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Orthopedic Coding Alert

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Turn to Intraoperative Findings in Soft Tissue Ruptures

Question: Our patient, a 76-year-old female, presented for progressively severe pain in the right hip for which she was extensively treated with steroid injections, physical therapy, and activity modification. The preoperative MRI demonstrated complete disruption of the gluteus minimus and medius tendons. She was operated and the intraoperative diagnosis was a massive soft tissue disruption with rupture of the IT band. Deep bursal biopsies were done. After placing the patient in lateral decubitus position, the following procedures were done in the right hip under aseptic conditions:Repair gluteus minimus tendon Repair gluteus medius tendon Transfer gluteus maximus muscle to the greater trochanter Repair IT bandThe operative note read as under:"A standard posterior approach to the hip joint was utilized to gain access to the external rotators and abductor musculature. A sharp incision was made over the greater trochanter. The subcutaneous fat was divided sharply and the IT band was identified. Patient [...]

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