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Advanced Surgical AuditingAuditing Surgical Services

Surgical Auditing

Steps for Surgical Auditing

1. Determine the scope of the audit.

2. Verify the documentation is complete.

3. Review the operative note in its entirety.

4. Verify the procedures have not been unbundled when more than one procedure code is

reported.

5. Review MUEs for the codes to prevent reporting excessive units.

6. When sequencing multiple codes, make sure it is done in RVU order.

7. Verify medical necessity.

8. When coding for an assistant surgeon, make sure an assistant surgeon is approved for the

surgery.

9. Verify proper modifier use.

10. Make sure all charges are captured.

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Audit Scope

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• Random

• Targeted• Payer

• Apply payer rules

• CMS (LCD, NCD, NCCI)

• Private payer policies (NCCI, payment policy, medical policy)

• Denial

• Findings on previous audits

• New providers

Complete Documentation

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• Pre-operative information

• Patient demographics

• Surgery date

• Preoperative anesthesia

• Indication for procedure

• Intra-operative information

• Pre-operative diagnosis

• Postoperative diagnosis

• Surgeon/asst/co-surgeons

• Procedure title

• Findings

• Procedure details

• Tissue/organ removed

• Materials removed/inserted

• Closure information

• Wound status

• Blood loss/replacement

• Drainage

• Complications noted

• Post-operative condition of patient

• IV infusion record (if applicable)

• Signatures

• Supports procedure (CPT/HCPCS)

• Supports medical necessity (ICD-10-

CM)

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Review Entire Note

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• Documentation review tips

• Do not code from headers

• Look up terms

• Use resources for terms

• Ask when you do not understand what

is being done

Bundling

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• CPT guidelines

• Example: 43194 (removal of foreign body), 43192-51 (directed

submucosal injection)

Rationale: GI Endoscopy-When bleeding occurs as a result of an

endoscopic procedure, control of bleeding is not reported separately

during the same operative session.

• NCCI edits

• Example: 15271 (skin graft), 13100 (complex repair)

Rationale: 15271 is column 1, 13100 is column 2, CCM1

When 13100 is performed at the same time and site as 15271 it is considered

inclusive. If performed on different sites, modifier 59 or X {E,P,S,U) would

need to be applied.

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Bundling: Surgical Guidelines

CPT GSP

•Subsequent to the decision for surgery, one E/M visit on the date immediately prior to or on the date of the procedure (including history and physical)

•Local anesthesia: defined as local infiltration, metacarpal/digital block, or topical anesthesia

•Operation itself

•Immediate post-operative care, including dictation of operative notes, talking with family and other physicians

•Writing orders

•Evaluation of patient in post-anesthesia recovery

•Normal, uncomplicated follow-up care

Medicare GSP - Minor

Surgeries•Same-day services (either

preoperative or postoperative care)

•Intraoperative care

•Care within the defined global

period

Medicare GSP – Major

Surgeries•Preoperative visits beginning with the day before the day of surgery

•Intraoperative services that are a usual and necessary part of a surgical procedure

•All additional medical or surgical services required of the physician within 90 days of the surgery due to complications that do not require additional trips to the operating room

•Related follow-up visits made within the 90 day postoperative period

•Post surgical pain management by the surgeon

•Any related supplies, services, procedures normally required for the particular surgery

Review MUE

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HCPCS/C

PT Code

Practitioner

Services MUE

Values MUE Adjudication Indicator MUE Rationale

11046 10 3 Date of Service Edit: Clinical Clinical: Data


11732 9 3 Date of Service Edit: Clinical Code Descriptor / CPT Instruction










28825 10 2 Date of Service Edit: Policy Clinical: Data


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Review MUE

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11047 Debridement, bone (includes epidermis, dermis, subcutaneous

tissue, muscle and/or fascia, if performed); each additional 20 sq cm,

or part thereof (List separately in addition to code for primary

procedure)

Total measurement maximum= 220 sq cm

64450 Injection, anesthetic agent; other peripheral nerve or branch

Sequencing of Codes: Case Example

Indications for Surgery: The patient has an excision of a painful

cyst on midline upper back. The lesion has previously ruptured

and has significant scarring. The patient also has a painful cyst

on the left upper back. The patient is allergic to penicillin and

takes aspirin and Micardis for blood pressure. Informed

consent was obtained from the patient. Risks of the procedure,

including bleeding, infection, scarring, and recurrence, was

explained, and the patient acknowledged understanding of

these potential complications.

