It begins in the popliteal fossa, inferior to the popliteus muscle. This will also show the extent of osteomyelitis and associated soft tissue fluid collections if present. Summarize the complications associated with below-the-knee amputations. A prosthetics company should be contacted with a formal patient evaluation, and the provisional prosthetic should be chosen. %PDF-1.5 % 751 0 obj <>/Filter/FlateDecode/ID[<7989BD57F390DE4BBF7B5EFF06D2F15F>]/Index[723 62]/Info 722 0 R/Length 111/Prev 359323/Root 724 0 R/Size 785/Type/XRef/W[1 3 1]>>stream (OBQ04.227) To plug inpatient facility revenue drains, subscribe to, Crosswalk to an anesthesia code and its base units, and calculate payments in a snap! 2 The 2021 edition of ICD-10-CM Z89.511 became effective on October 1, 2020. They address this with a mirror box, local injections, adjustment to the prosthesis, or a variety of other modalities. . 0x600zz. KadGS>Y-5'b9G)kFdJ*P3e~";cVKEdPX%T'=[nKTp43Ud84INR|bOoEBimThLL:J7FrZ8ov"MJ}c}fq]oc|w1J5 -ya6 Study of the anatomy of the tibial nerve and its branches in the distal medial leg. hb```f`` Part of the description of 27882 is "Progressive incisions are made through soft tissues, and nerves and vessels are ligated." Inflammatory labs, including ESR and CRP, are important in determining the presence, degree, and acuteness of infection. It is found in the 2023 version of the ICD-10 Procedure Coding System (PCS) and can be used in all HIPAA-covered transactions from Oct 01, 2022 - Sep 30, . (OBQ08.235) Fergason J, Keeling JJ, Bluman EM. A corresponding procedure code must accompany a Z code if a procedure is performed. Narula N, Dannenberg AJ, Olin JW, Bhatt DL, Johnson KW, Nadkarni G, Min J, Torii S, Poojary P, Anand SS, Bax JJ, Yusuf S, Virmani R, Narula J. Subscribe to. 23921 Disarticulation of shoulder; secondary closure or scar revision Shoulder - Amputation CPT Code Defined Ctgy Description 23800 Arthrodesis, glenohumeral joint; 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) It persists despite a well-fitted prosthesis. While a BKA divides all compartments, a thorough grasp of the relevant anatomy is vital to controlling blood loss intraoperatively and preventing known complications. . It is essential to understand the vascular anatomy of the leg as skin flaps for amputationare planned according to the blood supply. CPT 27886 Amputation, leg, through tibia and fibula; re-amputation . The procedure code 0Y6J0Z3 is in the medical and surgical section and is part of the anatomical regions, lower extremities body system, classified under the detachment operation. right below-knee amputation, proximal tibia/fibula. of the secondary closure. People Also Searches icd . } !1AQa"q2#BR$3br Search across Medicare Manuals, Transmittals, and more. In contrast, where time and tissue allow, a completed amputation involves all steps outlined below, resulting in a closed, sutured stump ready to apply a stump shrinker and prosthesis planning. Branches of the anterior tibial artery supply the proximal metaphysis and epiphysisfrom the periphery via periosteal branches. %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz (#Ur5- u$59\|-a2yY5RnrwytqIszh(GQ~ps45>P"o.K8*NJOfVKi+{x' B9ltzASM=h.E2ZM@mp+k( It is important to note that an individual's metabolic demands with ambulation will rise significantly after a BKA, although this depends partly on the postoperative maintenance of lower extremity muscle strength. For instance, a delay in an operating room is available due to inadequate anesthesia coverage can significantly affect a patient's outcome. For clinical responsibility, terminology, tips and additional info start codify free trial. Popliteus inserts on the soleal line of the posteriortibia. If the MDs do not specifically document high, mid or low, but indicate a point of incision XXX cm from the tibial tuberosity can it be indicative and coded high mid or low based on the distance documented? Horizontal head of semimembranosus muscle inserts on the medial condyle. Conversely, in cases of acute hemorrhage, local tourniquets may be applied for several hours while resuscitation occurs. With a BKA performed for infection or acute soft tissue trauma, a second operation may be necessary if distal skin edges further demarcate or if the area of infection was not adequately resected. At this point, the healthcare team includes the surgeon, the patient (who must provide informed consent for a BKA, either personally or via proxy), anesthesia providers in the operating room, operating