Is this correct to code the procedure bellow with 79.39? Thank you very much in advance.
PREOPERATIVE DIAGNOSIS:
Pubic symphysis dislocation with right-sided zone 2 sacral fracture.
POSTOPERATIVE DIAGNOSIS:
Same.
PROCEDURES PERFORMED:
1. Closed reduction and percutaneous pinning of sacral fracture. 2. Open reduction and internal fixation of pubic symphysis.
A midline Pfannenstiel incision was made and carried down to the fascia of the anterior rectus sheath. This was incised longitudinally, and the fibers of the rectus abdominis muscles were then split bluntly down to its insertion onto the pubis. Care was taken to protect the bladder with a malleable retractor doing the surgical exposure. The periosteum over the symphysis was reflected, and using two 3.5-mm cortical screws with the Jungbluth clamp under direct visualization, the symphyseal diastasis was reduced. Our reduction was confirmed to be adequate on the AP, inlet and outlet imaging, and a four-hole R88, model symphyseal plate was then used to stabilize the diastasis definitively. Again, intraoperative fluoroscopy did reveal adequate placement of all hardware as well as maintenance of our fracture reduction.
Attention was then directed to placement of one transsacral screw at the S1 level. Under the fluoroscopic image of a lateral projection of the sacrum, a start point into the posterior superior aspect of the S1 body was obtained. A percutaneous stab wound was then made using a scalpel blade, and the pigsticker was then placed along the sacrum. Under fluoroscopic guidance an appropriate trajectory for transsacral screw was then placed and the wire then tested with response of the EHL and tibialis anterior at 17 milliamps. The screw was 8 mm by 175 mm, as preoperatively templated. The screw was then placed over the guide wire and had a response at 23 milliamps of the tibialis anterior, as well as the EHL. We were acceptable of this and continued to proceed, verifying adequate extraforaminal placement on all of these fluoroscopic images.
The wounds were then copiously irrigated. The anterior rectus sheath was closed in a figure-of-eight fashion using a #1 Maxon stitch. A deep drain was placed in the space of Retzius, and the overlying subcutaneous tissue was closed in similar fashion using a 2-0 Vicryl stitch. The overlying skin was closed with a 3-0 nylon in vertical mattress fashion. A 3-0 nylon stitch was also used to close the percutaneous wound about the sacrum.
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