03/19/2005    David Sands, DPM

Bunionectomy Complication

Query: Bunionectomy Complication

I have a patient whom last month I performed a
Scarf-type bunionectomy. Last week, she banged
her toe and the osteotomy was displaced, as well
as both screws. I have her scheduled for removal
of the screws, and revision open reduction
internal fixation (ORIF) of the displaced
osteotomy. What is the appropriate way to code
this?

This revision surgery is within the 90-day
global period. I assume removal of the screws
are included in the procedure.

David Sands, DPM
Jamaica Estates, NY

Codingline Response: I would code this procedure
as CPT 28485 (open treatment of metatarsal
fracture, with or without internal or external
fixation). I would also append that procedure
with a "-78" modifier to indicate a return to
the operating room in a global period with a
related problem.

The removal of the screws would not payable
separately.

Tony Poggio, DPM
Alameda, CA

Additional responses are posted at
http://www.codingline.com

Other messages in this thread:

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09/03/2002    Howard Bonenberger, DPM, Dave Luongo, DPM

Bunionectomy Complication (Scott Hughes, DPM)

RE: Bunionectomy Complication (Scott Hughes, DPM)
From: Howard Bonenberger, DPM, Dave Luongo, DPM

I have read with interest the responses that have
been posted and some of them mention the
possibility of EHL rupture or over-lengthening
however this would not account for the lack of
active plantarflexion. Also, you don't describe
any flexion deformity at the MTPJ or IPJ which
would be occurring if the EHL were severed and
the flexors left intact. I, too have seen
patients who feel that they cannot move the
operated part. If this is the case you may
determine this by having the person actively flex
and extend the lesser MTPJ's slowly while you
passively move the first MTPJ in the same
direction. They will begin to see that their toe
isn't going to "fall off" and will begin to
recruit the hallux muscle-tendon units as they
move the other MTPJ's. I hope that it is this
simple...we have all seen it and this maneuver
usually works
.
If it is excessive shortening of the metatarsal
then you will have to decide if it warrants
reoperation with insertion of a graft (this could
possibly be obtained by shaving a little more off
of the medial met head if you don't need too much
bone). I would suggest that it would be easier
to lengthen the met rather than trying to shorten
to the correct physiologic tension the
tendons both dorsally and plantarly. Have a
neurologist stimulate the extensors and flexors
electrically to see if they can move the hallux
before you take this patient back to the OR. Be
there when he does it so you can see exactly what
happens.

Good luck... please keep writing to let all of us
know how things are going.

Howard Bonenberger, DPM
Howardbon@aol.com

-----------------------------

It is possible that you sutured the EHL to the
capsule or other structure in your closure or
that
there are adhesions to your skin closure. I
would try to palpate the tendon on ROM. You
should be able to feel if it was severed. If the
patient had DF prior to surgery, I doubt it is
from polio. I hope this helps.

Dave Luongo, DPM
Paramus, NJ.
MYFOOOTDOC@aol.com

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09/02/2002    Norman Calihman DPM

Bunionectomy Complication (Scott Hughes DPM)

Re: Bunionectomy Complication (Scott Hughes DPM)
From: Norman Calihman, DPM

First, I'd like to commend Dr. Hughes for
reaching out for help early
on as opposed to 'wishing' a potential problem
away.
Given the scenario he describes, this seems like
a situation all foot surgeons encounter on
occasion. I think he is dealing with a case
of 'patient guarding'.

This is an involuntary protective mechanism which
is controlled by the CNS and generally dissipates
with physical therapy within several weeks.

He mentioned that the EHL becomes 'tense' and I
assume he means upon active dorsiflexion. I would
suggest that you make sure the EHL was
not severed inadvertently which would be an
obvious explanation for
this scenario. Another possibility would be
paresis caused by a
tourniquet. Since the pt. is consulting a
physiatrist, an EMG and NCV
can be performed to rule both of these
complications out.

I've seen a number of cases where just a 5th toe
was operated on and
the pt. said they couldn't move their entire foot
which I attributed
to this 'guarding' mechanism.

It sounds like the patient will be fine and that
you did a good job.
The patient needs to be reassured that she will
in all likelihood
recover completely.Please let us know the outcome.

Norman Calihman DPM
Fort Lee, NJ
footdoc1@aol.com

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Two additional pieces of information regarding my
patient who has lost
muscle function at the 1st MPJ following an
Austin. First, after talking more with her she
relates a history of polio, although she states
she has never experienced any weakness or other
symptoms. Second, I did do an EHL lengthening,
and while it is always possible this severed the
tendon, it was nowhere near 'coming apart' in
surgery.

Opinions so far are split between splinting the
1st MPJ in DF, or
encouraging normal activity and waiting for
normal function to return.
I appreciate everyone's input.

Scott Hughes, DPM
Monroe, MI
drhughes@monroepodiatry.com

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08/31/2002    Elliot Udell, DPM, Howard J Bonenberger, DPM, Robert Schwartz, C.Ped

Bunionectomy Complication (Scott Hughes, DPM)

Bunionectomy Complication (Scott Hughes, DPM)
From: Elliot Udell, DPM, Howard J Bonenberger,
DPM, Robert Schwartz, C.Ped

Occasionally when we do work on and around the
first met phalangeal joint, the extensor tendon
might be severed. On occasion and for certain
clinical criteria, it may be necessary to
lengthen this tendon. Invariably there is a
temporary loss of motion. This heals with time
and it may take months for it to return. I would
observe the toe for at least several months and
see if there is any improvement. Based on the
fact that there is passive motion, and the tendon
appears from your examination results to be
tightening, I would venture to guess that the
active range of motion would gradually return on
its own.

Elliot Udell, DPM
Hicksville, NY
Elliotu@aol.com

----------------

It sounds like first met was shortened
excessively thus eliminating physiologic tension
(which explains why both the flexors and
extensors don't move the joint) or less likely
the tendons (the short flexors and extensor) were
severed. How does the pre-op AP first met length
compare to the post op
AP met length?

Howard J Bonenberger, DPM
Amherst, NH
Howardbon@aol.com

-------------

Put her in a rigid rocker sole shoe with a high
toe box, so she can ambulate, pain-free.

Robert Schwartz, C.Ped
New York, NY
rss@eneslow.com

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08/30/2002    Scott Hughes, DPM

Bunionectomy Complication

Bunionectomy Complication
From: Scott Hughes, DPM

I have a 47 year old white female patient who has
no active ROM in her 1st MPJ 3 weeks status post
Austin bunionectomy. Her PMH is unremarkable, no
allergies. Her only medications were Vioxx and
Vicodin post op. She has excellent passive ROM,
the osteotomy and the sesmoids are in perfect
position, no other complications, she just can't
move her hallux. I can feel the EHL tense but
there is no movement, she can plantarflex 1 or 2
mm. I sent her for PT including electrical
stimulation, without any improvement, and she has
requested not to return because it was too
painful. I've referred her now to a
physiatrist. Any other suggestions or
information would be appreciated.

Scott Hughes, DPM
Monroe, MI
drhughes@monroepodiatry.com