This month’s operation report features open reduction subchondroplasty. The practice of the procedures in this report is nothing new and this is considered a standard 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: 05/XX/2021
PREOPERATIVE DIAGNOSIS:
1. Subchondral fracture BML lesion of lateral femoral condyle.
2. Osteochondral defect of lateral femoral condyle.
3. Posterior horn lateral meniscus tear.
POSTOPERATIVE DIAGNOSIS:
1. Subchondral fracture BML lesion of lateral femoral condyle.
2. Osteochondral defect of lateral femoral condyle.
3. Posterior horn lateral meniscus tear.
PROCEDURES PERFORMED:
1. Open reduction lateral condylar fracture subchondroplasty with calcium phosphate.
2. Partial lateral meniscectomy.
3. Debridement of osteochondral lesion.
4. Decompression of ganglion cyst of the ACL graft.
ASSISTANT: A. V., PA.
PA was necessary to help position the patient, manipulate the leg. This allowed the operation to occur efficiently as well as safely.
ANESTHESIA: General
ANESTHESIOLOGIST: R. S., M.D.
COMPLICATIONS: None.
ANTIBIOTICS: 2 g Ancef perioperatively.
INDICATIONS: This 21-year-old athletic baseball player, patient has sustained trauma to his left knee while playing baseball. He was treated by his team physician and trainer for a bone bruise for a long period of time with protected weight-bearing. Repeat MRI revealed that he had developed a ganglion in his previous ACL reconstruction that was 10 years prior with autogenous graft. MRI also revealed blistering of his articular cartilage indicating the possibility of an osteochondral defect. MRI also revealed a significant BML lesion that had been unresolved in spite of all conservative care. He was having significant continued discomfort and pain. MRI changes were different from the year prior where his graft showed no ganglion, had less blistering, and a smaller BML lesion since he is not improving. The procedure, risks, alternatives, and expectations discussed in detail with the patient of undergoing arthroscopy, the possibility of meniscectomy, subchondroplasty of lateral femoral condyle BML lesion, and finally decompression of the ganglion cyst and check the integrity of the ACL graft as well as a cartilage biopsy. Cartilage biopsy was done from later MACI reimplantation at a later date after cloning cartilage.
TECHNIQUE: The patient was brought to the operating room after successful general anesthesia and had both knees examined. The patient was found to have a trace Lachman, pivot shift, and anterior drawer in his right knee. He had a similar trace anterior drawer, pivot shift, and Lachman in his left knee. After returning in good stability, his left lower extremity was then prepped and draped in usual orthopedic fashion. Tourniquet was applied. However, no tourniquet was used. After appropriate time-out, standard arthroscopic portals were made. The patellofemoral joint was visualized and found to be pristine. The trochlear groove was pristine. The medial compartment and medial meniscus were pristine. Anterior cruciate ligament graft was intact. It was in continuity, had good tension, however, was found to have a cyst. Utilizing a spinal needle, cyst was decompressed. The graft was again inspected and found to have good integrity. The lateral compartment was visualized and found to have a small radial tear of the lateral meniscus. This was resected to stable borders. Articular cartilage was then probed utilizing a nerve hook. The patient was found to have a soft articular cartilage for a 21-year-old male; however, it was not delaminated at the central weight-bearing portion. However, more posteriorly, there was a defect measuring approximately 4 x 8 mm of exposed unstable fibrillated articular cartilage. This was debrided using a meniscal shaver to stable borders. These were measured approximately 4 mm x 8 mm. Noting that he had an osteochondral defect, it was elected to go ahead and do a cartilage biopsy for a later MACI procedure. Utilizing a ring curette, the cartilage was then obtained for later reinsertion for a MACI. After doing this, attention was directed to the subchondral lesion. A C-arm was brought in the room utilizing a spinal needle. The area of the BML lesion was then identified utilizing the MRI for a guide. The drill was then drilled in. The calcium phosphate was then mixed. Three syringes were then placed in the lesion utilizing C-arm control. It was found that it filled the area of the BML lesion perfectly. At the conclusion of this, there was a small wafer of bone that was noticed. This could not be palpated and hence left alone feeling this would not be an issue. Scope was then placed back into the knee to be sure that there was no calcium phosphate material into the joint, none was seen. The lesion on this chondral was again identified, feh that this may or may not be a problem that will require cartilage transplant unless he has symptoms since some of the symptoms may be from the BML lesion. Intraoperative picture was taken to document all pathology at the conclusion of the case. Marcaine without epinephrine was injected in the portals. Marcaine 15 cc with epinephrine was injected in the joint. He will be tested non-weightbearing for approximately 10 days. He may begin weightbearing as tolerated after 10 days. He will go back to his university for working out for range of motion and strengthening.