Case Study #2-  Hint: 2PCS Codes Required PREOPERATIVE DIAGNOSES:…

Case Study #2-  Hint: 2PCS Codes Required

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PREOPERATIVE DIAGNOSES: 1. Chronic lateral ankle instability, left ankle  2. Peroneal tendon tear, left ankle POSTOPERATIVE DIAGNOSES: Chronic lateral ankle instability, left ankle NAME OF PROCEDURES: Modified Brostrom lateral ankle stabilization procedure, left INDICATION: The patient was seen in the office complaining of chronically painful lateral ankle instability with pain in the peroneal tendon area. All conservative treatments up to this point have been unsuccessful in alleviating symptoms. Thus, surgical options were offered along with all potential complications, risks, and expected outcomes being fully explained to the patient’s level of understanding. No guarantees were given. Of note, the clinical and radiographic findings do correlate well with the above diagnoses. DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed upon the operating table in the supine position. Upon administration of general anesthesia, and after the patient was placed in the lateral position, the left lower extremity was scrubbed, prepped, and draped in the usual aseptic manner. The left lower extremity was exsanguinated via Esmarch and the previously applied pneumatic thigh tourniquet on the left side was then inflated to 300 mm Hg.

Attention was then directed to the lateral aspect of the left ankle. Here, a U-type incision was placed around the fibula, giving posteriorly approximately 5 cm superior to the tip of the fibula overlying the peroneal tendons. This was brought distally 1 cm inferior to the tip of the fibula. It was then brought around anterior to the fibula giving excellent access to the anterior talofibular ligament. The incision was in total approximately 11 cm in length. The incision was carefully deepened down through the subcutaneous tissues with care being taken to identify and retract all vital and neurovascular structures. All bleeders were ligated and cauterized as necessary. Next, through meticulous dissection, the incision was deepened down to the level of the peroneal tendon sheath and the lateral ankle ligaments and capsule as well as extensor retinaculum. Next, the peroneal tendon sheath was pierced and transected from inferior to superior through the incision. Peroneus brevis tendon and longus were identified. They were taken out of the groove. Attention was directed to the peroneus brevis first. There was noted to be no split in the peroneus brevis, which was noted on the MRI report. The consistency of the brevis was intact. There was no gross pathology present within it. There was noted to be low-lying muscle belly on the peroneus brevis, which likely was impinging in the peroneal retinaculum and peroneal tunnel, causing the patient the pain. The small bulge of this muscle was resected several centimeters above the peroneal retinaculum. Next, after this was performed, attention was directed to the peroneus longus. There was no gross pathology present in the peroneus longus. This was examined throughout the entire length of the incision, as was the peroneus brevis. After this was performed, the peroneal tendons were placed back in the groove. They were not subluxing on dorsiflexion and eversion. The wound was then flushed with copious amounts of sterile normal saline. The peroneal sheath with peroneal retinaculum was repaired with 3-0 fiber wire and 2-0 Vicryl throughout its entirety. After this was performed, the foot was placed through range of motion. The peroneal tendons were palpated through the sheath and noted to have a smooth congruent slide within the sheath.

Attention was directed to the anterior capsule, including the ATFL here at approximately 1 cm anterior and distal to the fibula. A capsular and ligamentous incision was placed in a curvilinear fashion, and the capsule and ATFL were transected. This incision followed the anterior and distal portion of the fibula down inferiorly to the peroneal tendons. Next, the capsule and ATFL, which was noted to be very attenuated and decreased in size, was reflected up to the fibula, giving exposure to the anterior portion of the fibula. Next, a drill hole was placed and a 3.0 Arthrex absorbable anchor was placed into the fibula according to manufacturer’s protocol. This was pulled on with tension and was noted to be very securely placed. Next, the distal portion of the ATFL and capsule was then sutured with the fiber wire attached to the anchor with the foot held in a dorsiflexed and everted position. After this was performed, the proximal flap of the capsule and ATFL was then sutured in a vest-over-pants type fashion with 3-0 fiber wire and 2-0 Vicryl over the previous capsule. The extensor retinaculum was incorporated into this. Once again, this was done with the foot being held in the dorsiflexed and everted position. After this was performed, the correction of the deformity was assessed and noted to be excellent. The inversion was limited with only approximately 5 degrees of inversion being noted. The foot was held in an excellent anatomically correct position. Next, the wound was flushed with copious amounts of sterile normal saline. The subcutaneous tissues were closed with 3-0 Vicryl and the skin was closed with 4-0 nylon in horizontal mattress type suture technique. At this time approximately 11 cc of Marcaine plain was infiltrated along the incision sites and in a high ankle block of the left ankle. The wounds were then covered with Betadine soaked Owen’s silk, sterile 4 × 4s, Kling, and Kerlix in the formation of a moderate compressive dressing. The tourniquet was released at this time with the hyperemic response being noted to all digits of the left foot. At this time, a very well padded below-the-knee cast was applied to the left lower extremity. The cast was bivalved with Ace wraps applied. The anesthesia was discontinued. The patient was taken to recovery.

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