Procedure #1: Excision cyst midline upper back.

4/6/2016 10

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Description of Procedure: The preoperative measurements of

the lesion was 1.1 cm. The proposed excision lines were

drawn. Anesthesia was delivered locally with 5.0 cc of 1%

Xylocaine with epinephrine buffered 1:10. The site was

cleansed with Betadine. The site was prepped and draped in

the usual sterile fashion. An incision was performed with a

number 15 blade extending deep, through the dermis and into

the subcutaneous fat. This tissue was dissected from the

patient with care to preserve histologic features. The cyst was

not enucleated intact, but the contents and cyst wall remnants

were extracted. The specimen was placed in a bottle of

Formalin labeled with the patient’s identifying information.

4/6/2016 11

The specimen was sent for pathologic and/or margin

analysis. The surgical site was undermined to a

distance of 1.0 cm. Hemostasis was obtained by

electrocautery and vessels ligated as necessary. In

order to prevent dehiscence due to wound tension, an

intermediate layered closure was performed. Three 4-0

Vicryl sutures were placed subcuticularly utilizing a

simple inverted interrupted stitch. Four 4-0 Nylon

sutures were placed cutaneously utilizing a simple

interrupted stitch. The final length of the surgical repair

was 2.5 cm. The surgical site was cleansed with saline.

4/6/2016 12

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A sterile dressing was applied utilizing the following:

sterile petrolatum, gauze, and taped into place to form

a pressure bandage. The patient tolerated the

procedure well. Postoperative instructions were given

to the patient. The patient was instructed to return in

nine days for suture removal. Since the cyst ruptured

during the surgery, we will have him take a course of

Cipro, which cleared the secondary infection after the

cyst ruptured several weeks ago.

4/6/2016 13

Procedure #2: Excision cyst left upper back.

Description of Procedure: The preoperative measurement of

the lesion was 1.5 cm. The proposed excision lines were

drawn. Anesthesia was delivered locally with 6.0 cc of 1%

Xylocaine with epinephrine buffered 1:10. The site was

cleansed with Betadine. The site was prepped and draped

in the usual sterile fashion. An incision was performed with

a number 15 blade extending deep, through the dermis and

into the subcutaneous fat. This tissue was dissected from

the patient with care to preserve histologic features. The

cyst was enucleated intact via sharp and blunt dissection.

4/6/2016 14

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The specimen was placed in a bottle of Formalin labeled with

the patient’s identifying information. The specimen was sent

for pathologic and/or margin analysis. The surgical site was

undermined to a distance of 1.0 cm. Hemostasis was

obtained by electrocautery and vessels ligated as

necessary

4/6/2016 15

In order to prevent dehiscence due to wound tension, an

intermediate layered closure was performed. Three 4-0 Vicryl

sutures were placed subcuticularly utilizing a simple inverted

interrupted stitch. Four 4-0 Nylon sutures were placed

cutaneously utilizing a simple interrupted stitch. The final length

of the surgical repair was 2.9 cm. The surgical site was

cleansed with saline. A sterile dressing was applied utilizing the

following: sterile petrolatum, gauze, and taped into place to

form a pressure bandage. The patient tolerated the procedure

well. Postoperative instructions were given to the patient. The

patient was instructed to return in nine days for suture removal.

4/6/2016 16

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Prescribed Cipro 500 mg 1 tab b.i.d. (Oral) (Quantity: 20

Refills: 0). The patient was released in good condition.

Pathology:

Specimen #1: Ruptured epidermoid cyst. Slide interpreted

by ABC laboratory. No further treatment needed. The

patient will be notified of the results via letter.

