2. Operative Report
PREOPERATIVE DIAGNOSIS:Displaced left patella fracturePOSTOPERATIVE DIAGNOSIS:Displaced left patella fracturePROCEDURE PERFORMED:Open reduction and internal fixation of left patella using cannulated screws and 18-gauge wire
INDICATIONS: This 42-year-old female with type 1 diabetes mellitus became unsteady on her feet, fell, and had a displaced patellar fracture with bleeding into the quadriceps. All questions were answered and the consent was signed.
PROCEDURE: Regional block anesthesia was administered as patient could not be cleared for general anesthesia at this time. A cuff was placed in the upper portion of the left thigh. The leg was then prepped and draped in sterile fashion. Compressive wrap was applied distally. The leg was exsanguinated. Tourniquet was inflated.
Incision was made sharply through skin and subcutaneous tissue. Dissection was carried down to the patella fracture. A large hematoma was encountered, thoroughly evacuated and irrigated. The fracture included a fairly transverse fragment. A bone scrub was used to clean soft tissue debris from the cancellous surfaces. When a clean fracture site was achieved, the reduction forceps was used to hold the patella in a reduced position anteriorly. X-ray imaging also confirmed the reduction. Guide pin was placed and the knee was flexed slightly from superior to inferior. A 4.5 Synthes stainless steel screw system was utilized. Position was confirmed by lateral radiograph, by palpation and visualization. The second screw was then placed on the lateral aspect of the patella and again confirmed with x-ray imaging, palpation and visualization. Good purchase was achieved by both screws. A tension band wiring was then performed by threading the wire through both screws and then back upon itself. Soft tissues were then repaired laterally using interrupted Fiberwire suture and closed over the top of the hardware to prevent irritation. Subcutaneous was closed over that with Vicryl suture and the skin was closed with nylon.
I cannot figure out the ICD-10_PCS code for this. I’ve looked and looked.