Surgery revision question (coding)

[billBOB213]

Hi everyone, hope you all are having a great day.

Did an MIS bunion case yesterday that I am not happy with and want to revise. As far as coding goes, as we are in global period, would I use another bunionectomy code or just hardware removal code for the ASC paperwork?
I am happy with fixation, but feel like the proximal screw is too long so probably taking out and replacing with smaller screw. The longer screw is keeping the capital fragment from touching the 1st met, it is close but would sleep better if it was right on it.

Any help would be appreciated.

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[CutsWithFury]

Hi everyone, hope you all are having a great day.

Did an MIS bunion case yesterday that I am not happy with and want to revise. As far as coding goes, as we are in global period, would I use another bunionectomy code or just hardware removal code for the ASC paperwork?
I am happy with fixation, but feel like the proximal screw is too long so probably taking out and replacing with smaller screw. The longer screw is keeping the capital fragment from touching the 1st met, it is close but would sleep better if it was right on it.

Any help would be appreciated.

hardware removal code. You already made an osteotomy. You are not making another osteotomy. Just switching screws

 

[Pronation]

Hi everyone, hope you all are having a great day.

Did an MIS bunion case yesterday that I am not happy with and want to revise. As far as coding goes, as we are in global period, would I use another bunionectomy code or just hardware removal code for the ASC paperwork?
I am happy with fixation, but feel like the proximal screw is too long so probably taking out and replacing with smaller screw. The longer screw is keeping the capital fragment from touching the 1st met, it is close but would sleep better if it was right on it.

Any help would be appreciated.

I think for screw exchanges only a hardware removal code is billable. Just curious if you would be willing to share a pic of the post op X-ray

 

[billBOB213]

 

[billBOB213]

I think that proximal screw was too long and pushed the capital fragment distally

Plan is to put guide pins in, remove screws, compress met head and use same distal screw and little smaller proximal screw

 

[Pronation]

I think that proximal screw was too long and pushed the capital fragment distally

Plan is to put guide pins in, remove screws, compress met head and use same distal screw and little smaller proximal screw

Thanks for sharing. I think your plan is sound, I would sleep better at night knowing there was contacting bone at the osteotomy especially with a big shift. I also wouldn’t be completely surprised if this healed in this position but would rather not risk it.

I also think your MTP alignment will improve a bit because that long proximal screw is keeping the met head tilted over medially instead of having the articular surface pointed straight forward. PASA or whatever we call that stuff.

 

[Pronation]

Will your post op weightbearing course change given the screw exchange or will you decide based on how well the exchanged screws bite?

 

[NatCh]

I think that proximal screw was too long and pushed the capital fragment distally

Plan is to put guide pins in, remove screws, compress met head and use same distal screw and little smaller proximal screw

Just curious, have you already talked to the patient about this plan?

 

[air bud]

When did you notice this? Any reason you left OR of hospital/AsC like this?
I can think of a midfoot fusion where I notice I airballed a screw into a joint. Noticed in post op. Talked to the patient and said we are going back in. Patient had a pop block. Did without anesthesia in OR. Worked great. Patient understood it was best idea.

 

[air bud]

I would throw a non threaded k wire in the same orientation as your screws. Back screws out past osteotomy. Then refixate. Probably will have new trajectory of fixation. But could just reinsert screws, get good compression. Then back out one, switch length and then do the other.

Or none of that works and you open up.

 

[Pronation]

I would throw a non threaded k wire in the same orientation as your screws. Back screws out past osteotomy. Then refixate. Probably will have new trajectory of fixation. But could just reinsert screws, get good compression. Then back out one, switch length and then do the other.

Or none of that works and you open up.

This is also a sound plan but the more I think about it the more I remember that the enemy of good is better. The MTP alignment is probably good enough. A simple exchange is probably sufficient with less headaches and still good outcome.

 

[Pronation]

When did you notice this? Any reason you left OR of hospital/AsC like this?
I can think of a midfoot fusion where I notice I airballed a screw into a joint. Noticed in post op. Talked to the patient and said we are going back in. Patient had a pop block. Did without anesthesia in OR. Worked great. Patient understood it was best idea.

This is probably something worth thinking about if this gets brought up by peer review.