Specimen #2: Epidermoid cyst. Slide interpreted by ABC

laboratory. No further treatment needed. The patient will

be notified of the results via letter.

4/6/2016 17

Medical Necessity

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Indications & Limitations of Coverage:

1. Effective for dates of service before January 01, 2014, laparoscopic sleeve gastrectomy will be covered in patients less than

61 years old if all the requirements of the NCD, including the June 2012 Decision Memo and all diagnoses, which are coded in

the Noridian LCD are met. These requirements include, but are not limited to:

A. The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2,

B. The beneficiary has at least one co-morbidity related to obesity, and

C. The beneficiary has been previously unsuccessful with medical treatment for obesity.

For dates of service January 01, 2014 the age restriction is changed to include age less than 65 years. This change is made to

bring consistency in policy across Noridian’s Medicare Parts A and B jurisdictions. The other requirements mentioned above

remain in effect other than the date of service.

2. Patients 61 years and older (before January 01, 2014) may be considered for laparoscopic sleeve gastrectomy on an

individual case basis. If a reconsideration request is made on a denied claim, the Medical Directors will review all evidence

submitted by the provider supporting the treatment in the individual patient. (Please note the Medical Directors have reviewed

all references cited in the CMS Decision Memo.)

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Assistant Surgeon

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21310 Closed tx nose fx w/o manj 1 0 0

21315 Closed tx nose fx w/o stablj 1 0 0

21320 Closed tx nose fx w/ stablj 1 0 0

21335 Open tx nose & septal fx 1 0 0

21346 Opn tx nasomax fx w/fixj 1 1 0

21461 Treat lower jaw fracture 1 1 0

21480 Reset dislocated jaw 1 0 0

HCPCS MOD DESCRIPTION ASST SURG CO-SURG TEAM SURG

Modifiers 80, 81, 82, AS

Modifier Use

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Common Surgical Modifiers

• 22

• 58

• 59

• 78

• 79

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Common Surgical Coding Errors: Modifier 22

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Incorrect use of modifiers

Procedure:

Gastrostomy revision.

T-tube change.

Procedure: The patient was taken to the operating room, laid in supine position while general anesthesia was induced. The Foley was used to measure the tract length and the tract length was felt to be about 3.5 cm. A Foley was removed and abdomen was prepped and draped in usual sterile fashion. A large mass on the superior portion of the G-tube was excised along with a large amount of scar tissue. This was followed down to the gastric mucosa and the mucosa was sutured in a 180 degree fashion on the superior side to the skin. This made a nice gastrostomy tract. 8 ML 25% Marcaine was injected as a local block. Next, a 16 X 4.0 Boston Scientific G-tube was placed and the balloon filled. This seemed to fit fairly well. Antibiotic was placed on the wound. Patient tolerated procedure well, awoke in the recovery room in stable condition.

Codes reported: 43760-22

• Staged or related procedure or service by the same

physician during the postoperative period.

• Used when:

• The service is planned or staged

• The service is more extensive than the original service

• Therapy following a surgical procedure

• Not used when:

• Reporting the treatment of a complication from the original

surgery

Modifier 58

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• Distinct procedural service

• Used to indicate:

• Different surgical session

• Different procedure or surgery

• Different site or organ system

• Separate excision or incision

• Separate lesion or injury

Modifier 59

Modifiers: X {E, P, S, U}

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Subset of 59

• XE Separate Encounter: A service that is distinct because it occurred during

a separate encounter

• XS Separate Structure: A service that is distinct because it was performed

on a separate organ/structure

• XP Separate Practitioner: A service that is distinct because it was performed

by a different practitioner

• XU Unusual Non-Overlapping Service: The use of a service that is distinct

because it does not overlap usual components of the main service

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• Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.

• Failure to submit the procedure with modifier 78 will result in claim denial

• Example: Patient has a liver transplant on 3/2/16, on 3/3/16 the patient is returned to the OR and the physician re-opens the abdomen to control bleeding. Modifier 78 is appended to the procedure performed on 3/3/16.

Modifier 78

Modifier 79

• Unrelated procedure or service by the same physician or

other qualified healthcare professional during the

postoperative period.

