE DIAGNOSES: Rheumatoid arthritis—severe of the right hand with subluxation and dislocations of all of her MP joints and instability. OPERATION: Right hand metacarpophalangeal joint arthroplasties with silicone implants to the index, middle, ring and little fingers, tendon transverse and realignments, capsule release of the index, ring and little fingers and arthrodesis of the metacarpophalangeal joint of the right thumb. IMPLANTS USED Size 4 for the index finger. Size 5 for the middle finger. Size 3 for the ring and little finger. Right medical silicone implants. There was one Acutrak 30-mm screw placed for the arthrodesis of the thumb. INDICATIONS: This is a 47-year-old female who presents because of a progressive deformity from rheumatoid arthritis. She has been on Prednisone, methotrexate, folic acid, Remicade which has really helped reduce some of her rheumatoid nodules to the digits, so we have already completely reconstructed the contralateral hand, is here fore the right hand. PROCEDURE/FINDINGS The patient was placed in the supine position on the operating room table. After adequate general endotracheal anesthesia was obtained, she was prepped and draped in the usual sterile fashion. A transverse incision was made at the MP joint level. This was carried down through skin and subcutaneous tissue, carefully dissected and flaps created. Protecting the vasculature in the web space to preserve that throughout the course of dissection. We then opened up the extensor mechanism. All of the extensors were dislocated ulnarly, and we released them on their radial border. Mobilized the sagittal bands on the ulnar side and on the radial side opened the capsular tissue, debrided the synovitis and we proceeded to do the same procedure on all digits. Advanced Clinic Hand Surgery 72 Exercise 17 - continued We released the tight intrinsic on the ulnar side, mobilized the extensor tendon, debrided the joint and then using oscillating saw removed whatever was remaining of the metacarpal head and flattened the surface of the proximal phalanx. We then used the _______ instruments. First an initial probe was placed and then the size was successfully enlarged both proximally and distally, basing our size on the distal degree of tolerance. Once both canals were rasped free and the MP joint was mobilized so that the proximal phalanx completely brought out dorsal to the metacarpal cut, we knew we had adequate release and the digits were straight. We then trialed all the prosthesis and assessed the mobility and stability of the fingers. Once we were happy with this, using a no-touch technique, we placed the implant arthroplasties, first the #4 in the index finger, the #5 in the middle finger, the 33 in the ring and little finger. Closing the capsular tissue with 4-0 PDS and then we transposed the extensor and performed a pantsover-vest type of repair to the sagittal bands, centralizing and to some degree radializing the extensor mechanism with multiple Tycron sutures. We had good alignment and balance of the fingers once this was completed. We confirmed the position of the prosthesis radiographically. Once this part was completed we opened the thumb which had a previous attempt at arthrodesis a number of years earlier. Dr. __________ was unsuccessful. The extensor mechanism was split, the joint opened, the capsule opened and the synovitis debrided. Using a rongeur we contoured the head of the metacarpal and some good cancellous bone. We used a small K-wire to make some holes at the edge of the articular surface cortical bone interface of the proximal phalanx using small osteotome and a curette to debride the sclerotic area. We then were able to reduce this, placed one oblique K-wire, keeping the MP joint in approximately 20 degrees of flexion. We drilled, tapped and placed the appropriate length Acutrak screw. We used a 30 mm headless Acutrak screw, obtained good arthrodesis with some supination to the thumb for easier pinch. Once this was completed, we let down the tourniquet, obtained meticulous hemostasis, copiously irrigated the sounds and closed all the wounds with 5-0 Prolene suture. Xeroform, 4 x 4’s, bulky dressing and plaster splint applied. The patient tolerated the procedure well and was discharged to the recovery room in satisfactory condition. Advanced Clinic Hand Surgery 73 Exercise 18. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT OPERATION: Repair of abductor pollicis first dorsal interosseous and primary repair of the common digital nerve to the left thumb. ANESTHESIA: General endotracheal anesthesia. PREOPERATIVE DIAGNOSIS: Laceration to left first web space. POSTOPERATIVE DIAGNOSIS: Laceration to the left first web space. OPERATION INDICATIONS: This is a patient who was seen in the Emergency Room after a knife laceration to his first web space involving the left hand. He was examined in the Emergency Room and found to have a sensory deficit to the left thumb as well as division of his abductor pollicis and first dorsal interosseous. He presents now for repair. OPERATIVE PROCEDURE: The patient was brought to the operating room, placed in the supine position. IV access was