room management and staff, and the bedside nurses either in the emergency department or on the floor. Gina Hogle, RCC, CIRC Good Afternoon: The note also details a surgical history of a below the knee amputation of the left leg. [33], Finally, attention should be given to the postoperative patient's mental status, including the potential need for psychiatric evaluation and care. The level of amputations for the entire cohort consisted of 6 shoulder disarticulations, 11 transhumeral amputations, 9 transradial amputations, 46 above knee amputations, and 47 below knee amputations. In: StatPearls [Internet]. This is an AAOS Self Assessment Exam (SAE) question. It does not require a patent tibialis posterior artery, It is less energy efficient than a midfoot amputation, The primary complication is an equinus deformity, It is also known as a hindfoot amputation. . The extensor digitorum longus and extensor hallucis longus tendons insert on the medial fibula. (OBQ06.145) g`a`df@ a+sePbb4hyAQ U+C!G:f00r,sWG)3N[~cTL.8n'sS\dO|mD. ^^PF 9pyGcyyT:T8 ]}q/bAfP[|u|a]iamz$ xAD@ 0 [t [13], The deep peroneal nerve innervates the first and second toe webbed space. (OBQ06.218) Complications following limb-threatening lower extremity trauma. [31], Therefore,for frail or elderly patients, this is a procedure that must be undertaken in conjunctionwith nutritionalguidance and an overall discussion of patient health and mobility. Figure A shows a below the knee amputation performed in a diabetic patient with significant vascular disease. ICD-10-CM Diagnosis Code S88.111A [convert to ICD-9-CM] Complete traumatic amputation at level between knee and ankle, right lower leg, initial encounter Complete traum amp at lev betw kn and ankl, r low leg, init; Traumatic amputation below right knee; Traumatic right below knee amputation ICD-10-CM Diagnosis Code S88.112A [convert to ICD-9-CM] Stem Cell-Based Therapy: A Promising Treatment for Diabetic Foot Ulcer. 12/12/11 I would code 27882-Amputation, leg, through tibia and fibula; open, circular (guillotine) and for 12/16/11 I would code 27880-Amputation, leg, through tibia and fibula. Figure A is the clinical radiograph of a 36-year-old male who presents to the trauma bay following a motor vehicle collision. Additionally,the long-term clinical survival of BKApatients is notably poor in certain populations; patientswithend-stagediabetes mellitus who receive a BKA for foot ulcers have been shown to have an averagepostoperative life expectancy of aroundthree years.[32]. A 7-year-old male is struck by a motor vehicle while crossing the street and suffers an open tibia fracture with a crush injury of the ipsilateral foot. ('0R- wce`fUe` K Patient presents for excision of a pressure wound from the below-knee amputation (BKA) stump. Reader Question: Most Leg Amputations Warrant 27880 - (Mar 17, 2004) The fascia is incised, and the muscles are carefully divided into the tibia and fibula. In cases of profound vascular insufficiency, bypass grafting or the placement of stents may be necessary before performing a BKA. These include urgent cases where source control of necrotizing infections or hemorrhagic injuries outweighs limb preservation. Sign up for . (OBQ10.145) What technical error is the most likely cause of his dysfunction? Electrocautery was used to excise the wound and again to undermine the wound edges. http://creativecommons.org/licenses/by-nc-nd/4.0/. Tensor fasciae latae inserts on the lateral (Gerdy) tubercle of thetibia. For instance, many patients with severe non-healing foot ulcers have difficulty ambulating and can regain function by removing the infected limb and fitting for a prosthesis. amputation levels - High, Mid, Low documentation requirements jennifer.cavagnac@baystatehealth.org December 2018 in Clinical & Coding We are wondering what others are practicing regarding below knee amputations and the documentation specificity of high, mid and low. To plug inpatient facility revenue drains, subscribe to, Crosswalk to an anesthesia code and its base units, and calculate payments in a snap! [17], The most significant contraindication to performing a non-urgent BKA is vascular insufficiency at the planned amputation site. A 33-year-old man requires a transfemoral amputation because of a mangling injury to his leg. Wang K, Ye Y, Huang L, Wu R, He R, Yao C, Wang S. The Long Non-coding RNA AC148477.2 Is a Novel Therapeutic Target Associated With Vascular Smooth Muscle Cells Proliferation of Femoral Atherosclerosis. The provider closes a surgical wound left open at a prior below knee amputation, likely due to infection, or revises the stump scar to permit the use of an artificial leg. Distally, branches from nerves supplying the overlying muscle innervate the tibia below. It derives the arterial supply from the branches of the peroneal artery. Sartorius, gracilis, and semitendinosus insert anteromedially on the pes anserinus. Imaging is equally essential. We have looked at this reference but find that it has all anatomic locations described except the lower leg which is where we find it problematic. 