• Example: Patient fractures ankle has ORIF to left ankle.

Unsteady on crutches the patient falls and fractures left

wrist requiring closed treatment of the wrist.

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Capture Supported Charges

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•Report all procedures performed

• Imaging guidance

•Diagnostic procedures

•Devices (facility)

•HCPCS Level II versus CPT

Audit Practice

• Steps for the Audit

• Is the documentation complete?

• Are the procedures clearly described?

• Does the diagnosis support medical necessity?

• Are the codes reported supported by the documentation?

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Case 1

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PREOPERATIVE DIAGNOSIS: Pernicious anemia without previous screening.

POSTOPERATIVE DIAGNOSES:

1. Esophageal ulcer.

2. Hiatal hernia.

3. Nonspecific gastritis.

4. Multiple colon polyps with a large polyp at the ascending colon removed with piecemeal polypectomy and labeled with Indian ink tattoo.

5. Diverticulosis.

6. Hemorrhoids.

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DESCRIPTION OF PROCEDURE:Description of the EGD: Risks and benefits were explained to the patient, and informed consent was obtained. The patient was brought to the GI endoscopy unit and placed in the left lateral decubitus position, and a bite block was placed into the mouth. Then, under direct visualization, a video gastroscope was passed through the bite block, from the posterior pharynx, into the esophagus. Examination of the esophagus revealed erythema and edema with irregularity of the Z-line and a focal ulceration that was linear. The scope was passed into the stomach, which revealed erythema. The scope was retroflexed with examination of the cardia and fundus, which revealed small hiatal hemia. The scope was deflexed, passed into the pylorus, into the duodenal bulb, which was endoscopically normal. The second portion of the duodenum was unremarkable. Biopsies were obtained of the duodenum, antrum, and distal esophagus. Air was suctioned, and the scope was withdrawn. The patient tolerated the procedure well

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Description of the colonoscopy: Risks and benefits were explained 10 the

patient before the EGD, and informed consent was obtained. The patient's stretcher was rotated in the room. He was in the left lateral decubitus position, and a digital rectal examination was performed. Then, under direct visualization a video colonoscope was passed into the rectum. The scope was retroflexed with examination of the anorectal junction, which revealed hemorrhoids. The scope was deflexed, passed through the entire colon to the level of the cecum. There was a large 4-cm polyp at the cecum, which was grabbed with snare wire, removed with electrocautery, and suctioned to a trap. There were three 5-mm polyps at the ascending colon that were grabbed with snare wire,

removed with electrocautery, and suctioned to a trap. There was a 1-cm broad flat carpeting polyp that was removed with snare polypectomy technique multiple times and India ink tattooed for demarcation and suctioned to a trap.

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There was a large pedunculated polyp measuring about 1 cm at the descending colon that was grabbed with a snare wire, removed with electrocautery, and suctioned to a trap. Diverticulosis was noted throughout the colon predominantly in the sigmoid colon.At the sigmoid colon, two 5-mm sessile polyps were grabbed with a snare wire, removed with electrocautery, and suctioned to a trap. Prep was suboptimal with some semisolid stool predominantly in the rectosigmoid. No other polypoid lesions or masses were seen. Air was suctioned, and the scope was removed. The patient tolerated the procedure well.

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PLAN:Check the biopsies and have the patient follow up in a few weeks. He needs a repeat upper endoscopy in three to six months to demonstrate esophageal ulcer healing, check for Barrett's. Continue him on his Nexium. He is to have a repeat colonoscopy in six months as well to review the area that was India ink tattooed.

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Case 1 Reported Codes

• 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or

other lesion(s) by snare technique

• Z12.11 Encounter for screening colonoscopy NOS

• 43239 Esophagogastroduodenoscopy, flexible, transoral; with

biopsy, single or multiple

• K22.10 Ulcer of esophagus without bleeding

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Case 2

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CARDIOPULMONARY SERVICES / CATHETERIZATION

LABORATORY REPORT

PROCEDURE(S):

1. Percutaneous transluminal coronary angioplasty of the left circumflex ostium.

2. Percutaneous coronary intervention with placement of a 3.5 x 8 Taxus stent in

the left main trunk.