established and he was given a general endotracheal anesthetic. The left arm was then prepped and draped in a sterile fashion. The old sutures were removed and the wound was opened up. The wound was then thoroughly irrigated with saline solution and inspected. We found that the abductor pollicis and first dorsal interosseous were divided and this was expected from his prior evaluation in the Emergency Room. Careful dissection was carried out and the common digital nerve to the thumb was identified and was found to be divided at the level just proximal to the first metacarpal. The digital nerve to the radial aspect of the index was dissected and was not injured and was in continuity. The abductor pollicis and the first dorsal interosseous were then reapproximated using interrupted 3-0 Vicryl sutures to the fascia. After this was done, the common digital nerve to the thumb was repaired under the microscope using interrupted 9-0 nylon stitches suturing the epineurium to the epineurium. After this was completed, the wound was once again irrigated with saline solution and this irrigant was sucked out. The skin was then closed using interrupted Ethilon stitches. A dorsal splint was then placed and situated such that the thumb would be kept in IP flexion at the operation and at the conclusion of the operation, it was let down without incident. The tourniquet time was 215 minutes. The general endotracheal anesthetic was reversed and the patient was transported to the recovery room in satisfactory condition. ESTIMATED BLOOD LOSS: Approximately 20 cc. Advanced Clinic Hand Surgery 74 Exercise 19. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Left extensor pollicis longus tendon rupture. POSTOPERATIVE DIAGNOSIS: Left extensor pollicis longus tendon rupture. PROCEDURE PERFORMED: Left extensor indicis proprius to extensor pollicis longus tendon transfer. ANESTHESIA: General. COMPLICATIONS: None. PROCEDURE: The patient was brought to the operating room and placed supine and given general anesthesia. A well-padded pneumatic tourniquet was applied and set at 250. The arm was prepped and draped sterilely. The arm was exsanguinated and tourniquet inflated. A 0.5 cm incision was made over the distal second metacarpal over the extensor indicis proprius and the tendon was identified and was harvested. The gap in the extensor hood was closed using #4-0 Mersilene. We then made a 2 cm transverse incision over the third and fourth dorsal compartment and the extensor indicis proprius was retrieved from this location. We then made a 1.5 cm incision over the distal first metacarpal and the extensor hood of the thumb was visualized. The extensor pollicis longus tendon was then seen. We then transferred the EIP tendon to adjacent to the EPL and using an interweaver technique the EIP was attached to the EPL distally. This was done while getting tension on the repair such that there was an extended posture of the MCP with the wrist in neutral. Excellent excursion was appreciated and the repair was reinforced using #4-0 Vicryl. The tourniquet was released. The wounds were irrigated using normal saline and the wounds were closed using #4-0 Vicryl and #4-0 Prolene. Sterile bulky dressing was applied. The patient was placed in thumb-spika posture splint. The patient tolerated the procedure well without any complications. Advanced Clinic Hand Surgery 75 Exercise 20. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Right thumb pan trapezial arthritis. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Right thumb trapeziectomy and ligament reconstruction tendon interposition. (LRTI). ANESTHESIA: Axillary block. INDICATIONS FOR OPERATION: The patient is a 69-year-old gentleman with a long history of bilateral thumb pain. He’s been treated nonoperatively for pan trapezial arthritis with splints and anti-inflammatory drugs and has been unresponsive and he now is scheduled for surgical intervention. DESCRIPTION OF OPERATION: The patient is brought to the operating room and axillary block anesthesia was performed. After adequate anesthesia the right upper extremity was prepped and draped in the usual sterile manner. The limb was exsanguinated with an ACE wrap, tourniquet brought to 275 mm of mercury. Longitudinal incision was made over the base of the thumb, metacarpal, carried sharply down through the skin and subcutaneous tissue. Superficial radial nerve was identified and protected. The capsule over the trapeziometacarpal joint was then sharply incised. The radial nerve was identified and retracted approximately and perforators were cauterized. Subperiosteal dissection was then carried around the trapezium. It was split with a sagittal saw and removed piecemeal. A flexor carpiradialis tendon was then harvested in the proximal forearm and pulled through the defect left by the trapezium. The base of the metacarpal was then removed using the oscillating saw. A 4 mm bur was then used to make a tunnel through the metacarpal at the base. The tendon was then passed up through this hole and folded on down itself and held in place with 4-0 Ti-Cron incorporating the lower capsule. The remaining tendon was then woven in an Anchovy type fashion and placed in the defect. The capsule was then closed using 4-0 Ti-Cron. Tendon interval closed with 4-0 Vicryl. Tendon interval closed with 4-0 Vicryl. Skin closed with 4-0 vicryl and 4-0 Nylon. The patient was placed in a standard postoperative bulky dressing with a splint. He tolerated the procedure well and was brought to the recovery room in stable condition. Advanced Clinic Hand Surgery 76 Exercise 21. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT OPERATION: Trapezium resection, ligament reconstruction and tendon interposition arthroplasty, left thumb. Excision of nodule, dorsum of left index finger. ANESTHESIA: Axillary block. PREOPERATIVE DIAGNOSIS: Pan trapezial arthritis, left wrist. Nodule dorsum of left index finger. POSTOPERATIVE DIAGNOSIS: OPERATIVE INDICATIONS: Pain at the base of the right thumb, unrelieved by conservative treatment, and secondary to x-ray confirmed arthritis. There was a small, slightly tender nodule over the dorsum of the left index finger, of undetermined etiology. OPERATIVE FINDINGS: There was extensive arthritis on both sides of the trapezium, and in the joint between the scaphoid and trapezoid. There was a small solid nodule sitting on the extensor tendon just distal to the proximal interphalangeal joint over the dorsum of the left index finger. The nodule was well circumscribed. OPERATIVE PROCEDURE: A longitudinal incision was made over the dorsal radial aspect of the base of the left thumb. Care was taken to identify and protect the branches of the superficial radial nerve. The extensor retinaculum over the first extensor compartment was divided longitudinally, completely releasing the EPL and EPB tendons. A longitudinal capsular incision was made between the EPL and EPB tendons. The capsule was carefully dissected from the trapezium, and from a portion of the base of the first metacarpal. The trapezium was removed piecemeal. The opposing surfaces of the scaphoid and trapezoid were also removed down to cancellous bone. A drill hole was then made traversely across the base of the first metacarpal, emerging at the deep volar beak of the metacarpal. A longitudinal strip of the extensor carpi radialis tendon was removed through multiple transverse forearm incisions. The tendon strip was transected proximally, and left attached distally. It was delivered into the trapezial cavity, and dissected to the base of the second metacarpal. The tendon strip comprised approximately 75% of the tendon. The tendon strip was passed through the hole at the base of the first metacarpal, looped back around itself and then pulled tightly, and secured with #3-0 Tycron sutures. A portion of the remaining tendon implant was placed in the space between the scaphoid and trapezoid, and held there with a #3-0 Tycron suture, placed through some soft tissue in the depths of the wound. This appeared to hold the tendon in a good position. The remaining portion of the tendon that was harvested was tied in multiple knots, which were secured with #3-0 Tycron sutures. Advanced Clinic Hand Surgery 77 Exercise 21 - continued This implant was then placed in the trapezial cavity, and was held there with a #3-0 Tycron suture that had been placed through the remaining portion of the FCR tendon in the depths of the cavity. This held the tendon implants in good position. The capsule was carefully repaired with #3-0 Tycron sutures. The skin incisions were closed with #40 Nylon sutures. A transverse incision was made over the dorsum of the index finger, just distal to the proximal interphalangeal joint, and directly over the nodule. The nodule was dissected free from the surrounding tissues and completely removed, and sent to pathology. The skin was closed with #4-0 nylon sutures. Then 5 cc of 2% Xylocaine with epinephrine mixed with 5 cc of 0.5% marcaine was used for median and radial nerve blocks at the wrist. A moist, bulky compressive type dressing was applied, and anterior and posterior plaster splints. The pneumatic tourniquet was used during the procedure. The patient tolerated the procedure well, and was sent to the recovery room in satisfactory condition. DRAINS: None. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: None. I was present during the entire operation. Advanced Clinic Hand Surgery Exercise 21 - continued PATHOLOGY REPORT FINAL DIAGNOSIS: 1. LEFT INDEX FINGER, EXCISION (B) - GIANT CELL TUMOR OF TENDON SHEATH. Comment: An addendum will be issued following decalcification of the specimen from part A. ** Report Electronically Signed Out** ************************************************************** SPECIMEN(S) SUBMITTED: Part A: LEFT SYNOVIUM Part B: NODULE LEFT INDEX FINGER CLINICAL DATA: LEFT THUMB ARTHRITIS GROSS DESCRIPTION: A. Received fresh are multiple, tan-pink, bony fragments aggregating to 2 x 2 x 0.6 cm. The specimen is entirely submitted in formalin for decalcification at A1. B. Received fresh is a rubbery, pink-tan, oval-shaped nodule that measures 0.6 x 0.3 x 0.3 cm. Specimen is submitted in entirety in formalin in cassette B1. Addendum: ** SIGNED OUT 04/21/98** *** REPORT OF DECALCIFIED TISSUE*** LEFT INDEX FINGER REGION, EXCISION (A) SYNOVIUM WITH FIBROSIS AND OSTEOCARTILAGENOUS TISSUE SEGMENTS. (Age: 71) F 78 Advanced Clinic Hand Surgery 79 Exercise 22. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSES: 1. Degenerative osteoarthritis, carpometacarpal joint, left thumb. 2. Carpal tunnel syndrome, left hand. 3. Stenosing tenosynovitis, left long finger. POSTOPERATIVE DIAGNOSES: 1. Degenerative osteoarthritis, carpometacarpal joint, left thumb. 2. Carpal tunnel syndrome, left hand. 3. Stenosing tenosynovitis, left long finger. OPERATION PERFORMED: 1. Trapezium resection arthroplasty, left thumb, with flexor carpi radialis interpositional graft. 2. Carpal tunnel release, left hand. 3. Release of flexor tendon sheath, left long finger. ANESTHESIA: General. PROCEDURE: The patient was placed supine on the operating table at which time she was put to sleep under general anesthesia. Following this the left arm was prepped with Betadine Solution for a full five-minute prep. The area was then draped in a sterile fashion and a tourniquet applied. Attention was turned first to the volar aspect of the long finger. Here a transverse incision was made and carried down through skin and subcutaneous tissue. Careful blunt dissection was made down to the underlying flexor tendon sheath. The sheath was opened longitudinally and the flexor tendons exposed. Once opened it was noted that the tendons could glide smoothly with no further impingement. The area was then irrigated with saline solution. The skin edges were anesthetized with Marcaine and closed with #5-0 nylon suture. Attention was then turned to the palmar aspect of the hand where a curved incision was made over the palmar aspect and carried down through skin and subcutaneous tissue. Careful blunt dissection was made down to the underlying transverse carpal ligament. The ligament was opened longitudinally and the underlying median nerve exposed. The area was explored and no other evidence of significant abnormalities could be noted. The area was irrigated with saline solution. The skin edges were anesthetized with Marcaine and the skin closed with #5-0 nylon suture. Advanced Clinic Hand Surgery 80 Exercise 22 - continued Next, two small transverse incisions were made over the palmar aspect of the wrist and in the mid forearm. These were over the areas of the flexor carpi radialis tendon. The tendon was then transected at its musculotendinous junction and pulled through into the distal wound. Attention was then turned to the radial aspect of the wrist. Here an S-shaped incision was made and carried down through skin and subcutaneous tissue. Blunt dissection was made down to the underlying capsule. The capsule was then opened and the carpometacarpal joint exposed. There was noted to be evidence of marked degenerative changes with marked erosion of the articular surfaces. Multiple loose bodies were encountered and removed. Once the capsule was opened, the saw was then used to transect the trapezium. This was then removed piecemeal. Once adequately exposed and cleared, the flexor carpi radialis tendon was then grasped in the wound and pulled through. An oblique hole was then made through the base of the metacarpal and the tendon was pulled through this. The tendon was then brought back and sutured in on itself to maintain the position of the metacarpal. There was good stability once done. The tendon was then rolled and placed in to the space left by the trapezium. This was sutured into the position. Following this the capsule was closed over this. The areas were irrigated with saline solution, following which then the subcutaneous tissues were closed with #3-0 Vicryl, skin edges were anesthetized with Marcaine and closed with #5-0 Vicryl suture. All wounds were then dressed in a sterile fashion and a short-arm cast with a thumb spica was applied. The tourniquet was released and the patient returned to the Recovery Room in satisfactory condition. Advanced Clinic Hand Surgery 81 Exercise 23. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE RECORD PREOPERATIVE DIAGNOSIS: Arthritis, right and left hands. POSTOPERATIVE DIAGNOSIS: Arthritis, right and left hands. OPERATION: 1. Injection of left thumb carpometacarpal joint. 2. Right thumb carpometacarpal arthroplasty with flexor carpi radialis tendon transfer. 3. Right middle finger distal interphalangeal joint arthrodesis. ANESTHESIA: General. INDICATIONS: This 55-year-old female with severe arthritis of both hands presents for definitive treatment after failure of conservative treatment. PROCEDURE: The patient was taken to the operating room and placed in the supine position. After general anesthesia was obtained and 600 mg IV clindamycin given, the left thumb was prepped sterilely and the CMC joint injected with 1 cc of 40 mg DepoMedrol and 1 cc of 0.5% Marcaine with epinephrine. Next, a tourniquet was placed high on the right upper extremity, and the right upper extremity was prepped and draped in the usual sterile fashion. The arm was then elevated and exsanguinated and the tourniquet inflated to 250 mmHg. The total tourniquet time was less than 2 hours. First, the middle finger was addressed using a S-shaped incision over the dorsum of the DIP joint. The skin was incised. Dissection was carried out down to the extensor mechanism where distal and proximal flaps were raised. The extensor mechanism was incised exposing the joint. The collateral ligaments were taken down. There was severe arthritis noted. Using a rongeur both ends of the joint were prepared down to good cancellous bleeding bone. Next, using the Accu-Chek fusion set, the bone was prepared and a 24-mm screw was placed given excellent fixation and good apposition of the 2 fusion sites. No graft was used. Good placement of the hardware and alignment of the joint were noted on AP, lateral, and oblique view of the C-arm. Next, using a 5-0 nylon the extensor mechanism and skin closed in one large layer. A digital block was then performed with 0.5% Marcaine plain for postoperative anesthesia. Advanced Clinic Hand Surgery 82 Exercise 23 - continued Next, using a modified Wagner incision, the skin was incised. In the subcutaneous tissue, the dorsal central branch of the radial nerve was identified and protected. First, the dorsal compartment was identified. First dorsal compartment release was performed and released from the dorsal side. Next, using a #15 blade, arthrotomy was made into the CMC joint as well as the STT joint isolating the trapezium. Subperiosteal dissection was carried out around as much of the trapezium as possible. Next, using an osteotome and mallet, the trapezium was broken up into 4 quadrants. Using a rongeur, the trapezium was then removed completely. Careful attention was paid to protect the underlying flexor carpi radialis tendon. Once complete removal of the trapezium was obtained, the FCR was identified at the base of our wound, and the sheath was entered. It was released proximally and distally. Next, with tension placed on the flexor carpi radialis tendon, a counter incision was made proximally over the tendon. The incision was taken down to the level of the flexor carpi radialis sheath. The sheath was also opened and opened proximally and distally by exposing the tendon. Another incision approximately 15 cm above the wrist crease was also made. The tendon was circumferentially dissected free. Using a #15 blade the tendon was released and brought forth all the way sequentially through each of our incisions up into and including the CMC joint. With the tendon in place them, a bur was used to make an entry hole into the proximal end of the metacarpal. A dorsal ulnar hole was made connecting this to the entry hole in the base of the metacarpal. Next, our tendon was woven through the end of the metacarpal out the dorsal ulnar hole and back onto itself where it was sewn down with 2-0 PDS suture. The metacarpal was held distracted and slightly opposed while sewing this in. With this completed then the remainder of the tendon was rolled up into an anchovy and sewn together with the 2-0 PDS suture. This was then placed as a spacer between the metacarpal and the scaphoid. Next, the 2-0 PDS was used to repair the capsule of the CMC and STT areas. A 3-0 undyed Vicryl was used to repair the remaining deep tissues. Through the procedure, copious irrigation was performed and hemostasis was obtained with bipolar electrocautery. Finally, all wounds were approximated with 5-0 nylon suture. All areas were infiltrated with 0.5% Marcaine with epinephrine for post-op anesthesia. Advanced Clinic Hand Surgery Exercise 23 - continued Next, for the middle finger, dry sterile dressing was placed and held with tube gauze. Xeroform was placed over all wounds, and bulky dressing was applied and held with Kerlix. A radial thumb spica splint was then applied and held with Kerlix and an Ace wrap. The estimated blood loss was minimal. The IV fluid replaced was less than 3000 cc of crystalloid. Drains and packs were none. Complications were none. The patient tolerated the procedure well and was taken to the recovery room in a good postoperative condition. 83 Advanced Clinic Hand Surgery 84 Exercise 24. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE RECORD PREOPERATIVE DIAGNOSES: 1. Right thumb carpometacarpal arthritis. 2. Right thumb metacarpal phalangeal joint arthritis. 3. Right carpal tunnel syndrome. POSTOPERATIVE DIAGNOSES: 1. Right thumb carpometacarpal arthritis. 2. Right thumb metacarpal phalangeal joint arthritis. 3. Right carpal tunnel syndrome. OPERATION: 1. Right endoscopic carpal tunnel release. 2. Right carpometacarpal arthroplasty with flexor carpi radialis tendon transfer. 3. Metacarpal phalangeal joint arthrodesis with local graft. ANESTHESIA: General. INDICATIONS: This is a 70-year-old female with significant cardiac history who has the above problems. We have been treating her conservatively. She has failed conservative treatment which has included injections and splints. She presents for definitive treatment. PROCEDURE: The patient was brought to the operating room and placed in the supine position. Local infiltration with 0.5% Marcaine plain was performed for anesthesia. A tourniquet was placed high on the right upper extremity, and the right upper extremity was prepped and draped in the usual sterile fashion. The arm was exsanguinated and the tourniquet inflated to 250 mmHg. The total tourniquet time was less than 2 hours. A transverse incision was made at the proximal wrist crease. Dissection was carried out down to the distal antebrachial fascia. A distally based flap was made. The proximal portion of the distal fascia was released under direct vision with the scissors. Using the Agee system, the undersurface of the transverse carpal ligament was identified. First using the synovial spoon, then the small and then large dilators were placed within the carpal canal. The Agee system was placed in the canal, and the distal aspect of the ligament was identified, the blade elevated, and the distal one-third of the ligament was released. The blade was retracted, and our distal release was checked. Good release was noted. The blade was brought back to the level of the previous release site, re-elevated, and the remainder of the ligament was released under direct vision. Advanced Clinic Hand Surgery 85 Exercise 24 - continued Our release was checked one more time with the blade retracted, and good release again was appreciated. No pulsatile bleeding was noted. the wound was copiously irrigated. Hemostasis was obtained with electrocautery. The wound was gently approximated with #5-0 nylon. Next, using a modified Wagner incision, the skin was incised. In the subcutaneous tissue, the dorsal central branch of the radial nerve was identified and protected. First, the dorsal compartment was identified. First dorsal compartment release was performed and released from the dorsal side. Next, using a #15 blade, arthrotomy was made into the CMC joint as well as the STT joint isolating the trapezium. Subperiosteal dissection was carried out around as much of the trapezium as possible. Next, using an osteotome and mallet, the trapezium was broken up into 4 quadrants. Using a rongeur, the trapezium was then removed completely. Careful attention was paid to protect the underlying flexor carpi radialis tendon. Once complete removal of the trapezium was obtained, the FCR was identified at the base of our wound, and the sheath was entered. It was released proximally and distally. Next, with tension placed on the flexor carpi radialis tendon, a counter incision was made proximally over the tendon. The incision was taken down to the level of the flexor carpi radialis sheath. The sheath was also opened and opened proximally and distally by exposing the tendon. Another incision approximately 15 cm above the wrist crease was also made. The tendon was circumferentially dissected free. Using a #15 blade the tendon was released and brought forth all the way sequentially through each of our incisions up into an including the CMC joint. With the tendon in place the, a bur was used to make an entry hole into the proximal end of the metacarpal. A dorso-ulnar hole was made connecting this to the entry hole in the base of the metacarpal. Next, our tendon was woven through the end of the metacarpal out the dorso-ulnar hole and back onto itself where it was sewn down with 2-0 PDS suture. The metacarpal was held distracted and slightly opposed while sewing this in. With this completed then the remainder of the tendon was rolled up into an anchovy and sewn together with the 2-0 PDS suture. This was then placed as a spacer between the metacarpal and the scaphoid. Advanced Clinic Hand Surgery 86 Exercise 24 - continued Next, the 2-0 PDS was used to repair the capsule of the CMC and STT areas. A 3-0 undyed Vicryl was used to repair the remaining deep tissues. Throughout the procedure, copious irrigation was performed and hemostasis was obtained with bipolar electrocautery. Finally, the MP joint was addressed. Dissection was carried down to the MP joint. Careful attention being paid to protect the dorsal-central branch radial nerve. Arthrotomy was made dorsally. The carotid ligaments were taken down. Using a rongeur, the end of the metacarpal as well as the proximal portion of the proximal phalanx were denuded over the sclerotic bone, which was present, down to good bleeding cancellous bone. Next, two 0.045-mm K-wires were placed through the metacarpal down into the proximal phalanx with the MP joint held at approximately 25% of flexion. There was good opposition of the cancellous bony surfaces. Local graft from the excised trapezium from the previous arthroplasty was harvested and added as local graft filling all the areas nicely. With this completed then, 3-0 Vicryl was used to repair the capsule with the retinaculum. The skin was approximated with 5-0 nylon. The whole area was infiltrated with 0.5% Marcaine with epinephrine for postoperative anesthesia. Xeroform and a bulky dressing were applied and a radial thumb spica splint was applied immobilizing the thumb and wrist. This was held with Kerlix and an Ace wrap. The estimated blood loss was minimal. The IV fluid replaced was less than 2000 cc of crystalloid. Drains and packs were none. Complications were none. The patient tolerated the procedure well and was taken to the recovery room in a good postoperative condition. Advanced Clinic Hand Surgery 87 Exercise 25. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT PREOPERATIVE DIAGNOSES: 1. Severe right pantrapezial arthritis. 2. Right carpal tunnel syndrome. POSTOPERATIVE DIAGNOSES: Same. PROCEDURE: 1. Right thumb basilar joint tendon interpositional arthroplasty and reconstruction of the palmar oblique carpal metacarpal ligament with a distally based flexor carpal radialis tendon transfer. 2. Right carpal tunnel release. ANESTHESIA: General. SKIN PREPARATION: Hibiclens. FINDINGS: This lady presents with established right carpal tunnel syndrome and severe basilar joint arthritis. PROCEDURE: General anesthesia was given, right hand and forearm were scrubbed with Hibiclens and draped as usual. Extremity was exsanginated and the tourniquet was inflated. An incision was made in the proximal palm along the access of the ring finger. The skin and subcutaneous tissues were separated and palmar fascia was incised and a transverse carpal ligament was transected. A distal brachial fasciotomy was subcutaneously performed. Contents of the carpal tunnel were explored. Some thickening of the synovium was noted but did not appear pathological. The basilar joint of the thumb was approached through a dorsal incision. Skin and subcutaneous tissues were separated. The radial sensory nerves were carefully retracted. The dorsal capsule was transversely opened. The trapezium was removed piecemeal preserving the soft tissue connections. The peroneus longus was harvested through three transverse incisions as a free graft. The radial part of the flexor carpal radialis was harvested as the distally based tendon transfer passed into the trapezial area. A drill hole was created in the base of the thumb metacarpal. A wire loop was passed to pass the flexor carpal radialis through the drill hole and back onto the insertion of the tendon. The extra tendinous tissue was fashioned in the form of a bowel which was placed at the site of the trapezium. The capsule was meticulously repaired. The tendon transfer was tightened and sutured to itself. The tourniquet was released. Advanced Clinic Hand Surgery 88 Exercise 25 - continued Hemostasis was obtained with electrocoagulation. The wounds were closed with 6-0 Prolene interrupted and continuous sutures after obtaining hemostasis. Sterile dressings with a thumb Spica cast were applied and the patient was sent to the recovery room in satisfactory condition. Sponge, needle and instrument counts were correct. Advanced Clinic Hand Surgery 89 Exercise 26. Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. OPERATIVE REPORT OPERATION: Radical debridement of extensor tenosynovium with preparation of extensor pollicis longus for extensor indicis proprius to extensor pollicis longus transfer, and metacarpophalangeal joint arthrotomy and synovectomy of the second ray. ANESTHESIA: Axillary block. PREOPERATIVE DIAGNOSIS: Right hand rheumatoid deformities: specifically, extensor pollicis longus rupture and florid tenosynovectomy. POSTOPERATIVE DIAGNOSIS: Right hand rheumatoid deformities: specifically, extensor pollicis longus rupture and florid tenosynovectomy, plus infiltrative tenosynovitis of fourth and second dorsal compartments accompanying the ruptured extensor pollicis longus. OPERATIVE INDICATIONS: The patient is a 46-year-old, left hand-dominant project coordinator. He is an avid golfer. He was seen by my colleague in rheumatology. He noted the inability to extend his dominant right thumb and quite a bit of dorsal swelling. For these reasons, my colleague made a consultation to me, which I appreciate greatly. I admitted the patient and had a long discussion with him. We talked about the patholophysiology of rheumatoid disease and the fact that these tendon ruptures may herald more significant disease and possible further problems. We talked about the risks, benefits and alternatives of the above-mentioned procedures, and he understood them implicitly, including the risks and benefits of infection, bleeding, damage to skin, nerves, blood vessels, bone, and soft tissues, failure of the operation, need for more operation and the risks of anesthesia. He consented to the performance of the above-mentioned procedures. OPERATIVE PROCEDURE: The patient was taken to the operating room and placed on the table in the supine position after a successful axillary block anesthesia. A pneumatic tourniquet encircled the proximal brachium and was inflated to 250 mmHg for 36 minutes. Through a longitudinal incision based on the dorsal aspect of the wrist, great care was taken to dissect down without injury to subcutaneous neurovascular structures. Thick flaps were raised. The third dorsal compartment was opened to find a tremendous amount of tenosynovium, and it was empty and devoid of the extensor pollicis longus. The proximal and distal stumps were located and controlled. Notably, there was extensive tenosynovium of an infiltrative nature in the second dorsal compartment. Careful tenosynovectomy of the extensor carpi radialis longus and brevis tendons was undertaken. Advanced Clinic Hand Surgery 90 Exercise 26 - continued The fourth compartment was opened for the same purpose, and