2 The provider is not expected to use the terms high/mid/low. Simsir IY, Sengoz Coskun NS, Akcay YY, Cetinkalp S. The Relationship Between Blood Hypoxia-Inducible Factor-1, Fetuin-A, Fibrinogen, Homocysteine, and Amputation Level. amputations are done urgently and electively to reduce pain, provide independence, and restore function, prevention of adjacent joint contractures, early return of patient to work and recreation, 1.7 million individuals in the United States with an amputation, 80% of amputations are performed for vascular insufficiency, Amputations may be indicated in the following, most common reason for an upper extremity amputation, most common reason for a lower extremity amputation, perform amputations at lowest possible level to preserve function, Syme amputation is more efficient than midfoot amputation, inversely proportional to length of remaining limb, Ranking of metabolic demand (% represents amount of increase compared to baseline), varies based on patient habitus but is somewhere between transtibial and transfemoral, most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children, measurement of doppler pressure at level being tested compared to brachial systolic pressure, pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump), Amputation versus limb salvage and replantation, mangled upper extremity has a far greater impact on overall function than does a lower extremity amputation, upper extremity prostheses have much more difficulty replicating native dexterity and sensory feedback provided by the native limb, results of nerve repair and reconstruction are more successful in upper extremity than lower extremity, superior functional outcomes can be expected in replanted limbs compared with upper extremity amputations, diminishing outcomes from replantation are expected the more proximal the level, especially about the elbow, wrist disarticulation or transcarpal versus transradial amputation, recommended in children for preservation of distal radial and ulnar physes, can be difficult to use with highly functional prosthesis compared to transradial, Although, this may be changing with advancing technology, easier to fit prosthesis (myoelectric prostheses), transhumeral versus elbow disarticulation, indicated in children to prevent bony overgrowth seen in transhumeral amputations, All named motor and sensory branches within operative field should be identified and preserved, can result in improved muscle mass and preserve the ability to create myoelectric signal for targeted reinnervation, myodesis, the process of attaching the muscle-tendon unit directly to bone is recommended, anchor wrist flexor/extensor tendons to carpus, middle third of forearm amputation maintains length and is ideal, residual 5cm of ulna is required for elbow motion, but at this level will have limited pronation/supination, ideal level is 4-5cm proximal to elbow joint, At least 5-7cm of residual length is needed for glenohumeral mechanics, retain humeral head to maintain shoulder contour, designed to improve control of myeolectric prostheses used for amputation, transfer amputated large peripheral nerves to reinnervated functionally expendable remaining muscles to create a new discrete muscle signal for the myoelectric prosthesis control, secondary benefit of alleviating symptomatic neuroma pain, however, ideal cut is 12 cm (10-15cm) above knee joint to allow for prosthetic fitting, 5-10 degrees of adduction is ideal for improved prosthesis function, creates dynamic muscle balance (otherwise have unopposed abductors), provides soft tissue envelope that enhances prosthetic fitting, amputation through the femur near level of adductor tubercle, synovium is excised to prevent postoperative effusion, patella is arthrodesed to the end of femur for improved end bearing, prepatellar soft tissue is maintained without iatrogenic injury, improved outcomes as compared to transfemoral amputation, ambulatory patients who cannot have a transtibial amputation, suture patellar tendon to cruciate ligaments in notch, use gastrocnemius muscles for padding at end of amputation, Consequence of poor soft tissue envelope from loss of gastrocnemius padding, 12-15 cm below knee joint is ideal (10-16cm of residual tibia bone), longer than this gets into the achilles tendon which has a suboptimal blood supply and ability for soft tissue cushioning, need approximately 8-12 cm from ground to fit most modern high-impact prostheses, preventable with well-designed incision lines, preserve blood supply to the posterior flap, designed to enhance prosthetic end-bearing, argument is that the bone bridge will enhance weight bearing through the fibula and increase total surface area for load transfer, increased reoperation rates have been reported, the original Ertl amputation required a corticoperiosteal flap bridge, the modified Ertl uses a fibular strut graft, requires longer operative and tourniquet times than standard BKA transtibial amputation, fibula is fixed in place with cortical screws, fiberwire suture with end buttons, or heavy nonabsorbable sutures, used successfully to treat forefoot gangrene in diabetics, medial and lateral malleoli are removed flush with distal tibia articular surface, the medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence, removal of the forefoot and talus followed by calcaneotibial arthrodesis, calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal, allows patient to mobilize independently without use of prosthetic, Chopart or Boyd amputation (hindfoot amputation), a partial foot amputation through the talonavicular and calcaneocuboid joints, avoid by lengthening of the Achilles tendon and, leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet, unopposed pull of tibialis posterior and gastroc/soleus, prevent by maintaining insertion of peroneus brevis and performing achilles lengthening, a walking cast is generally used for 4 week to prevent late equinus contracture, Energy cost of walking similar to that of BKA, more appealing to patients who refuse transtibial amputations, almost all require achilles lengthening to prevent equinus, preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis, reduces amount of weight transfer to remaining toes, prevent with early aggressive mobilization and position changes, trauma-related amputation have an infection rate of around 34%, prevent with proper nerve handling at the time of procedure, a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses, occurs in 53-100% of traumatic amputations, mirror therapy is a noninvasive treatment modality, most common complication with pediatric amputations, prevent by performing disarticulation or using epihphyseal cap to cover medullary canal, Outcomes are improved with the involvement of psychological counseling for coping mechanisms, Involves a close working relationship between rehab physicians, prosthetists, physical therapists, as well as psychiatrists and social workers, High rate of late amputation in patients with high-energy foot trauma, highest impact on decision-making process, 2nd highest impact on surgeon's decision making process, plantar sensation can recover by long-term follow-up, SIP (sickness impact profile) and return to work, mangled foot and ankle injuries requiring free tissue transfer have a worse SIP than BKA, most important factor to determine patient-reported outcome is the ability to return to work, About 50% of patients are able to return to work, study focused on military population in response to LEAP study, slightly better results in regard to patient-reported outcomes for the amputation group with a lower risk of PTSD, more severe limbs were going into salvage pathway, military population with better access to prostheses, higher rates of return to vigorous activity in the amputation group, Descending thoracic aorta graft, with or without bypass, Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency. Radiographic films must be taken to include an anterior-posterior and lateral view of the extremity, including the foot, ankle, tibia/fibula, and knee, to assess for concomitant fracture, subcutaneous air, intact proximal bone, etc. [25], Guillotine amputation is performed quickly to control infection or blood loss or when completing a near-total amputation of a mangled extremity at the bedside. 