AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2026 Issue 2; Ask the Editor

Trochleoplasty

A patient with a history of chronic patellar subluxation presented for surgical intervention due to left patellar instability with a medial patellofemoral ligament tear, type D trochlear dysplasia and a loose body in the knee. During the procedure, a 5 cm long tibial tubercle osteotomy was performed and the trochlea was exposed. A trochleoplasty was performed using osteotomes, burr and Arthrex guided burrs to create a thin shell osteotomy. A pushlock anchor was placed in the central trochlea and then affixed to another pushlock anchor over the lateral trochleoplasty. Additional fixation was obtained by placing compression screws in the medial and lateral trochlear flaps. Following the trochleoplasty portion of the procedure, tibial tubercle fixation was performed with bone graft followed by reconstruction of the medial patella-femoral ligament using allograft tendon.Is the trochleoplasty inherent to the reconstruction procedure to repair the patellar instability or is it separately reported? If it is separately reported, what is the ICD-10-PCS code for trochleoplasty? ...

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