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The procedure described by CPT® Code 26551 involves a complex surgical technique known as a toe-to-hand transfer with microvascular anastomosis, specifically utilizing the great toe. This procedure is designed to reconstruct a digit, typically the thumb, in cases of traumatic or congenital absence. The great toe is partially transferred, incorporating the nail and pulp, and potentially a portion of the distal phalanx, while preserving the bony structure of the toe itself. The remaining bone is covered with skin grafts to ensure proper healing and aesthetic appearance. The surgical process requires meticulous preparation of both the donor site (the great toe) and the recipient site (the hand), including the identification and isolation of tendons, nerves, and blood vessels for successful anastomosis. This intricate procedure not only restores functionality but also aims to enhance the cosmetic outcome of the hand, making it a vital option for patients requiring digit reconstruction.
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The procedure described by CPT® Code 26551 is indicated for the following conditions:
The surgical procedure begins with the preparation of the hand to receive the toe transfer. The recipient site on the hand is incised, and any existing scar tissue is excised to create a clean area for the transfer. The bone stump in the hand is then prepared, ensuring that the underlying structures are ready for the attachment of the toe flap. The surgeon meticulously dissects the tissues of the hand, identifying and isolating the extensor and flexor tendons, as well as the nerve ends, which are crucial for restoring function. Blood vessels in the hand are also located and prepared for the subsequent anastomosis.
Next, the incision lines are outlined on the skin surrounding the great toe. A dermal flap is elevated from the toe, taking care to preserve the dorsalis pedis artery and a large subcutaneous dorsal vein, which are essential for the microvascular anastomosis. The dissection continues around the toe until the nail and pulp are completely excised, and a portion of the distal phalanx may also be included in the flap to enhance the transfer.
Once the toe flap is prepared, it is transferred to the hand, where the blood vessels from the toe are anastomosed to the corresponding vessels in the hand. Additionally, the nerves from the toe are connected to the nerves in the hand to restore sensation. A bone autograft is harvested, typically from the iliac crest, where a skin incision is made, and the muscle is stripped to expose the bone surface. The harvested bone is shaped and sized to fit the bony portion of the finger being reconstructed.
The bone graft is then securely attached to the bone stump in the hand, and the soft tissue toe flap is wrapped around the graft to form a new thumb. To ensure stability during the healing process, Kirschner wires are utilized to hold the bone graft in place until osteosynthesis occurs. Finally, full-thickness skin grafts or flaps may be applied as needed to cover the donor site on the great toe, promoting optimal healing and recovery.
Post-procedure care involves monitoring the surgical site for signs of infection and ensuring proper healing of both the hand and the donor site on the great toe. Patients may require pain management and physical therapy to regain function in the hand. Follow-up appointments are essential to assess the integration of the bone graft and the success of the anastomosis, as well as to manage any complications that may arise during the recovery process.
| Short Descr | GREAT TOE-HAND TRANSFER | Medium Descr | TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND | Long Descr | Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 161 - Other OR therapeutic procedures on bone |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | F2 | Left hand, third digit | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 1997-01-01 | Added | First appearance in code book in 1997. |
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