CLINICAL PROFILE: This 68 year old man has a longstanding history of

coronary artery disease. He has had previous bypass grafting times 2, and prior

interventions in the left circumflex and left main coronary artery. He presents

with recurring unstable angina and recent diagnostic catheterization demonstrated

severe left main in-stent restenosis. Consultation was obtained with

cardiovascular surgery who preferred an interventional approach. His previous

left main stent was a Cypher stent.

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PROCEDURE IN DETAIL: After informed consent was obtained from the

patient, he was brought to the Catheterization Laboratory and sedated with a

combination of versed and fentanyl. Twenty cubic centimeters of 2% lidocaine

was locally infiltrated, and the right femoral artery entered with an #8Fr. sheath.

An #8Fr. J14 guide catheter with side holes was advanced but did not engage the

left main ostium and was removed. An #t8Fr. JL5 guide with side holes was

advanced and did provide coaxial alignment into the left main trunk, though

guide support was somewhat minimal. Intravenous Angiomax was begun and

intracoronary nitroglycerin was given. A 190 cm advanced high torque wire was

advanced down the circumflex system and parked in the distal first obtuse

marginal branch. We then performed baseline intravascular ultrasound from the

ostium in the circumflex through the left main trunk. This showed no evidence

of neointimal growth in either the circumflex or left main.

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It did show under expansion of stents. The left main stent showed severe

recoiling. This appeared to be the mechanism of the restenosis in the left main

trunk. The left main was then sequentially dilated with high pressure dilatations

with 3.5 followed by 4.0 PowerSail balloons. The proximal circumflex was

dilated with 3.5 Quantum balloon to high pressures. We then placed a 3.5 x 8

Taxus stent within the left mid and proximal left main trunk. This was entirely

placed within the previous Cypher stent. This stent was deployed at high

pressures and post dilated with a 5.0 PowerSail balloon to high pressures.

Repeat angiograms showed an excellent result and repeat ultrasound showed

acceptable stent expansion. There remained a focal area of eccentricity within

the left main.


• 92937 Percutaneous transluminal revascularization of or through

coronary artery bypass graft (internal mammary, free arterial,

venous), any combination of intracoronary stent, atherectomy and

angioplasty, including distal protection when performed; single vessel

• 92924 Percutaneous transluminal coronary atherectomy, with

coronary angioplasty when performed; single major coronary artery

or branch

• 92925 each additional branch of a major coronary artery (List

separately in addition to code for primary procedure)

• I25.10 Atherosclerotic heart disease of native coronary artery without

angina pectoris

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Case 3

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Operative report

Procedure: Excision of infected mesh and repair of incisional hernia with

Surgisis mesh.

Anesthesia: General endotracheal.

Justification for procedure: The patient is a 51-year-old woman who

presented to the trauma clinic from Puerto Rico with a foul-smelling

open wound in the upper abdomen with an infected mesh. It was

extremely purulent. We admitted the patient, started her on antibiotics

and made a plan to excise the mesh. The patient consented and

understood the risk of fistula and other complications.

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Description of the procedure:

The patient was taken to the operating room and placed in reverse

trendelenburg. After adequate anesthesia and endotracheal intubation were

achieved, the patient was prepared and draped in the normal sterile fashion.

a second time out was taken and she was indeed identified by name. The

procedure began by carefully excising the mesh from the fascia. This was

difficult and we went through several pairs of gloves because of ripped tears

of the gloves from all the tackers that were placed circumferentially around

this repair. There was a large amount of purulent drainage around and under

the mesh. We have sent this for culture. The mesh was embedded and actually

seemed to have its rough side against the intestine where the intestine had to

be dissected off the mesh using a scalpel as it was quite adherent to it in

places.

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The outside of the portion of the mesh seemed extremely smooth.

after a very tedious dissection, this was performed and attention taken to

remove all the tackers, the mesh was finally removed and sent for pathology.

