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Orthopedic Coding Alert

Reader Question:

Confirm Malunion for Distal Fibular ORIF

Question: For a patient diagnosed with status post open reduction internal fixation right ankle with the mortise disruption, our surgeon did an operative repair. There was no nonunion. It was apparently a fracture that had shifted.The operative note reads as follows:"The patient was taken to the operating room. The right leg was draped in the usual sterile fashion and antibiotics were administered. A straight lateral incision was made and the plate and hardware were removed without difficulty. There was bony consolidation noted at the distal tibio-fibular joint and this was resected with an osteome and with a rongeur. Soft tissue was released around the distal fibula. Care was taken to protect the peroneal tendons. The fracture site was idenified, an osteotome was inserted to complete the osteotomy. At this point tricortical allograft was inserted measuring approximately 6 or 7 mm in width. Stacked osteotomes were inserted to effect winding and [...]


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