CASE 8-16 Operative Report, Fusion with Autograft

Assign a diagnosis code for the osteoarthritis of the foot and a sequelae/late effects code for the bone fracture of the extremity. Note the "due to old calcaneal fracture," which is the indication for the sequelae/late effects code. Code only the autograft for services provided.

LOCATION: Outpatient, Hospital

PATIENT: Rose Stich

SURGEON: Mohomad Almaz, MD

PREOPERATIVE DIAGNOSIS: Posttraumatic subtalar osteoarthritis, left hindfoot, due to old calcaneal fracture

POSTOPERATIVE DIAGNOSIS: Posttraumatic subtalar osteoarthritis, left hindfoot, due to old calcaneal fracture

PROCEDURE PERFORMED: Left subtalar fusion using moldable autograft obtained from the left iliac crest

OPERATIVE PROCEDURE: After suitable general anesthesia had been achieved, the patient's left iliac crest and left foot and ankle were prepped and draped in the usual manner. Before prepping, a thigh tourniquet was applied but initially not inflated. Bone graft was harvested from the left iliac crest. A 10-cm (centimeter) incision was made and carried down through the subcutaneous fat. The fascia was incised in line with the crest starting about 2 cm back from the anterior-superior iliac spine. Cortical cancellous bone graft was then harvested from the inner table. Defect was packed with Gelfoam. The wound was closed in layers. The skin was closed with staples.

The leg was then elevated. The tourniquet was inflated. The incision was made from the tip of the fibula to the base of the fourth metatarsal. The distally based flap of the extensor digitorum brevis was elevated off the lateral aspect of the calcaneus. Fat pad and the sinus tarsi were split in line with the skin incision. Anterior process of the calcaneus was excised. The capsule was incised. A lot of thickened synovial tissue was removed. The joint surfaces were noted to be substantially damaged from the old calcaneal fracture. The remaining articular cartilage and scar tissue were removed with a curet and rongeur. The subchondral bone was then carefully burred down to a bleeding surface. Autograft from the iliac crest was then packed in between the bone surfaces. Using an image intensifier, a large-fragment cannulated screw was then placed starting at the talar neck across the posterior face of the subtalar joint into the central aspect of the calcaneal body. Further gap in the fusion at the sinus tarsi area was filled with autograft and allograft. The wound was then closed. Skin was closed with 4-0 nylon. Dressing and a Robert Jones dressing with a posterior fiberglass splint were then applied. The tourniquet was released. Following tourniquet release, good circulation was noted to return to the foot. The patient tolerated the procedure well and returned to the recovery room in stable condition.

CPT CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ___________________________________

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