0SPD3MZ
Removal Knee Joint, Left to No Qualifier with Synthetic Substitute, Unicondylar Lateral, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | S Lower Joints |
| Operation | P Removal |
| Body Part | D Knee Joint, Left |
| Approach | 3 Percutaneous |
| Device | M Synthetic Substitute, Unicondylar Lateral |
| 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 a lower joint, such as internal fixation hardware, a spacer, drainage tubing, or an external fixator frame. These procedures are performed once the device has served its purpose - for example, after a fracture has healed and screws are no longer needed - or when a device is causing pain, infection, or mechanical irritation and needs to come out. Removal can be a planned, staged part of treatment or an unplanned procedure prompted by a complication.
Because the device itself, not the joint tissue, is the focus, these procedures are typically less extensive than the original surgery that placed the device, though scar tissue and bony ingrowth around older hardware can make removal technically demanding.
Anatomy & Axis Detail
Knee Joint, Left
The left knee joint shares the same tibiofemoral and patellofemoral architecture as the right, functioning as a weight-bearing hinge stabilized by cruciate and collateral ligaments along with the menisci. Removal at this site involves extracting retained cement, broken hardware, or other foreign material left in the joint from a prior left knee procedure such as arthroplasty, meniscal repair, or fracture fixation. Its superficial position beneath a modest soft tissue envelope generally allows more straightforward surgical access than deeper joints like the hip, though care must still be taken around the neurovascular structures of the popliteal fossa posteriorly. As with the right knee, laterality should be documented precisely given how commonly patients undergo staged or bilateral knee procedures.
Approach: Percutaneous
Percutaneous describes entry by needle or instrument puncture through the skin or mucous membrane to reach the site of the procedure, without cutting the tissue open or using a visualizing scope. It differs from Open in that the site itself is never exposed, and from Percutaneous Endoscopic in that no endoscope is used to see internal structures. Common examples include needle biopsies and injections.
Device: Synthetic Substitute, Unicondylar Lateral
This value designates a unicondylar lateral synthetic substitute, a partial knee implant replacing only the lateral femoral and tibial condyle when degenerative disease is isolated to that compartment while sparing the medial side. It offers a more conservative alternative to total knee arthroplasty. It differs from the Unicondylar Medial device by treated compartment, and from Patellofemoral substitutes, which replace the trochlear groove and kneecap articulation instead.
Coding & Documentation
The operative note must identify the specific device being taken out and confirm nothing is being put in its place; if a new device replaces the old one, the more specific combination root operation (such as Revision) may apply instead of a plain Removal. The body part coded is the joint from which the device is taken, using the device's original insertion site. A recurring error is coding Removal when hardware is being exchanged for a different device during the same procedure, which should instead be captured as Revision, or when the device is being taken out specifically because it failed, which some coders mistakenly still classify simply as Removal without checking whether Revision criteria are met.