 

[Boba Foot]

This MIS **** is going to age poorly.

 

[Feli]

This MIS **** is going to age poorly.

It did last time around too.

 

[Pronation]

It did last time around too.

Yea but it’s different this time bro. It squirts water automatically onto the burr

 

[CutsWithFury]

View attachment 361864

This is not good. You need to remove both screws and revise this. The capital fragment can't be suspended in air. This will not bone callus in that well.

 

[wakaflocka88]

This is not good. You need to remove both screws and revise this. The capital fragment can't be suspended in air. This will not bone callus in that well.

I’m not mentally ready to try any MIS bunions. Worse case scenario and need to open - what would you do?

 

[CutsWithFury]

I’m not mentally ready to try any MIS bunions. Worse case scenario and need to open - what would you do?

This is an easy fix. Take the screws out and press the capital fragment to touch the metatarsal and re-throw screws. Did the OP even drill through the capital fragment?

 

[Pronation]

I’m not mentally ready to try any MIS bunions. Worse case scenario and need to open - what would you do?

Convert to partial 1st ray amputation

 

[billBOB213]

Thanks for sharing. I think your plan is sound, I would sleep better at night knowing there was contacting bone at the osteotomy especially with a big shift. I also wouldn’t be completely surprised if this healed in this position but would rather not risk it.

I also think your MTP alignment will improve a bit because that long proximal screw is keeping the met head tilted over medially instead of having the articular surface pointed straight forward. PASA or whatever we call that stuff.

I agree with this, I thought it could possibly heal buuuut I want to make sure it for sure heals, thanks for feedback

 

[Pronation]

Anyway I wanted to say thanks for taking the liberty to post your complication. I think this brought up some good talking points.

 

[billBOB213]

When did you notice this? Any reason you left OR of hospital/AsC like this?
I can think of a midfoot fusion where I notice I airballed a screw into a joint. Noticed in post op. Talked to the patient and said we are going back in. Patient had a pop block. Did without anesthesia in OR. Worked great. Patient understood it was best idea.

Valid questions, so IntraOp I thought it was close enough that could get some bony callus and could heal, but probably just fooling myself as I thought about it during the day.

Haven’t done a ton of these yet, almost at double digits, all have healed good and good results thus far (knock on wood). I like them and would do all MIS and lapidus’ all day and leave the Austins alone.
There is still a learning curve, this is first time I’ve encountered this and it’s a good learning experience if it happens again.

 

[billBOB213]

Convert to partial 1st ray amputation

This

 

[billBOB213]

This is an easy fix. Take the screws out and press the capital fragment to touch the metatarsal and re-throw screws. Did the OP even drill through the capital fragment?

No and this is another viable option, thought about this as well and could just do this and keep same screws

 

[billBOB213]

I’m not mentally ready to try any MIS bunions. Worse case scenario and need to open - what would you do?

Open it and plate it. Absolute worst case scenario

 

[billBOB213]

It did last time around too.

When was ‘the last time’ your referring to?

 

[billBOB213]

Hopefully I got to all the questions/comments. Came back from clinic and got a lot of feedback 👍🏼

 

[CutsWithFury]

No and this is another viable option, thought about this as well and could just do this and keep same screws

why didn't you drill through capital fragment? I'm very confused

 

[billBOB213]

I usually don’t drill through cortex of the distal lateral aspect of the capita fragment, just into capital fragment
I didn’t explain it good there

I’m in the head, but busting through the cortex on lateral aspect is something I could have tried to not have that screw distract the capital fragment

 

[billBOB213]

Anyway I wanted to say thanks for taking the liberty to post your complication. I think this brought up some good talking points.

Your welcome, yes for a coding question it seems to have gone off on a different path haha

I don’t mind though, all good feedback

 

[billBOB213]

Just curious, have you already talked to the patient about this plan?

Yep
Patient on board

 

[air bud]

This is an easy fix. Take the screws out and press the capital fragment to touch the metatarsal and re-throw screws. Did the OP even drill through the capital fragment?

Right. But have a wire across it to keep from falling off. Same trajectory and should compress along the wire.

 

[air bud]

Your welcome, yes for a coding question it seems to have gone off on a different path haha

I don’t mind though, all good feedback

Thanks for sharing. Great learning experience for you and others on here

 

[DYK343]

Glad you admitted the mistake to your patient and yourself. Takes guts to do that. Weve all had complications. Not everyone admits it.