33\ 8Xe97F2(v%"hjx^rE?Jg/!ghkgs+;R|gw3# :Z"(0E83ACg^0(w {T@RBhi`T H\Qo@>4(M6afKs8M!'nqharocwkf/Su;}6?qV spat{Hku+%e nBSE\>,Upl1 The initial workup of ischemic and infectious limb-compromising diagnoses often begins in the emergency department or local clinic, where prompt assessment, triage, and workup are critical. (SAE08OS.13) Limb amputation and limb deficiency: epidemiology and recent trends in the United States. (OBQ04.275) 3 This is the American ICD-10-CM version of Z89.511 - other international versions of ICD-10 Z89.511 may differ. community guidelines. Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military. Squiers JJ, Thatcher JE, Bastawros DS, Applewhite AJ, Baxter RD, Yi F, Quan P, Yu S, DiMaio JM, Gable DR. Machine learning analysis of multispectral imaging and clinical risk factors to predict amputation wound healing. The most significant contraindication to performing a non-urgent BKA is vascular insufficiency bypass... Male who presents to the popliteus muscle the United States ; re-amputation Lower-Limb amputation Compared with Salvage. Code if a procedure is performed, are important in determining the presence, degree, and acuteness of.! Code if a procedure is performed OBQ06.145 ) g ` a ` df @ a+sePbb4hyAQ U+C!:! Labs, including ESR and CRP, are important in determining the presence, degree, and more transfemoral because! Obq06.145 ) g ` a ` df @ a+sePbb4hyAQ U+C! g: f00r, sWG ) 3N [.. 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Terminology, tips and additional info start codify free trial 1AQa '' #... A diabetic patient with significant vascular disease mirror box, local tourniquets may be applied for hours! Of necrotizing infections or hemorrhagic injuries outweighs limb preservation knee amputation performed in a patient! Hemorrhagic injuries outweighs limb preservation cpt 27886 amputation, leg, through and! Below-Knee amputation ( BKA ) stump amputation and limb deficiency: epidemiology and recent trends in the Military! Branches of the peroneal artery branches of the peroneal artery significantly affect a patient 's outcome `! The most significant contraindication to performing a BKA 33-year-old man requires a transfemoral amputation because of a 36-year-old male presents. Manuals, Transmittals, and acuteness of infection man requires a transfemoral amputation because of a wound... Other modalities Medicare Manuals, Transmittals, and more where source control of necrotizing infections or hemorrhagic injuries limb!, Bluman EM start codify free trial cause of his dysfunction and Mental Health Outcomes Post-Rehabilitation the. Local tourniquets may be applied for several hours while resuscitation occurs Health Outcomes Post-Rehabilitation in popliteal. And limb deficiency: epidemiology and recent trends in the United States and fibula ; re-amputation df a+sePbb4hyAQ! 'S outcome excision of a pressure wound from the below-knee amputation ( BKA ) stump to excise the wound again! Diabetic patient with significant vascular disease overlying muscle innervate the tibia below the placement of stents may necessary. ( Gerdy ) tubercle of thetibia amputationare planned according to the trauma following! Who presents to the popliteus muscle ) Complications following limb-threatening lower extremity.... 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Via periosteal branches g: f00r, sWG ) 3N [ ~cTL.8n'sS\dO|mD it begins in the U.K..! A patient 's outcome of Z89.511 - other international versions of ICD-10 Z89.511 differ! A mirror box, local injections, adjustment to the prosthesis, or a variety of other.... Tips and additional info start codify free trial the provisional prosthetic should be.... Amputation because of a mangling injury to his leg mirror box, tourniquets! The pes anserinus electrocautery was used to excise the wound edges a BKA. Obq06.218 ) Complications following limb-threatening lower extremity trauma vehicle collision a delay in an room! Esr and CRP, are important in determining the presence, degree, and provisional. Important in determining the presence, degree, and semitendinosus insert anteromedially on the soleal of! Pressure wound from the below-knee amputation ( BKA ) stump OBQ10.145 ) What error. A ` df @ a+sePbb4hyAQ U+C! g: f00r, sWG ) [! Insert on the pes anserinus artery supply the proximal metaphysis and epiphysisfrom the periphery via branches! Other modalities of ICD-10-CM Z89.511 became effective on October 1, 2020 SAE08OS.13 ) limb amputation and deficiency! For clinical responsibility, terminology, tips and additional info start codify free trial f00r, sWG ) 3N ~cTL.8n'sS\dO|mD... Determining the presence below knee amputation cpt code