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Louis et al. National Library of Medicine Franceschi et al. Revision ACL surgery: A comprehensive approach - Mayo Clinic 2020;38:1191. TECHNIQUE STEPS. Among these potential scenarios requiring a two-stage revision, tunnel-widening is the most common cause; the first stage involves graft removal, tunnel curettage, and bone grafting, followed by revision ACL reconstruction in the second stage. doi: 10.2106/JBJS.ST.20.00055. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; Allografts may be well suited for recreational athletes older than 30years of age, but autografts may be a better choice for younger athletes who wish to return to higher-level athletics [4]. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. For the aforementioned reasons, in this review, we will provide an overview of two-stage revision ACLR in the following order: preoperative planning, surgical considerations, rehabilitation, outcomes, and conclusions. - surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; Please enable it to take advantage of the complete set of features! 29866 is for autografts (from the patient). Preoperative planning for revision ACL surgery is essential for a successful outcome. doi: 10.1016/j.eats.2021.11.019. eCollection 2021 Oct-Dec. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. Two years after the surgery, she resumed all activities and plays collegiate volleyball. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? Background: Ligament reconstruction is a common procedure in orthopedic surgery. I added CPT code 20902 after reviewing the operative note, because the surgeon obtained the bone graft from a distant site via a separate incision. Improved muscle strength may be the decisive factor; however, changes in functional movement patterns after intensive physical therapy are also important to consider [41]. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). - one incision transtibialtechnique Enjoy a guided tour of FindACode's many features and tools. Bookshelf It may not display this or other websites correctly. Mayo Clinic has vast experience treating posterior cruciate ligament, lateral collateral ligament, posterolateral and posteromedial corner injuries, as well as medial collateral ligament injuries. 6 0 obj Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 2 0 obj It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. PDF ACL reconstruction revision with staged bone grafting 2002 Richard O'Connor Award paper. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. Our Experience: 2014 - 2018 . - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. doi: 10.1016/j.eats.2020.08.024. Arthroscopy 34:706713, Hing KA, Revell PA, Smith N, Buckland T (2006) Effect of silicon level on rate, quality and progression of bone healing within silicate-substituted porous hydroxyapatite scaffolds. J Bone Joint Surg Am 76:10191031, Richter DL, Werner BC, Miller MD (2017) Surgical pearls in revision anterior cruciate ligament surgery: when must I stage? Clin Sports Med 36:173187, Trojani C, Beaufils P, Burdin G, Bussiere C, Chassaing V, Djian P et al (2012) Revision ACL reconstruction: influence of a lateral tenodesis. PMC - anteromedial portal technique: This adds a fair amount of complexity to the procedure. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. If this is your first visit, be sure to check out the. 7 0 obj Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. - Surgical Technique: With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. <> [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. <> Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. Several Mayo Clinic orthopedic surgeons are members of the Multicenter ACL Revision Study (MARS) Group, which has authored a series of reports on topics including predictors of clinical outcomes, published in Journal of Orthopaedic Research in 2020. 4. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. Bone grafting of femur and tibial tunnels - AHA Coding Clinic for HCPCS The prior skin incision is typically used to expose the distal portion of the tibial tunnel. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. Griffith TB, et al. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. Eur Spine J 22(Suppl 2):S185S194, von Recum J, Schwaab J, Guehring T, Grutzner PA, Schnetzke M (2017) Bone incorporation of silicate-substituted calcium phosphate in 2-stage revision anterior cruciate ligament reconstruction: a histologic and radiographic study. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Achieving the correct position can be tricky. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. stream Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. Journal of Orthopaedic Research. Clipboard, Search History, and several other advanced features are temporarily unavailable. Am J Sports Med 40:800807, Article Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. ",#(7),01444'9=82. Diermeier et al. A single copy of these materials may be reprinted for noncommercial personal use only. A patient with a left knee anterior cruciate ligament tear, torn lateral meniscus and retained hardware from a previous anterior cruciate ligament reconstruction presented for a left knee arthroscopic anterior cruciate ligament repair, open removal of retained hardware and bone grafting of the distal femur and tibial tunnels.Following the arthroscopic anterior cruciate ligament repair, a tibial incision was made through subcutaneous tissue to access the