The wound was irrigated and debrided well. A 13 x 22 Surgisis mesh was then

placed in the area of the fascia and tacked up in a stoppa technique. Two

Jackson-Pratt drains were placed superiorly and inferiorly under the skin

flaps that were left. The wound was dressed with saline. The mesh sat very

nice against the viscera. The patient will be treated with a binder.

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• 49560 Repair initial incisional or ventral hernia; reducible

• 11008 Removal of prosthetic material or mesh, abdominal wall for

infection (eg, for chronic or recurrent mesh infection or necrotizing

soft tissue infection) (List separately in addition to code for primary

procedure)

• T85.79XA Infection and inflammatory reaction due to other internal

prosthetic devices, implants and grafts, initial encounter

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Case 4

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OPERATIVE REPORT

PREOPERATIVE DIAGNOSES:1. Right anterior cruciate ligament tear.2. Bucket handle displaced medial meniscus tear.

POSTOPERATlVE DIAGNOSES:1. Right anterior cruciate ligament tear.

2. Bucket handle displaced medial meniscus tear plus grade 3 osteoohoudral defect of medial femoral condyle.

PROCEDURES PERFORMED:1. Arthroscopic right ACL reconstruction with posterior tibialis allograft.2. Medial meniscus repair.

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ANESTHESIA: Laryngeal mask general with a right femoral nerve block.

ESTIMATED BLOOD LOSS: Minimal

COMPLICATIONS: None.

DISPOSITION: Stable.

INDICATIONS:

The patient is a 36-year-old African-American female who sustained the above injury during the slip and fall. She presented with a locked knee that was swollen, but have positive anterior drawer and Lachman’s test. An MRI showed an ACL tear and displaced bucket-handle medial meniscus tear. Operative intervention was deemed necessary.

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DESCRIPTION OF PROCEDURE:The patient was brought to the operating theater and placed in the supine position, with where a right femoral nerve block was induced without difficulty. Laryngeal mask general anesthesia was then induced without difficulty. Ancef1g IV was given perioperatively. A nonsterile tourniquet was applied to the right thigh and the knee was pre-injected with Marcaine and epinephrine. Exam under anesthesia did reveal 2+ anterior drawer and 2+ Lachman test. The right lower extremity was then prepped and draped in usual sterile fashion.

A #11 blade was used to create the lateral portal in the usual fashion. The scope was inserted into the patellofemoral joint. The undersurface of the patella and the femoral trochlear articular surfaces were pristine. The suprapatellar pouch had mild synovitis, but there was no evidence of loose bodies. Medial and lateral gutters were inspected and were devoid of loose bodies or synovitis.

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A valgus stress was applied and medial compartment inspected. Of immediate note was large displaced fragment of meniscus, displaced anteriorly and into the notch of the femur. The medial portal was created in the usual fashion and a probe was used to reduce the meniscal tear. The tear was predominantly along the red-red junction near the periphery of the meniscus, which extended from the posterior horn to the middle of the body of the meniscus. A curved 4.5 shaver was used to debride the inner portions of the tear to stimulate vascular ingrowth. Once reduced, a metal skin was inserted through the medial portal and the meniscus was fixed with FasT-Fix all-inside suture repair device from Smith & Nephew. The posterior horn was first fixed by piercing the meniscal tissue and then piercing the capsule and deploying the fist bioabsorbable tab. This was then pulled out in a mattress fashion. Another tab was made to the meniscus and tear, and the second tab was released posterior to the capsule.

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A knot was then cinched down reducing the meniscus to the capsule. The knot was then cut. Two more sutures were placed in exactly the same fashion extending up to the posterior horn body margin of the tear. These were placed in a horizontal fashion, and the scope had been placed in the medial portal with a better angle to the lateral portal for the suture placement. Probing of the repair revealed that it was exceptionally stable and the meniscus was reduced.