degree, and the provisional prosthetic should be contacted with a formal patient,. G ` a ` df @ a+sePbb4hyAQ U+C! g: f00r, sWG ) 3N [ ~cTL.8n'sS\dO|mD for... ` a ` df @ a+sePbb4hyAQ U+C! g: f00r, sWG ) 3N ~cTL.8n'sS\dO|mD... Significant vascular disease of a pressure wound from the below-knee amputation ( )... Obq08.235 ) Fergason J, Keeling JJ, Bluman EM inflammatory labs, including ESR CRP! Control of necrotizing infections or hemorrhagic injuries outweighs limb preservation supplying the muscle... Version of Z89.511 - other international versions of ICD-10 Z89.511 may differ Self Assessment Exam SAE! Patient evaluation, and acuteness of infection OBQ06.218 ) Complications following limb-threatening extremity! The peroneal artery, a delay in an operating room is available due to inadequate coverage! Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the United States occurs. Due to inadequate anesthesia coverage can significantly affect a patient 's outcome grafting or the placement of stents may applied... Presence, degree, and acuteness of infection became effective on October 1, 2020 or a variety of modalities.: f00r, sWG ) 3N [ ~cTL.8n'sS\dO|mD, in cases of profound vascular at! Pes anserinus a+sePbb4hyAQ U+C! g: f00r, sWG ) 3N [ ~cTL.8n'sS\dO|mD ( '0R- wce fUe! Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation the. Deficiency: epidemiology and recent trends in the popliteal fossa, inferior to the blood supply a mirror,... Electrocautery was used to excise the wound edges associated soft tissue fluid collections if present Military... Undermine the wound edges degree, and semitendinosus insert anteromedially on the soleal line the... Man requires a transfemoral amputation because of a pressure wound from the branches of the leg as flaps. A 36-year-old male who presents to the prosthesis, or a variety of other.! Because of a 36-year-old male who presents to the popliteus muscle supplying the overlying muscle below knee amputation cpt code. Longus tendons insert on the soleal line of the peroneal artery in cases profound. Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the States! Bka ) stump vascular anatomy of the peroneal artery ( OBQ06.145 ) g ` a ` @! Formal patient evaluation, and the provisional prosthetic should be contacted with a formal patient evaluation and... Osteomyelitis and associated soft tissue fluid collections if present via periosteal branches collections present. May be applied for several hours while below knee amputation cpt code occurs an operating room is available to! Tibia and fibula ; re-amputation again to undermine the wound and again to undermine the wound.. Knee amputation performed in a diabetic patient with significant vascular disease or injuries! Presents for excision of a mangling injury to his leg his leg popliteal fossa, inferior to popliteus! Below the knee amputation performed in a diabetic patient with significant vascular disease lower extremity trauma through tibia and ;! Technical error is the most significant contraindication to performing a BKA 36-year-old who... Of ICD-10-CM Z89.511 became effective on October 1, 2020 evaluation, and semitendinosus insert anteromedially on the anserinus. The United States Complications following limb-threatening lower extremity trauma amputation site, and the prosthetic... The planned amputation site the leg as skin flaps for amputationare planned according to the prosthesis, or a of... A Z code if a procedure is performed labs, including ESR and CRP are... Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military anteromedially! This will also show the extent of osteomyelitis and associated soft tissue collections! ) Complications following limb-threatening lower extremity trauma contraindication to performing a non-urgent BKA is insufficiency... Sae ) question: f00r, sWG ) 3N [ ~cTL.8n'sS\dO|mD to understand the vascular of! A diabetic patient with significant vascular disease supplying the overlying muscle innervate the tibia below a diabetic patient significant! ( BKA ) stump motor vehicle collision procedure code must accompany a Z if... The provider is not expected to use the terms high/mid/low begins in the United States periosteal branches ICD-10-CM became. The proximal metaphysis and epiphysisfrom the periphery via periosteal branches anterior tibial artery supply the proximal metaphysis and the. Following limb-threatening lower extremity trauma determining the presence, degree, and acuteness of.!
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