Researchers randomly assigned 40 patients undergoing two-stage revision ACL reconstruction to receive either autologous iliac crest cancellous bone graft for tunnel grafting (control group; n=20) or silicate-substituted calcium phosphate in the form of sculptable microgranules (Actifuse MIS System, Baxter) as a bone graft substitute . - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); An Observational Study Using Navigated Measurements 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. They observed that an average 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. Towson, MD 21204 Revision ACL graft failure rates were reported by 5 studies, including 1 study with ABM (6.1%), 1 study with AC (8.3%), 1 study with TBA (0%), and 2 studies with ICBG (0% and 2%). A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. -Femoral tunnel placement in single-bundle anterior cruciate ligament reconstruction: a cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament.. Biomechanical Comparison Between Bashti Bone Plug Technique and TECHNIQUE STEPS. Background: Ligament reconstruction is a common procedure in orthopedic surgery. Spine J 7:475490, Jenis LG, Banco RJ (2010) Efficacy of silicate-substituted calcium phosphate ceramic in posterolateral instrumented lumbar fusion. Comparison of Femoral Tunnel Position and Clinical Results. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Sci Rep (2016) After 6 to 12weeks, failures tend to occur in mid-substance [11]. The anterior cruciate ligament (ACL) is a ligament that provides stability to the knee joint. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. endobj 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]. A Retrospective Comparative Study The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. 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 available data indicate that autograft for bone tunnel grafting in 2-stage ACL revision may be associated with a lower risk of revision ACL reconstruction graft failure compared with allograft bone. Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Study design: Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. A clinical, prospective, randomized, double-blind study. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. You are using an out of date browser. This site complies with the HONcode standard for trustworthy health information: verify here. 2021 Oct 12;11(4):e20.00055. Morphometric analysis of femoral and tibial tunnel locations revealed that the two procedures were based on the same anatomical concept, and BPTB grafts showed significantly better anterior knee stability than HT grafts, although no significant differences in other objective evaluations and all subjective evaluations were detected between the two graft types in anatomical ACLR. An official website of the United States government. He is only grafting the bone. An official website of the United States government. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). A clinical, prospective, randomized, double-blind study, Femoral Shaft Frx: Leg Lengths / Nail Lengths, Orthopaedic Specialists of North Carolina. Google Scholar, Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF (2017) Outcomes after 1-stage versus 2-stage revision anterior cruciate ligament reconstruction. Jul 22, 2009. Get timely coding industry updates, webinar notices, product discounts and special offers. 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 Orthop Relat Res. Would this qualify for CPT 29888 with a 52 mod? Resurfacing technique consisting of transplantation of multiple osteochondral grafts to smooth the area. - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. eCollection 2022 Mar. - Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position . Epub 2020 Apr 1. Provided by the Springer Nature SharedIt content-sharing initiative. Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. In the immediate postoperative period, the weakest part of any ACLR is the fixation. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? Reports suggest that a two-stage procedure is performed in only 8 to 9% of revision ACLRs [6]. It may not display this or other websites correctly. 2022 Feb 28;11(3):e463-e469. 3. new ACL graft. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Manage cookies/Do not sell my data we use in the preference centre. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. This process is repeated until there is full fill of femoral tunnel. Would you like email updates of new search results? Diermeier et al. 8600 Rockville Pike 2. Mayo Clinic is a not-for-profit organization. The second stage of the revision ACLR was performed a minimum of 3 months later, after obtaining a CT demonstrating adequate filling of the tunnels using a hamstring autograft though a transtibial drilling technique. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues. 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. Bone graft substitute for tunnel filling improved ACL reconstruction Preoperative planning for revision ACL surgery is essential for a successful outcome. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. in 30 deg flexion at the time of final fixation may result inexcessive graft tension when the knee is position in full extension; The site is secure. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study The surgeon should be sure to "bottom out" the cannula stylet into the femoral tunnel and allow the bone graft to gently push the stylet out of the tunnel as it is being filled . JavaScript is disabled. Arthroscopic knee procedure CPT codes range from 29866 to 29889. Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Because of weak bone from bone-grafted tunnels or enlarged tunnels, the surgeons should pay careful attention to the fixation methods and consider double fixation in all revisions [37]. These lesions are often difficult to see on MRI. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. Bethesda, MD 20894, Web Policies Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. It is commonly injured during high-intensity sports. endobj - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; CT scans to confirm healing at 3-5months after bone grafting [4, 12, 33, 34]. A Meta-analysis of 47,613 Patients. J Bone Joint Surg Am 100:9931000, Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. 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. 2015;43:2510. statement and eCollection 2020 Dec. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. [21] evaluated 88 patients who underwent one-stage revision ACLR. The new ligament was fixed to the tibia by a metallic screw and to the femur by a bioabsorbable screw. In addition, we obtain single leg knee-to-ankle lateral X-rays to assess for any sagittal plane malalignment as well as to look for excessive tibial slope. Cookies policy. - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. Cancel anytime. An Observational Study Using Navigated Measurements. One comparative cohort study reported that objective outcomes and subjective patient scores and satisfaction were not significantly different between one-stage and two-stage revision ACLRs and both groups had significantly improved objective outcomes and patient subjective outcomes without notable differences in failure rates [42]. <> Clipboard, Search History, and several other advanced features are temporarily unavailable. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. The authors declare that they have no competing interests. The appropriately sized OATS harvester is chosen 1 mm larger than the tunnel size and is used to harvest bone graft from the iliac crest through a percutaneous approach. They observed that an average of 5.8months was needed for healing of the autograft dowel to become visible on CT scans [11]. No restrictions are placed on their range of motion and patients were allowed to weightbear on the affected leg using crutches [17]. 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. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. Knee Surg Sports Traumatol Arthrosc 21:20722080, Magnussen RA, Debieux P, Benjamin B, Lustig S, Demey G, Servien E et al (2012) A CT-based classification of prior ACL femoral tunnel location for planning revision ACL surgery. Abstract The . This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Unable to load your collection due to an error, Unable to load your delegates due to an error. FOIA 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 Unauthorized use of these marks is strictly prohibited. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. Major reasons to proceed with a two-stage strategy include tunnel-widening or other loss of bone stock, tunnel malposition, arthrofibrosis, active infection, concomitant meniscal deficiency, malalignment, and focal chondral lesions and/or other ligamentous laxity that may require a staged approach [8, 9] (Table1). 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. The femoral tunnel was easily visualized with flexing the knee beyond 90 degrees. - over the top position: Bone graft substitute for tunnel filling improved ACL - Healio Approximately 200,000 anterior cruciate ligament (ACL) ruptures occur in the United States annually. 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]. Achieving the correct position can be tricky. stream We want our patients to be able to return to the activities they enjoy. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. The https:// ensures that you are connecting to the - Discussion: Bruce A. Few studies report the outcomes of two-stage revision ACLR alone. Correspondence to All rights reserved. The tibial tunnel looked to be in a good position. - one incision transtibialtechnique Bone graft, any donor area; minor or small eg, dowel or button) (20900) Bone graft, any donor area; major or large (20902) Insertion vascular pedicle into carpal bone (25430) Bone marrow; aspiration only (38220) Bone marrow transplantation; autologous (38241) Microvascular. Conclusion: Am J Sports Med 34:553564, MARS Group, Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK et al (2010) Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Louis et al. Levy, M.D., an orthopedic surgeon specializing in sports medicine at Mayo Clinic in Rochester, Minnesota, discusses Mayo's approach to revision ACL surgery. - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. The purpose of this article is to review the preoperative planning, surgical considerations, rehabilitation, and outcomes of two-stage revision ACL reconstructions and summarize the recent literature outlining treatment results. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. If this is your first visit, be sure to check out the. Clin Sports Med 18:109171, Yoon KH, Kim JS, Park SY, Park SE (2018) One-stage revision anterior cruciate ligament reconstruction: results according to preoperative bone tunnel diameter: five to fifteen-year follow-up. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Disclaimer. Purposes: We sought to introduce our new technique of Bashti bone plug for fixation of soft tissue graft in anterior cruciate ligament (ACL) reconstruction and to compare . Graft healing in anterior cruciate ligament reconstruction Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. The surgeon submitted CPT code 25431 alone. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 1998-2023 Mayo Foundation for Medical Education and Research. They observed that revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than revision ACLR alone, although there were no significant differences in anterior laxity or functional test results between the two groups. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. 4. . 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. For a better experience, please enable JavaScript in your browser before proceeding. 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. All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. 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. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. Is it appropriate to assign codes for both the arthroscopic and open portions of the procedure? Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. ACL Reconstruction - BTB Graft - Knee & Sports - Orthobullets proprioceptive reflex leading to a functional extension loss while the patient is awake. Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding A new technique for femoral and tibial tunnel bone grafting using the The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. - in the report byStrobel MJ, et al., the authors report a case of a painful reflex extension loss due tofemoral malplacement of anACLgraft in a female high-level athlete; 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 ]. Bone tunnel-related issues are frequently encountered during revision anterior cruciate ligament reconstruction. Varus or valgus malalignment can put strain on an ACL graft, whatever the malalignment's cause the patient's physiology, failed meniscal surgery or cartilage problems. Christensen JJ, et al. 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. Revision ACL surgery: A comprehensive approach. 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. Thomas et al. Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. 2021 Nov 16;10(12):e2699-e2708. [26] reported the use of a sCO2-sterilized bone allograft to fill tunnel defects as the first stage of a two-stage revision ACLR. - w/a right knee, place the tunnel at about the 9:30 to 10 oclock position; Am J Sports Med 40:800807, Article In addition, patients who receive revision ACL surgery might have other damaged ligaments. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. You must log in or register to reply here. 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 new harvest site for bone graft in anterior cruciate ligament revision surgery. For a better experience, please enable JavaScript in your browser before proceeding. - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Discover how to save hours each week. HHS Vulnerability Disclosure, Help Two-stage revision anterior cruciate ligament reconstruction. Please enable it to take advantage of the complete set of features! Griffith TB, et al. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. Epub 2005 Aug 10. MARS Group. Unauthorized use of these marks is strictly prohibited. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. California Privacy Statement, Secure graft fixation is critical in ensuring a successful two-staged ACLR. 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). The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. Uchida et al. Conclusions. Epub 2007 Jan 5. doi: 10.1016/j.eats.2021.08.013. But no significant difference was observed between the two groups. sharing sensitive information, make sure youre on a federal JCM | Free Full-Text | Femoral Tunnel Position Affects Postoperative To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. However, the small number of included patients, especially in the group of patients without revision ACLR, is limited. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. 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. HHS Vulnerability Disclosure, Help A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. Please enable it to take advantage of the complete set of features! National Library of Medicine If no autograft is available for revision surgery, they advise augmentation of the allograft with the lateral extra-articular iliotibial band procedure to reduce the high failure rate associated with the use of the allograft. If this is your first visit, be sure to check out the. endobj Staged ACL Revision | Medical Billing and Coding Forum - AAPC eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. 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]. doi: 10.1016/j.arthro.2006.07.054. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The indication for bone grafting and between-stage protocol varied among studies. J Orthop Sci (2010) . Comparison of Femoral Tunnel Position and Clinical Results. View all the articles associated with any code, right from the code page. The femoral tunnel was a little high. A new and innovative procedure. Bookshelf - Editorial: The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction Arthrosc Tech. a meta-analysis of 32 studies. Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation, Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study, The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint, Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling, Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. -increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used Purpose: Epub 2018 Dec 17. - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Learn how to get the most out of your subscription.