Thomas et al. We focus on many factors including the status of the menisci, cartilage, alignment, tibial slope and other knee ligaments, as well as technical issues from the index surgery, such as the positioning of ACL sockets and tunnels. 8600 Rockville Pike (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. Federal government websites often end in .gov or .mil. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. A clinical, prospective, randomized, double-blind study. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. - Discussion: Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. Accessibility 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]. 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). - open technique(which might be required with arthroscopy malfunction). According to the result of the multicenter ACL Revision Study (MARS) Group, the risk of graft re-rupture following revision ACLR in patients receiving an autograft is 2.78 times less likely than in those receiving an allograft [35]. 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 . 2002 Richard O'Connor Award paper. View all the articles associated with any code, right from the code page. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. Outcomes of repeat revision anterior cruciate ligament reconstruction. Study design: Overview. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. 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. Although there are many proposed theories for tunnel lysis, it is most accurate to state that this condition has a multifactorial origin; mechanical and biologic causes have been reported, and both contribute to enlarged graft tunnels [11, 13]. Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; and transmitted securely. 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]. eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Bone Joint J. - Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. -Morphology of the Femoral Intercondylar Notch 2005 Nov;33(11):1701-9. doi: 10.1177/0363546505276759. Phys Ther 85:740749, PubMed 2022 May 11;11(6):e971-e976. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. A two-stage procedure is technically more demanding than the primary or one-stage procedure and outcomes are potentially inferior, especially for active patients who make a high demand on their bodies. - anteromedial portal technique: - lateral tunnel placement: An average Lysholm score at 2 years post operation was 96.6 points 2.1 (91100 points). 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. Failed ACL with Tunnel Enlargement: How I Bone Graft & Stage It Charles H. Brown Jr.,MD Director Abu Dhabi, United Arab Emirates . 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]. Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? Mayo Clinic sports medicine surgeons routinely perform revision surgery for patients who have undergone one or more ACL reconstructions elsewhere, and have published extensively on this topic. Her alignment, tibial slope and cartilage were all normal. It is commonly injured during high-intensity sports. [21] evaluated 88 patients who underwent one-stage revision ACLR. This content does not have an Arabic version. A Retrospective Comparative Study. Arthrosc Tech. $.' 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? 2020 Sep;140(9):1211-1219. doi: 10.1007/s00402-020-03421-7. Bookshelf I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. 5 0 obj Root tears also put tremendous forces on the ACL graft and can lead to rotational instability and graft failure. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. A clinical, prospective, randomized, double-blind study, Femoral Shaft Frx: Leg Lengths / Nail Lengths, Orthopaedic Specialists of North Carolina. JavaScript is disabled. 1 0 obj With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. They observed that an average of 5.8months was needed for healing of the autograft dowel to become visible on CT scans [11]. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. In additional analyses, 24% (12/49) of patients were newly found to have concomitant knee injuries (e.g., chondral defects, meniscal lesions) at the time of the second-stage operative procedure. However, Thomas et al. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. Int Orthop 37:13691374, Uchida R, Toritsuka Y, Mae T, Kusano M, Ohzono K (2016) Healing of tibial bone tunnels after bone grafting for staged revision anterior cruciate ligament surgery: a prospective computed tomography analysis. - Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. 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). A lot of factors help us to determine whether a single revision or a two- or multiple-stage revision would be best for a particular patient. Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. Trojani et al. 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]. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. Salem HS, Axibal DP, Wolcott ML, et al. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). Bone Graft related CPT Codes. That would help me to provide some better guidance. a statistical evaluation. 1998-2023 Mayo Foundation for Medical Education and Research. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). But no significant difference was observed between the two groups. 2 0 obj Careers. The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. J Bone Joint Surg Am 100:9931000, Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. <> CT analysis also included the determination of the filling rates of the tunnels. Unauthorized use of these marks is strictly prohibited. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. Learn how to get the most out of your subscription. 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]. <> However, remarkable advances in knowledge of this process have been made based primarly on animal models. official website and that any information you provide is encrypted eCollection 2022 Mar. Keywords: We thank Eun-Ji Jeon and Min-Ji Kim for their support. It may not display this or other websites correctly. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. ACL Reconstruction - BTB Graft. CPT codes are grouped into 6 sections: 1. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. Please enable it to take advantage of the complete set of features! Tunnel malposition, widening, and interference pose unique challenges that may complicate surgery and compromise outcomes. et al. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. 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 . 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. HHS Vulnerability Disclosure, Help MeSH 2021 Nov 16;10(12):e2699-e2708. Recently, we recognized that patients needing ACL reconstruction who also have significant rotatory instability of the knee may have injuries in the anterolateral complex. Ligaments are strong bands of tissue that attach one bone to . Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Similarly, root tears of the lateral meniscus are often missed as well. Comparison of Femoral Tunnel Position and Clinical Results. - Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation sharing sensitive information, make sure youre on a federal Orthopaedic Specialists of North Carolina. This is the great debate in ortho coding. - historic techniques: Biazzo A, Manzotti A, Motavalli K, Confalonieri N. J Clin Orthop Trauma. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. Terms and Conditions, Anterior cruciate ligament (ACL) reconstruction remains the gold-standard treatment for young active patients with functional instability after an ACL injury. Unauthorized use of these marks is strictly prohibited. The surgeon submitted CPT code 25431 alone. Disclaimer. endobj <> [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. PubMedGoogle Scholar. This video may be inappropriate for some users. Keep your critical coding and billing tools with you no matter where you work. A decision that will often depend on the graft used during the primary ACLR. Am J Sports Med 32:543549, Groves C, Chandramohan M, Chew C, Subedi N (2013) Use of CT in the management of anterior cruciate ligament revision surgery. Preoperative planning for revision ACL surgery is essential for a successful outcome. Patrick C. McCulloch MD. 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. endobj Sorry. TJ!!X`Sz9Q*BeV={=F ' 0y^*2| '! Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. The important stages in assessing a patient with failed ACL surgery include history, patient selection, physical examination and investigations, choice of graft, surgical technique, and rehabilitation [7]. 8600 Rockville Pike The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. He did other procedures, but I have the codes for them. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Provided by the Springer Nature SharedIt content-sharing initiative. 4 0 obj Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery. a meta-analysis of 32 studies. . endobj 4. registered for member area and forum access. Optimal outcomes require a precise picture of how the ACL reconstruction failed. doi: 10.1016/j.eats.2021.11.019. 110 West Rd., Suite 227 An official website of the United States government. The insertion of an interference screw not only compresses the graft in the tunnel but also leads to an enlargement of the bone tunnel itself [13]. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. Outcomes of repeat revision anterior cruciate ligament reconstruction. Mayo Clinic has vast experience treating posterior cruciate ligament, lateral collateral ligament, posterolateral and posteromedial corner injuries, as well as medial collateral ligament injuries. and transmitted securely. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning Preoperative planning is critical to identify and characterize bone tunnel pathology. The femoral tunnel was a little high. Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. 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]. 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. 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. 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. - graft that tightens (pulls up into the tibial tunnel) with flexion will have a much higher likelyhood offailure and usually indicates a - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. 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. eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. An official website of the United States government. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. 2. 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. Often the meniscus hasn't healed after the initial surgery, or lesions might have been overlooked during surgery, in particular meniscal root tears or meniscal ramp lesions. - this technique allows for a more anatomic and precise placement of the femoral tunnel (more reliable posterior placement); 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]. There is no code for bone grafting. % 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. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver.