Assignment task: Read the following operative report and determine the appropriate CPT procedure code(s).
Preoperative Diagnoses:
Bunion left foot
Hammertoes 2 through 4 left foot
Postoperative Diagnoses:
Bunion left foot
Hammertoes 2 through 4 left foot
Indication:
On her hammertoes and bunion, the pain is less and more shoe pressure related. She had hammertoes on her right foot which we corrected about 14 months ago and wants the same procedure on her left foot in addition to addressing the other painful areas. More recently, she developed a burning pain on her 3rd toe dorsally which is a new symptom and was not present when she had her right foot hammertoes.
Examination of her feet reveals palpable foot pulses. Lesser toes 2 to 4 have plantar flexion contractures at the PIP joints. There is a rounded bony prominence on the dorsal medial 1st metatarsal head with laterally angulated 1st MTP joint. Preoperative weight-bearing x-rays of the left foot reveal plantar flexion contractures of the 2nd, 3rd, and 4th toe PIP joints. The 1st metatarsal has a bony prominence in the dorsal medial aspect. The 1 to 2 intermetatarsal angle is near normal at around 9 degrees, and the first metatarsal is quite short. The patient has elected to undergo surgical treatment of these painful areas of her left foot knowing her surgical alternatives, risks, hazards, and potential complications. She has undergone a preoperative medical evaluation by her physician, along with preoperative testing, and the results of these were reviewed. Need Online Tutoring?
Procedure(s):
Modified McBride bunionectomy left foot
Hammertoe correction 2 through 4 left foot
Details of Procedure:
With the patient supine on the operating room table, a safety strap was placed across her hips and a well-padded pneumatic tourniquet was placed above the left ankle. IV sedation was administered by the anesthesia department. A proximal Mayo and dorsal midfoot block was performed with 10cc of 1% lidocaine plain. The foot was prepped and draped in the usual aseptic fashion. A timeout was performed identifying, among other things, the correct patient and surgery site, the latter which I had marked in the preoperative area.
Attention was directed to the left foot. Anesthesia was supplemented with another 10 cc of 1% lidocaine plain. A linear incision was placed medial and parallel to the extensor hallucis longus tendon over the distal 1st metatarsal. Full-thickness skin flaps were created preserving the dorsal medial cutaneous nerve within the medial flap. A parallel incision was made in the 1st MTP joint capsule, which was dissected off the 1st metatarsal head exposing bony eminence. This was excised with a sagittal saw.
Attention was directed into the 1st interspace where a lateral release was performed including the adductor tendon, fibular sesamoid metatarsal ligament, lateral collateral ligaments, and the extensor hallucis brevis tendon.
Attention was directed back to the 1st metatarsal head, which was first remodeled with a power bur. The site was copiously irrigated with saline. Closure consisted of 3-0 Vicryl for the joint capsule dorsal medially and also some redundant medial capsule was excised transversely and repaired with a 3-0 Vicryl. Subcutaneous stitches were placed with 4-0 Vicryl in a simple inverted fashion.
Attention was directed to the three contracted toes where linear incisions were placed dorsal and parallel and centered over the PIP joints. Full-thickness skin flaps were created. The PIP joints were entered through transverse incisions and dissection exposed the proximal phalanx heads and medial phalanx bases, which were then excised transversely with sagittal saw. The sites were irrigated; toes were manipulated into anatomical alignment. 0.045 K-wires were placed into the base of the proximal portion of the distal phalanx of the tip of the toe and retrograded proximally into the proximal phalanxes down through their base on all three toes. The K-wires were cut and bent, and the tips were then placed beneath the surface of the toes through small stab incisions. The foot was loaded with good alignment of toes noted. Closure consisted of 4-0 Vicryl for the PIP joint, capsule, and tendon apparatus, and then the six incisions were closed with 4-0 Nylon in the horizontal mattress fashion. Prior to the hammertoe correction, 10 cc of 1% lidocaine plain were used to anesthetize these toes and then postop injection included 30 cc total of 0.5% Marcaine plain and a midfoot block.
The foot was dressed with Adaptic and gauze. The tourniquet was deflated; immediate perfusion returned to the tips of the toes. Dressing was extended above the ankle also covering the tips of the toes, and a mildly compressive Coflex wrap was applied including splinting the hallux in anatomical alignment.
The patient tolerated the procedures and anesthesia well and left the OR for ASU in good condition, vital signs stable, and a capillary fill time less than two seconds to all toes of the left foot.