eCollection 2020 Dec. 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? As our group described in 2013 in American Journal of Sports Medicine, all of these factors contribute to ACL failure and to the success of revision ACL surgery. They explained that because a bone tunnel of 15mm diameter with 45 of inclination resulted in a tibial tunnel aperture of >20mm, a 20-mm tunnel aperture was regarded as a candidate for grafting. 2022 May 11;11(6):e971-e976. Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. Conclusions. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Achieving the correct position can be tricky. You are using an out of date browser. <> Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. The femoral tunnel was a little high. 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. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. Resurfacing technique consisting of transplantation of multiple osteochondral grafts to smooth the area. Discover how to save hours each week. [34] evaluated 10 consecutive patients who underwent staged revision ACLR using autogenous bone grafting and reported that all patients had a full range of motion of the knees, a negative Lachmann sign and negative pivot-shift test . Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Disclaimer. No restrictions are placed on their range of motion and patients were allowed to weightbear on the affected leg using crutches [17]. - Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position . 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). Terms and Conditions, Orthopaedic Specialists of North Carolina. Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. It may not display this or other websites correctly. Van de pol et al. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. 3. 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. Bone grafting is commonly reported using iliac crest autograft and allograft bone chips and dowels, while hamstring autograft and BPTB autograft were the most utilized grafts during the second-stage definitive reconstruction. An active infection should be treated with irrigation and debridement with confirmation of eradication (e.g., normalized laboratory test results, negative cultures) before a patient has a new graft and implant put in place. This site needs JavaScript to work properly. Von recum et al. Tibial tunnel was found to be anterior, perhaps more inferior than would be in an anatomic ACL insertion. Google Scholar, van Eck CF, Schkrohowsky JG, Working ZM, Irrgang JJ, Fu FH (2012) Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft. 2023 BioMed Central Ltd unless otherwise stated. Mosaicplasty. Our Experience: 2014 - 2018 . Comparison of Femoral Tunnel Position and Clinical Results. 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. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . femoral tunnel too far anterior in the notch; [40] reported the results of 87 patients who underwent revision ACLR with a follow-up of more than 3 years. Optimal outcomes require a precise picture of how the ACL reconstruction failed. Coronal (a) and sagittal (b) view of computed tomography (CT) images demonstrate widening of the tibial tunnel in the setting of a failed anterior cruciate ligament reconstruction. MeSH 2020;48(3):767-777. eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Systematic review. <> The analysis included 7 studies with a total of 234 patients. Bookshelf Franceschi et al. Am J Sports Med 47:324333, Chmielewski TL, Hurd WJ, Rudolph KS, Axe MJ, Snyder-Mackler L (2005) Perturbation training improves knee kinematics and reduces muscle co-contraction after complete unilateral anterior cruciate ligament rupture. The authors declare that they have no competing interests. For an allograft, a single bone dowel approximately 1mm larger than the diameter of the tunnel is used and placed using a bone tamp for a press-fit technique, ensuring that the entire tunnel is filled [4]. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. NPI Look-Up Tool (National Provider Identifier), The official publication for Level I HCPCS (CPT-4 codes) for hospital providers, Also specific Level II HCPCS codes for hospitals, physicians and other health professionals, Fully searchable through Find-A-Code's Comprehensive Search, Codes mentioned in articles are linked to Code Information pages, Code Information page link back to related articles. PubMedGoogle Scholar. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Keywords: Levy, M.D., an orthopedic surgeon specializing in sports medicine at Mayo Clinic in Rochester, Minnesota, discusses Mayo's approach to revision ACL surgery. MeSH JavaScript is disabled. With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. TECHNIQUE STEPS. This adds a fair amount of complexity to the procedure. Epub 2016 Dec 30. I wanted to see the history here to better define the stages of reconstruction and see the indication for the procedure being performed in this stage. Use of silicate-substituted calcium phosphate bone substitute had equivalent knee laxity and clinical function outcomes compared with autologous bone graft 3 years after two-stage ACL . Silicate-substituted calcium phosphate (Si-CaP), which represents a synthetic, porous bone-graft substitute, may also be an appropriate bone-graft substitute [27,28,29,30]. Study design: Unable to load your collection due to an error, Unable to load your delegates due to an error. Am J Sports Med 36:851860, Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N et al (2013) Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. The greater the tibial slope, the higher the risk of graft failure as our group found in a 2015 study in American Journal of Sports Medicine. 6 0 obj 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. J Bone Joint Surg Am 100:9931000, Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. Tunnel orientation and size are the most important causes related to the two-stage procedure, as these enlarged tunnels may complicate graft placement and fixation [11, 12]. A 17-year-old female came to see us after two failed ACL surgeries. Remaining soft tissue was debrided along tibia. Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 1). Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. 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. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. Bone tunnel-related issues are frequently encountered during revision anterior cruciate ligament reconstruction. 7 0 obj Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-tendon-bone (BTB) autograft is associated with increased postoperative anterior knee pain and pain with kneeling and has the risk of intra- and postoperative patellar fracture. Get timely coding industry updates, webinar notices, product discounts and special offers. [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. The new ligament was fixed to the tibia by a metallic screw and to the femur by a bioabsorbable screw. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; Arthrosc Tech. Griffith TB, et al. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. doi: 10.1016/j.eats.2022.01.004. Arthroscopic knee procedure CPT codes range from 29866 to 29889. 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. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. In the immediate postoperative period, the weakest part of any ACLR is the fixation. doi: 10.2106/JBJS.ST.20.00055. In 2-stage revisions, bone grafting of the tunnels may be undertaken if the primary position was inaccurate or if osteolysis has caused widening of the tunnels. 8600 Rockville Pike The goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. Am J Sports Med 42:23012310, Noyes FR, Barber-Westin SD, Roberts CS (1994) Use of allografts after failed treatment of rupture of the anterior cruciate ligament. Two-stage revision anterior cruciate ligament reconstruction, https://doi.org/10.1186/s43019-019-0010-6, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. endstream Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. - over the top position: Noyes et al. 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? Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. Not applicable, this is a review article. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). Thomas et al. Knee Surg & Relat Res 31, 10 (2019). 2002 Richard O'Connor Award paper. If this is your first visit, be sure to check out the. Currently, the gold standard for measuring tunnel size is the computed tomography (CT) method. endobj This process is repeated until there is full fill of femoral tunnel. proprioceptive reflex leading to a functional extension loss while the patient is awake. The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. Thomas et al. - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a However, methods used to sterilize allograft material (e.g., gamma irradiation and autoclaving), are known to adversely affect the structural and other properties of the graft material [25]. 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. An official website of the United States government. 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. 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]. JFIF C The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Arthrosc Tech. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint Am J Sports Med 33:17011709, Battaglia TC, Miller MD (2005) Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. - most common error is non isometric anterior tunnel placement within intercondylar notch rather than at its normal posterior insertion; 2 0 obj A Retrospective Comparative Study - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. et al. [11] reported the results of 49 consecutive two-stage revision ACLRs in which the tibial tunnel was grafted (the bone graft was taken from the ipsilateral iliac crest) during the first stage, followed by an ACLR using various grafts and fixation methods for the second stage. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. The optimal and earliest possible timing of the two-stage procedure is still not clear. See our privacy policy. 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. Clin Sports Med 28:203214 vii, Islam A, Chapin K, Moore E, Ford J, Rimnac C, Akkus O (2016) Gamma radiation sterilization reduces the high-cycle fatigue life of allograft bone. Meniscal tears are another contributing cause. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. An Observational Study Using Navigated Measurements At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. 29866 is for autografts (from the patient). - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). Typically, a staged procedure requires an average delay of 4 to 6months to allow for the bone defect to heal [11, 18], likely subjecting patients to a prolonged period of knee instability and thus adding to the risk of meniscal injury, additional deterioration of muscle strength, and osteochondrosis [32]. CPT codes are grouped into 6 sections: 1. JavaScript is disabled. ACL Reconstruction - BTB Graft. 2002 Richard O'Connor Award paper. CT analysis also included the determination of the filling rates of the tunnels. - ref: Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. official website and that any information you provide is encrypted Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. 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]. Houston Methodist Orthopedics & Sports Medicine. Outcomes of repeat revision anterior cruciate ligament reconstruction. MARS Group. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? 2021 Oct 12;11(4):e20.00055. FOIA Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; Methods: endobj Accessibility Revision ACL surgery: A comprehensive approach. Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. 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]. 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 To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. We routinely obtain hip-to-ankle AP X-rays to assess for any coronal plane malalignment. Measurements are made perpendicular to the axial plane of the tunnel at the widest point [15]. Would you like email updates of new search results? - historic techniques: Uchida et al. At a mean follow-up 6.7years postoperatively, 66.7% of patients had returned to their preoperative sports activity level, 23.3% had changed to lower, non-impact sports, and 10% had given up any sports activity. When aperture fixation is not possible, familiarity with, and use of, all-inside tibial and femoral sockets with cortical suspensory fixation may be necessary [4]. Epub 2007 Jan 5. Clinically, many authors have reported good results for two-staged revision ACLR using autograft bone [4, 11]. In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Two-stage revision ACLR typically involves an initial bone-graft procedureto fill the widened or misplaced tunnelsand subsequent time to allow for the bone graft to heal sufficiently before the second stage is undertaken [5]. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. Ki-Cheor Bae. You must log in or register to reply here. government site. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. stream Conclusion: Would this qualify for CPT 29888 with a 52 mod? Louis et al. Background: At a mean follow-up of 6years, the laxity measurements achieved with a two-stage revision ACLR can be similar to those achieved after primary ACLR, although the IKDC rating is lower. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. A total 75 patients (75 knees) who underwent ACL reconstruction with tibialis anterior allografts were investigated between February 2015 and October . Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. -main criticism is that in some cases a transtibial tunnel will not allow for the exact desiredtunnel placement (you get what you get) Primary ACL reconstruction is recognized as a successful procedure, but failure has been shown to occur in approximately 10% of patients.
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