A 74 year-old male presented with ankle avascular necrosis of the talus with collapse of the body. after general anesthesia and
sterile prep, the patient was placed prone. a lateral incision was made. the fibula was dissected and approximately 6 cm of the fibula was removed for the autograft. there were a lot of free fragments of bone around the subtalar joint and the talus itself. the bone fragments were removed and a large defect consistent with avascular necrosis of the body of the talus was noted. an egg-shaped burr was introduced and the articulating cartilage of the ankle joint was excised and debrided. the subtalar joint was approached and resection of the articulating surface of the subtalar joint was completed. bone graft from the fibula was prepared on the back table. we made two large blocks to fill the defect in the talus and then additional small fragments of cortical cancellous bone to fill in smaller defects around the talus and ankle. fixation was performed in the calcaneocuboid. the talar screw was inserted, followed by fixation of the talonavicular, tibiotalar and additional compression. the ankle screws were inserted proximally and the wound was irrigated and closed in layers. what cpt® codes are reported?
This is a case of a patient that needs his subtalar joint to be immobilized by the fusion of supporting bones. This is called arthrodesis and the corresponding CPT code for arthrodesis procedures in the foot and toes is CPT 28715. The patient also underwent bone grafting from the fibula to fill in the defects in the talus. The CPT code for general grafts or implants procedures in the musculoskeletal system is CPT 20902-51.