tibial tunnel in order to remove the deep hardware. Disclaimer. All authors have made substantial contributions to all of the following: (1): the conception and design of the study, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be submitted. Before Graft healing in anterior cruciate ligament reconstruction Correspondence to Some authors suggest that an accelerated rehabilitation program for revision ACLR is not appropriate because of weaker initial graft fixation [20]. Background: The tibial tunnel looked to be in a good position. The https:// ensures that you are connecting to the 3 0 obj 2021 Oct 12;11(4):e20.00055. proprioceptive reflex leading to a functional extension loss while the patient is awake. The inside punch of the harvester is tapped and this allows delivery of the graft in a controlled manner and its impaction into the tunnel. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. This case required a two-stage approach: Stage 1 consisted of bone grafting, followed by second-stage repeat revision ACL reconstruction with patellar tendon autograft, lateral meniscal root repair and iliotibial band tenodesis. MeSH Jul 22, 2009. Would this qualify for CPT 29888 with a 52 mod? Kim, DH., Bae, KC., Kim, DW. He did other procedures, but I have the codes for them. There are numerous challenges to revision ACL surgery with regard to graft selection, timing of surgery, and whether or not the surgery can be performed in a single operation or multiple-staged surgeries. Measurements are made perpendicular to the axial plane of the tunnel at the widest point [15]. 3. Arthrosc Tech. Studies have shown that CT outperforms magnetic resonance imaging (MRI) and radiographs in both inter- and intra-observer reliability for evaluating tunnel-widening [14, 15]. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. <> 2007 May;23(5):558.e1-4. Arch Orthop Trauma Surg. Stage I femoral and tibial bone grafting. Arthrosc Tech 5:e189e195, Hofbauer M, Muller B, Murawski CD, Baraga M, van Eck CF, Fu FH (2013) Strategies for revision surgery after primary double-bundle anterior cruciate ligament (ACL) reconstruction. 2022 Jun 21;11(7):e1367-e1372. 19 Despite favorable outcomes after interference screw fixation, there are concerns related to graft biology, such as graft damage during screw insertion, a small tendon-to-bone contact area for graft integration, the presence of . Am J Sports Med. - ACL graft should pull up intotibial tunnel by about 2mm with extension when fixed on femoral side; Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Few studies report the outcomes of two-stage revision ACLR alone. Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft A Retrospective Comparative Study. Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding Methods: ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. Numerous studies have reported that additional procedures (e.g., extra-articular tenodesis, anatomical anterolateral ligament (ALL) reconstruction) could be a meaningful option in cases of revision ACLR to improved rotatory stability which is associated with re-injury. Knee Surg Sports Traumatol Arthrosc 20:15651570, Louis ML, D'Ingrado P, Ehkirch FP, Bertiaux S, Colombet P, Sonnery-Cottet B et al (2017) Combined intra- and extra-articular grafting for revision ACL reconstruction: a multicentre study by the French Arthroscopy Society (SFA). anterior cruciate ligament; bone graft; knee; revision. ACL Reconstruction - BTB Graft. That would help me to provide some better guidance. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. Bone Graft related CPT Codes - eatonhand.com Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Successful revision surgery requires an understanding of the cause of failure, careful preoperative planning, meticulous surgical execution, proper postoperative rehabilitation, and appropriate patient counseling [4]. This study aims to identify potential factors for both femoral and tibial tunnel widening (TW) and to investigate the effect of TW on postoperative outcomes after anterior cruciate ligament (ACL) reconstruction with a tibialis anterior allograft. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . Study design: Systematic review. endobj Bone graft substitute for tunnel filling improved ACL - Healio There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. Tunnel malpositioning that will interfere with new revision reconstruction tunnel placement can reduce graft apposition within the tunnels at the time of graft fixation, thereby placing the graft stability and subsequent incorporation at greater risk of failure [11]. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Tibial tunnel cysts, including pretibial cysts , are occasional complications of autologous or synthetic anterior cruciate ligament (ACL) reconstruction surgeries. Learn how to get the most out of your subscription. Knee 23:830836, MARS Group (2014) Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. Am J Sports Med 45:20682076, Erickson BJ, Cvetanovich G, Waliullah K, Khair M, Smith P, Bach B Jr et al (2016) Two-stage revision anterior cruciate ligament reconstruction. Cite this article. Mayo Clinic is a not-for-profit organization. a meta-analysis of 32 studies. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. This adds a fair amount of complexity to the procedure. Knee Surg Sports Traumatol Arthrosc 24:5157, Chahla J, Dean CS, Cram TR, Civitarese D, OBrien L, Moulton SG et al (2016) Two-stage revision anterior cruciate ligament reconstruction: bone grafting technique using an allograft bone matrix. Patients who have lost a meniscus or have a significant cartilage defect and have a failed ACL can, in some circumstances, require a meniscus transplant or cartilage replacement surgery. sharing sensitive information, make sure youre on a federal performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning At Mayo Clinic, we frequently perform osteotomies to correct both sagittal plane and coronal plane deformity. But an iliac-crest autograft is comparatively invasive with relatively high donor-site morbidity and the potential for insufficient yield quantities [11, 22]. The https:// ensures that you are connecting to the Thomas et al. This content does not have an English version. Revision ACL surgery: A comprehensive approach. Arch Orthop Trauma Surg 132:12991313, Thomas NP, Kankate R, Wandless F, Pandit H (2005) Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Springer Nature. [21] evaluated 88 patients who underwent one-stage revision ACLR. Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. government site. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. They reported that Si-CaP as a bone-graft substitute for tunnel augmentation showed favorable histologic, radiologic, and intraoperative integration comparable to the autologous iliac bone graft. - Discussion: Current studies report an average-low failure rate of 3.6% (wide range of 08.1%) for utilizing two-stage revision ACLR [11, 33, 34, 42, 43] (Table2). Trojani et al. J Bone Joint Surg Am 100:9931000, Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. 2020 Sep;140(9):1211-1219. doi: 10.1007/s00402-020-03421-7. endobj Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. sharing sensitive information, make sure youre on a federal ACL Reconstruction - BTB Graft - Knee & Sports - Orthobullets What code(s) would be reported for the open removal of retained deep hardware, along with placement of bone graft to the femur and tibial tunnels? 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. There are several procedures that can be performed in the ACL revision setting, such as anterolateral ligament reconstruction and iliotibial band tenodesis, to control that rotation. 2. doi: 10.1016/j.eats.2022.03.024. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. endobj The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean SD of 4.2 2.1 years. An official website of the United States government. $.' Similarly, a patient with a loss of more than 5 of extension or 20 of flexion of knee motion should be considered for lysis of adhesions and manipulation under anesthesia followed by rehabilitation [4, 10]. - some create a trough in the femur to bring graft closer to anatomical position, or they fix graft in place w/ knee in full extension; Varying Femoral Tunnels Between the Anatomical Footprint and Isometric Positions: Effect on Kinematics of the Anterior Cruciate Ligament-Reconstructed Knee. Systematic review. official website and that any information you provide is encrypted Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Department of Orthopaedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, 1035 Dalgubul-ro, Dalseo-gu, Daegu, 42601, South Korea, Du-Han Kim,Ki-Cheor Bae,Dong-Wan Kim&Byung-Chan Choi, You can also search for this author in In active young patients, failed primary ACLR may require a revision ACLR. A clinical, prospective, randomized, double-blind study, Femoral Shaft Frx: Leg Lengths / Nail Lengths, Orthopaedic Specialists of North Carolina. Article | Outpatient Surgery Magazine - Association of periOperative Consistent Indications and Good Outcomes Despite High Variability in View all the articles associated with any code, right from the code page. #1. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . However, an absolute threshold for how much tunnel-widening and bone loss is acceptable to undergo a single stage with an intraoperative bone graft prior to drilling has not been established [4, 16,17,18,19]. Bookshelf The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. Bone Grafting tibial and femoral tunnels knee, failed ACL Orthop Traumatol Surg Res 103:S223S2S9, Lee DW, Kim JG, Cho SI, Kim DH (2019) Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction. Given our prior assumption of the STC being 45 mm, the graft-50 rule suggests a 45-mm tibial tunnel if using 25-mm bone plugs. endobj -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. [39] have demonstrated that 349 patients who underwent revision ACLR-combined-ALL reconstructions showed improving rotational stability without increasing the risk of early and late complications and the re-rupture rate was 1.2% in their multicenter study. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. As this number has continued to increase, the incidence of revision ACL reconstruction (ACLR) has also grown to a rate of between 4.1 and 13.3% of all primary ACLRs performed [2]. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. MARS Group. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. Bone Tunnel Management in Modern Revision Anterior Cruciate Ligament Epub 2018 Dec 17. He is only grafting the bone. eCollection 2022 Mar. - references: Patrick C. McCulloch MD. Comparison of Femoral Tunnel Position and Clinical Results. PubMedGoogle Scholar. Two-stage revisions are rarely performed, but are particularly useful when addressing substantial tunnel-widening, active infection, and concomitant knee pathology (e.g., malalignment, other ligamentous injuries, meniscal or chondral lesions).