Removal screw tibia

PREOPERATIVE DIAGNOSIS: Retained hardware right tibia.

POSTOPERATIVE DIAGNOSIS: Retained hardware right tibia.

PROCEDURE: Hardware removal right tibia.

INDICATIONS: This 16-year-old male underwent intramedullary nailing of his right tibia fracture by me. He has healed his tibia uneventfully and his problems now revolve around his prominent hardware. He was PARd reference his options and accepts hardware removal.

DESCRIPTION OF PROCEDURE: Under general anesthesia and tourniquet control the patient's right leg was prepped and draped using normal sterile technique. The previous incisions were utilized to approach the proximal and distal screw holes. The proximal screw was approached first. This was not easily identifiable. Next, the distal screw was approached and it was easily identifiable and it was removed without difficulty. Dissection proximally was tedious and the proximal screw was not readily apparent. Image intensification was utilized to approach the proximal screw. The lateral portion of the proximal screw was palpated percutaneously and the end was identified. This was used as a marker. A single drill hole was made in the tibia and the screw head was identified slightly anterior to the drill hole itself. The vast majority of the screw head was overgrown with bone. The overgrown bone was removed without difficulty. The screw was backed out. Next, image intensifier was utilized to approach the proximal end of the rod. The proximal end was identified and bone was cleared away from the proximal end of the rod. This bone also invaded the screw cap. The bone was removed from the screw cap and the screw cap was removed. In order to place the inserter/extractor bolt the proximal rod had to be drilled to remove bone from the center portion of the rod. Once the bone was drilled the inserter extractor screw was tightened. The tuning fork hammer was utilized to remove the rod. This was done once the rod had broken free from the bone nearby. All hardware was removed to be sterilized and given to the patient. The wounds were copiously irrigated and closed with absorbable sutures on the subcutaneous tissues and the skin was closed with staples. Marcaine was instilled and a light dressing was placed at the knee and ankle.

TOURNIQUET TIME: 85 minutes.

BLOOD LOSS: Minimal.

COMPLICATIONS: None.

PLAN: The patient was given a prescription for 30 Vicodin for postoperative pain control. He will return to see me in the office in a week for dressing removal and a week later for removal of all staples. Next week we can remove some of the staples. We should also get an x-ray of his right tibia, 2 views, at that time.

Between now and the time the patient is seen next week he will be maintained on crutches with toe-touch weightbearing on the right side.

codes: 
Code: 
20680
Code Type: 
CPT
Code: 
78.67
Code Type: 
ICD-9
Code: 
0QPG04Z
Code Type: 
ICD-10