this was debrided . Smoothing of the dorsal aspect of the wrist, especially around Lister’s tubercle, was performed with a rongeur and rasps. Our previous plan was to assess the integrity of the extensor pollicis longus and likely transfer for it. The extensor indicis proprius was the tendon that we wished to transfer, and the patient understood that. With an incision over the metacarpophalangeal joint, great care was taken to dissect down without injury to the subcutaneous neurovascular structures. The extensor indicis proprius was located on the ulnar border of the joint, ulnarward of the proper extensor. A tremendous amount of tenosynovium at that level was encountered so that in addition to the harvest of the tendon, debridement and capsular reconstruction of the second metacarpophalangeal joint was performed. A tremendous amount of hypertrophic synovium was recovered. The erosions were smoothed locally. The articular surface looked reasonably good, although there was quite a bit of peripheral erosion and some cartilage softening. Copious irrigation and meticulous hemostasis was obtained. The wound was closed, and then the tendon was nicely centralized. Attention was turned toward the thumb, where the incision was extended over the carpal-metacarpophalangeal joint. The distal aspect of the extensor pollicis longus stump was controlled and utilizing a Pulver-Taft type weave with the Jacobson instruments, a nice tension was placed between the transferred EIP to the distal aspect of the EPL. Tension was assessed in fullest extension. The interphalangeal joint was in about neutral, and in flexion. There was extension at the IP joint of the thumb. Copious irrigation and meticulous hemostasis was maintained. The dorsal retinaculum was split to protect both the transferred tendons and the indwelling fourth compartment tendons. All wounds were closed in layers. Careful application of a sterile bulky dressing with a thumb spica attachment was performed. COMPLICATIONS: None. SPECIMENS: Resected tissue. DISPOSITION: The patient leaves the operating room alive and well, having tolerated the procedure without complication or complaint. He will stay overnight for pain control and IV antibiotics. He will return to me in approximately two to 14 days. We will likely deep him casted for a total of four weeks, and then start a motion program. Advanced Clinic Hand Surgery Exercise 26 - continued PATHOLOGY REPORT FINAL DIAGNOSIS: TENDON AND SYNOVIUM, RIGHT WRIST, EXCISION - SEVERE CHRONIC EXUDATIVE SYNOVITIS WITH RHEUMATOID NODULE FORMATION COMPATIBLE WITH ACTIVE RHEUMATOID SYNOVITIS. ** Report Electronically Signed Out ** ******************************************************************* SPECIMEN(S) SUBMITTED: SYNOVITIS DORSAL RIGHT WRIST CLINICAL DATA: RHEUMATOID ARTHRITIS, RIGHT EXTENSOR POLLICIS LONGUS, HAND GROSS DESCRIPTION: A. Received in formalin are multiple irregularly shaped fragments of pink-white fibrous tissue, fibroadipose tissue, and soft, pink-white tissue aggregating to 8 x 3 x 0.6 cm. The specimens are serially sectioned and representative sections are submitted in formalin in one cassette. (Age: 46) M 91 Advanced Clinic Hand Surgery Exercise 27 . Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. 92 Advanced Clinic Hand Surgery 93 Advanced Clinic Hand Surgery Exercise 28 . Please read the following clinical data and assign the appropriate CPT code(s) - modifiers: ______________________________________________. 94 Advanced Clinic Hand Surgery 95 Advanced Clinic Answer Key Exercise 1 20612-LT 25111-RT Exercise 2 26055-F2 26055-F3 26055-F7 26055-F8 Exercise 3 26055-F3 26055-F4 20550-F8 Exercise 4 26440-LT 26440-LT-59 Exercise 5 26121-LT Exercise 6 26123-F4 Exercise 7 26123-F4 Hand Surgery 96 Advanced Clinic Exercise 8 26123-F5 26125-F7 Exercise 9 26418-F6 Exercise 10 26418-F1 Exercise 11 26542-F5 Exercise 12 25431-RT Exercise 13 26852-F5 Exercise 14 26862-F4 Exercise 15 26841-RT Hand Surgery 97 Advanced Clinic Exercise 16 26952-F1 26862-F2 Exercise 17 26531-F6 26531-F7 26531-F8 26531-F9 26850-F5 Exercise 18 26591-LT 26989 64831 Exercise 19 26480-LT Exercise 20 25447-RT 25310-RT Exercise 21 25310-RT 25447-RT 26160-F1 Hand Surgery 98 Advanced Clinic Hand Surgery Exercise 22 25310-LT 25447-LT 26055-LT Per the Complete Global Service Data for Orthopaedic Surgery, American Academy of Orthopaedic Surgeons, code 25310 includes a “neuroplasty.” So code 64721 (open carpal tunnel release) was not assigned to this case. Exercise 23 25447-RT 25310-RT 26860-F7 Exercise 24 26852-RT 25310-RT 25447-RT Per the Complete Global Service Data for Orthopaedic Surgery, American Academy of Orthopaedic Surgeons, code 25310 includes a “neuroplasty.” So code 29848 (arthroscopic carpal tunnel release) was not assigned to this case. Exercise 25 25447-RT 25310-RT Per the Complete Global Service Data for Orthopaedic Surgery, American Academy of Orthopaedic Surgeons, code 25310 includes a “neuroplasty.” So code 64721 (open carpal tunnel release) was not assigned to this case. Exercise 26 26483-RT 99 Advanced Clinic Exercise 27 26356-LT 26356-LT-59 64831-LT Exercise 28 26356-F8 26350-F8 Hand Surgery 100