0QP90KZ
Removal Femoral Shaft, Left to No Qualifier with Nonautologous Tissue Substitute, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | Q Lower Bones |
| Operation | P Removal |
| Body Part | 9 Femoral Shaft, Left |
| Approach | 0 Open |
| Device | K Nonautologous Tissue Substitute |
| Qualifier | Z No Qualifier |
Operation Definition
Taking out or off a device from a body part
Procedure Overview
Removal procedures take out a device that was previously placed in or on a lower bone - hardware such as plates, screws, rods, pins, external fixator components, or spacers used in the pelvis, femur, tibia, fibula, patella, or foot bones. These devices are typically inserted to stabilize a fracture, hold a bone graft, or support a joint during healing, and removal happens once that purpose has been served or if the device is causing a problem.
Reasons for removal vary widely. Hardware may simply be scheduled for extraction after a fracture has healed, especially in children whose growing bones can be irritated by permanent implants. In other cases the device is removed because it has become infected, has loosened, is causing pain from irritating overlying soft tissue, or is interfering with a later procedure such as a joint replacement.
Anatomy & Axis Detail
Femoral Shaft, Left
The left femoral shaft, the elongated diaphyseal portion of the thighbone, is commonly instrumented with an intramedullary nail or plate after a mid-shaft femoral fracture. Removal in this context describes extracting that device once healing is complete, or sooner if the hardware becomes symptomatic, migrates, or is associated with infection. Because the femoral shaft carries substantial mechanical load during weight bearing and gait, the bone around a long-standing implant can remodel tightly against it, making extraction technically demanding and occasionally requiring specialized instrumentation. Documentation should specify laterality and the exact hardware removed, and should clearly separate this procedure from any bone debridement or resection performed at the same time, since those actions correspond to different root operations entirely.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Device: Nonautologous Tissue Substitute
Nonautologous Tissue Substitute refers to biologic material sourced from a donor or another species, such as an allograft or xenograft, used to replace a body part. It differs from Autologous Tissue Substitute by tissue origin outside the patient's own body, and from Synthetic Substitute by being biologic rather than manufactured material.
Coding & Documentation
Coders assign Removal when documentation confirms a device is being taken out and not replaced with another device during the same operative episode - if a new device goes in at the same site, the procedure is Change or a combination of Removal and another root operation such as Insertion, not Removal alone. The device type and the specific bone it was removed from both need to be identifiable from the operative note. A common error is coding Removal for hardware that is only being adjusted or repositioned rather than fully extracted, or overlooking that the removal of a device is bundled into a broader procedure when substantial additional work, like bone repair, is performed at the same site.