Definately have a plate available in case this goes to hell.

Werent people just fixing with nothing more than a K-wire down the 1st met shaft to act s a buttress to the capital fragment? What happened to that method of fixation?


Even when executed perfectly these minimally invasive bunion xrays sketch me out. They scream avn, non union, venous congestion, and always look like theyre teatering towards varus. I guess I need to get with the times as proponents are all in on this MIS but im still watching from the sidelines. I have sent a handful of patients to alternate surgeons who wanted MIS (or lapiplasty) because I currently dont offer the procedure.

 

[air bud]

Glad you admitted the mistake to your patient and yourself. Takes guts to do that. Weve all had complications. Not everyone admits it.

Definately have a plate available in case this goes to hell.

Werent people just fixing with nothing more than a K-wire down the 1st met shaft to act s a buttress to the capital fragment? What happened to that method of fixation?


Even when executed perfectly these minimally invasive bunion xrays sketch me out. They scream avn, non union, venous congestion, and always look like theyre teatering towards varus. I guess I need to get with the times as proponents are all in on this MIS but im still watching from the sidelines. I have sent a handful of patients to alternate surgeons who wanted MIS (or lapiplasty) because I currently dont offer the procedure.

Lapiplasty is the future. Just retire now bro. No other way to do a bunion.

 

[billBOB213]

Lapiplasty is the future. Just retire now bro. No other way to do a bunion.

Ayyy bro, you’ve obviously never heard of this-this is the way

https://redpointmedical3d.com/videos/RedPointMed_BetterBunion.mp4

She’s right, bunion surgery doesn’t have to be complex.
My obvious problem with the whole case is I didn’t get a CT 🤦🏻‍♂️ with a custom jig
Muh bad

 

[air bud]

Ayyy bro, you’ve obviously never heard of this-this is the way

https://redpointmedical3d.com/videos/RedPointMed_BetterBunion.mp4

She’s right, bunion surgery doesn’t have to be complex.
My obvious problem with the whole case is I didn’t get a CT 🤦🏻‍♂️ with a custom jig
Muh bad

Nailed it.

 

[Utvolsdpm]

Can anyone tell me about laser bunions while we are at it?

 

[dtrack22]

Plan is to put guide pins in, remove screws, compress met head and use same distal screw and little smaller proximal screw

did you see the patient in clinic post-op already? I would get new weight bearing films. That met head is going to shift medially post-operatively and will probably move slightly proximal as well. You could be going back to the OR for no reason. But if you do, wires and screw exchange is all I would do.

What happened to that method of fixation?

It’s still used in Europe but is not profitable and therefore will never be pushed by the medical device industry in the US

This isn’t directed at anyone, but I’ve always found the people who worry about MIS bunions having problems or not working, but will do any type of open metatarsal osteotomy without reservation…entertaining.

 

[air bud]

Oh you mean do the thing that we have practiced hundred or thousands of times and spent a few years learning vs doing a weekend course?

did you see the patient in clinic post-op already? I would get new weight bearing films. That met head is going to shift medially post-operatively and will probably move slightly proximal as well. You could be going back to the OR for no reason. But if you do, wires and screw exchange is all I would do.


It’s still used in Europe but is not profitable and therefore will never be pushed by the medical device industry in the US

This isn’t directed at anyone, but I’ve always found the people who worry about MIS bunions having problems or not working, but will do any type of open metatarsal osteotomy without reservation…entertaining.

 

[dtrack22]

Oh you mean do the thing that we have practiced hundred or thousands of times and spent a few years learning vs doing a weekend course?

You need to learn how to use the multi-quote function. I have no idea what you’re trying to say.

 

[air bud]

You need to learn how to use the multi-quote function. I have no idea what you’re trying to say.

Yes

 

[DYK343]

This isn’t directed at anyone, but I’ve always found the people who worry about MIS bunions having problems or not working, but will do any type of open metatarsal osteotomy without reservation…entertaining.

I think the resentment is just like Feli said they were all the rage awhile ago then they were suddenly considered taboo. Most of the DPMs doing them were doing them in their office under questionable sterility conditions (cash pay because insurance wouldnt cover in office bunion).

