3rd Qtr Physician 2016 Joint Surg Case Study #5
Aetna Commercial
Total Knee Arthroplasty-CPT 27447
The patient is 73 y/o morbidly obese male with 5 year history of progressive right knee pain which has been resistant to conservative measures including NSAIDs and home exercises for the last 4 months. Office visits are documented from 4 months ago through the present time.
He uses a cane and neoprene sleeve as well as ice modalities. He has not had joint injections.
Physical examination reveals an obese male with BMI 45. Right knee ROM is limited from 5-100 degrees with moderate varus deformity and crepitation with ROM. There is no instability, however a moderate joint effusion is present.
Gait is antalgic with a cane.
Xrays demonstrate end stage DJD with “bone on bone” medial joint line, large osteophytes and subchondral cysts with severe patellofemeral disease.
Surgeon requests to perform a rt total knee arthroplasty.
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