Proximal Realignment Lateral Retinacular Release and Imbrication for Instability Status Post Total Knee Replacement

A patient had a computed tomography (CT) of the right knee which demonstrated a lateral dislocation of a prosthetic patellar component. The provider diagnosed recurrent instability status post right total knee replacement due to scar tissue from the previous surgery. The patient underwent a proximal realignment lateral retinacular release and imbrication of the right knee. During the procedure, a medial parapatellar arthrotomy was made, and the patella was everted. The provider performed an inside-out lateral release and subsequently raised a subcutaneous flap through the anterior incision and formalized the lateral release by connecting it with an outside-in technique. Following this, proximal realignment was done by imbricating the medial soft tissue off the patella and medial aspect of the quadriceps through a pants-over-vest technique using sutures. What is the correct code assignment for a retinacular release and imbrication of the patellar component of a total knee replacement? ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This short coding case describes a patient with recurrent instability after right total knee replacement and a procedure involving lateral retinacular release and proximal realignment. It discusses the coding analysis in the context of ICD-10-PCS and is relevant to professionals reviewing orthopedic procedure documentation and code assignment.

Why This Topic Matters

The case highlights the kinds of documentation and procedural details that may be considered when evaluating code assignment for revision-related knee procedures.

What You Will Learn

  • The clinical context and operative details described in a case involving patellar instability after total knee replacement.
  • The ICD-10-PCS coding topics raised by the described release and realignment procedure.
  • intended_audiences
  • topics
  • medical_specialties
  • code_sets
  • codes
  • code_ranges

Who Should Read This

  • Medical coders
  • Health information management professionals
  • Orthopedic coding reviewers

Codes Discussed


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