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The femoral cartilage of the medial femoral condyle did have a small contained defect near the weightbearing portion of approximately 4 x 5 mm. There was no exposed subchondral bone and no reason to perform micro fracture. Pictures were taken through the procedure. The compartment was debrided and attention directed to the notch. Of note, was the extremely narrow V-shaped notch of the femur. There was a complete rupture of the ACL upon probing. ThePCL was intact. The remnant of the ACL was debrided using 4.5 shaver and the 90-degree ArthroCare wand. Again, this patient was set up for an ACL tear due to the extremely small stenotic ACL notch. A 5.5 acromionizer was used to perform a notchplasty in the usual fashion to create a V-shaped notch.

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Attention was directed to the lateral compartment with a figure of four varusstress applied to the knee. The lateral meniscus was probed and found to be intact including the popliteal hiatus. The lateral femoral condyle and tibialplateau articular surfaces were pristine.

On the back table, a posterior tibialis tendon allograft had been soaked in normal saline antibiotic solution after being thawed. Using FiberLoop on each free strand of the graft, an interlocking suture was placed 40 mm up from the tip of the tendon. The graft was then sized at 9.0 mm. It was then placed on a soft tissue tension device at 12 pounds for 25 minutes with a wet sponge applied.

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In the notch of the femur through the medial portal, the ACL guide for tibial drilling was

placed set at 55 degrees and the tunnel at 50 mm. A #15 blade was used to create a 2-cm long incision over the tibia down to periosteum, which was then elevated. The bullet was placed against on and the guide intraarticularly was placed on the posterior aspect of the ACL footprint and reference off the PCL and the posterior portion of the anterior

horn of the lateral meniscus. The extraarticular portion was two fingerbreadths medial to the tibial tubercle and approximately 50 degree angle. This was drilled into the joint and extension of the knee with the guide revealed good placement of the pin with no impingement noted. An 8.5-mm acorn reamer was then used to drill the tibial tunnel and excess bone was shaved and rasped. Through the tibial tunnel, a 6-mm over the top guide was placed in the 10 o'clock position making sure this was completely against the posterior wall. An 8.5 acorn reamer was hand delivered over the guidewire. This was over a Beath pin guidewire, which measurements have been taken one I hit the second cortex of the femur. It was then drilled through the thigh and then the acorn reamer was used to create a 35-mm depth tunnel with excellent back wall of 1 mm.

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Excess bony debris was debrided. A stab wound incision was made and the black Arthrex RetroButton depth gauge was used to measure that a 30-mm RetroButton would be necessary. RetroButton was then loaded on to the graft. This was then loaded on to Beath pin with its pulled suture. The Beathpin was then pulled through the knee with the RetroButton leading to the lateral aspect of the drilled tunnel, and the sutures exiting the thigh. The graft was then pulled into the tunnel and the RetroButton deployed with excellent pullout strength. The knee was ranged 15 times. The draft was showing to be in excellent position with no impingement on the lateral wall of the PCL or the notch. The joint was debrided and drained and attention direct tot the tibial fixation. A guidewire was placed anterior to the graft and with the knee in 30 degrees of flexion. A 40-Newton posterior drawer force was applied.

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A 10 x 35 mm Arthrex bioabsorbable delta tibial screw was then inserted with

excellent squeaky purchase. This was allowed to remain one thread proud of the

cortex. The tibial fixation was then backed up by drilling a unicortical drill hole with

a 5:30 second inch drill bit and then placing a 4.5-mm Arthrex PushLock anchor

noted with all four remaining strands of FiberWire suture. These were tensioned

and a PushLock anchor malleted into the hole secondarily fixing the graft.

Ranging of the knee revealed full range of motion and complete ablation of the

anterior drawer and Lachman’s test. The tibial wound was copiously irrigated with

normal saline. Fascia was closed with 0 Vicryl in interrupted fashion. The

subcutaneous tissue was closed with 3-0 Vicryl in interrupted fashion including

the portals, and the wound and the portals were closed with Dermabond. Knee

was injected with Marcaine and Duramorph. A sterile dressing was plied with an

over wrap of the Ace bandage, and the knee was placed in a hinged brace locked

in extension. The patient was extubated and taken to the Post-anesthesia

Recovery Room in stable condition.

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