Looks like that is changing - more OR based. The fixation is also a lot better now. I also like the potential for frontal plane rotation with this procedure.

Its the amount of lateral translation that really freaks me out when it should have been a lapidus. Cortical edge to cortical edge. How does that not stretch the vasculature? Apparently they heal weightbearing day 1 but it just seems iffy to me.

In a year or two if its still all the rage I might give it a try. Until then my 15-20 min austin add 5-10min akin is tried and true and works well for me. My patients walk out of the surgery center in a post op shoe. I try to avoid dorsal capsular work to limit stiffness post op. So far minimal complications.

 

[Redsting]

Ayyy bro, you’ve obviously never heard of this-this is the way

https://redpointmedical3d.com/videos/RedPointMed_BetterBunion.mp4

She’s right, bunion surgery doesn’t have to be complex.
My obvious problem with the whole case is I didn’t get a CT 🤦🏻‍♂️ with a custom jig
Muh bad

I wanna know how much this costs. Is there anywhere that would approve the cost of this?

 

[air bud]

I wanna know how much this costs. Is there anywhere that would approve the cost of this?

If you have to ask you can't afford it bro.

 

[billBOB213]

I think the resentment is just like Feli said they were all the rage awhile ago then they were suddenly considered taboo. Most of the DPMs doing them were doing them in their office under questionable sterility conditions (cash pay because insurance wouldnt cover in office bunion).

Looks like that is changing - more OR based. The fixation is also a lot better now. I also like the potential for frontal plane rotation with this procedure.

Its the amount of lateral translation that really freaks me out when it should have been a lapidus. Cortical edge to cortical edge. How does that not stretch the vasculature? Apparently they heal weightbearing day 1 but it just seems iffy to me.

In a year or two if its still all the rage I might give it a try. Until then my 15-20 min austin add 5-10min akin is tried and true and works well for me. My patients walk out of the surgery center in a post op shoe. I try to avoid dorsal capsular work to limit stiffness post op. So far minimal complications.

So THIS was a big reason I wanted to go away from Austin’s, I was never in love with the post op stiffness at 1st MPJ. The ROM post op MIS bunion is magnificent, unchanged. Probably just suck with my capsular work, but even in residency I feel like everyone’s Austin’s produced decreased ROM post op.
I am still learning MIS bunions but so far so good, happy with results.

** Today I did end up putting in a new shorter proximal screw, obviously not ideal to go back to OR but I’ll sleep better.
And it isn’t cheap, get that too. I mostly use inexpensive hardware for my other surgeries though (crossing screws for lapidus/MPJ fusions, k-wires for HTs), so I’ve built up some trust with the ASC and they don't squawk at my more expensive MIS stuff.

 

[billBOB213]

so all in all I coulda gotten better transverse plane correction still, and I wish I would started more proximal on that flute of base of met, but I think she will do really well. Her swelling was nonexistent, still amazes me with these MIS things.
Anyways thanks everyone for comments and for the coding help, consider this thread done ✅

 

[NatCh]

So THIS was a big reason I wanted to go away from Austin’s, I was never in love with the post op stiffness at 1st MPJ. The ROM post op MIS bunion is magnificent, unchanged. Probably just suck with my capsular work, but even in residency I feel like everyone’s Austin’s produced decreased ROM post op.

My Chevrons/Austins have all gotten stiff immediately afterward but a year or two later they've regained their ROM. Maybe not "textbook normal" ROM but adequate for normal gait and patient satisfaction. I just inform the patients that it takes time, at least a year to feel 100%. Not a big deal.

 

[NatCh]

so all in all I coulda gotten better transverse plane correction still, and I wish I would started more proximal on that flute of base of met, but I think she will do really well. Her swelling was nonexistent, still amazes me with these MIS things.
Anyways thanks everyone for comments and for the coding help, consider this thread done ✅

Looks much better.

 

[air bud]

so all in all I coulda gotten better transverse plane correction still, and I wish I would started more proximal on that flute of base of met, but I think she will do really well. Her swelling was nonexistent, still amazes me with these MIS things.
Anyways thanks everyone for comments and for the coding help, consider this thread done ✅

Looks great that will heal and she will love it