This month’s operation report features open repair of a toe fracture with allograft. The practice of this procedure is nothing new and this is considered a standard of practice that is essential for good patient recovery. When performing these operations, there are additional questions to be asked about the coding and billing involved. Continue reading below to learn more!
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DATE OF SURGERY: 03/xx/21
PHYSICIAN: K.N., M.D.
PREOPERATIVE DIAGNOSIS: Right second toe proximal phalanx fracture nonunion.
POSTOPERATIVE DIAGNOSIS: Right second toe proximal phalanx fracture nonunion.
PROCEDURE PERFORMED: Right second toe proximal phalanx nonunion repair.
BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE: The patient had sustained a second toe fracture. She had undergone immobilization for a period of 4 months without healing of the fracture as confirmed by CT scan. The risks and benefits of the above procedures were explained to the patient at length. The risks include pain, bleeding, infection, stiffness, swelling, continued nonunion, painful hardware, nerve injury, blood clots, and the possible need for further surgery in the future. Informed consent was obtained to proceed.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating table in supine position. After sedation anesthesia was induced and the second toe block was then performed, she was prepped and draped in the usual sterile fashion. An ankle Esmarch tourniquet was applied. The incision was made over the second toe proximal phalanx. Sharp dissection was carried out down to the fracture site. The fracture site was identified with nonunion tissue. There was some bony bridging present. This was not taken down as it was felt the fracture was satisfactorily aligned. Size small Trinity ELITE graft was then thawed and prepped in a standard fashion. The graft was reduced to the nonunion site. The defect was completely over the site of nonunion. This was refilled. A single Paragon 28, 2.0 mm cannulated screw was then placed perpendicularly across the fracture site. A lateral to medial direction secured with appropriate reduction and fixation. Thorough irrigation was carried out using saline. The skin was closed using nylon sutures. Wounds were dressed with Xeroform, 4×4’s, Kling followed by an Ace wrap. The patient tolerated the procedure well and no known complications. She was transferred to the recovery room in good condition.