2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. 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. Aust N Z J Surg 69:517521, Eagan MJ, McAllister DR (2009) Biology of allograft incorporation. Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? -Morphology of the Femoral Intercondylar Notch While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. 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. - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); Bethesda, MD 20894, Web Policies ACL Reconstruction - BTB Graft. A relatively small but challenging subset of patients requires two-stage revision ACLR. Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. 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. 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. American Journal of Sports Medicine. Arthrosc Tech. Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Bone Joint J. Data Trace is the publisher of 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. Our Experience: 2014 - 2018 . There are several techniques for bone grafting tunnels in one- or two-staged ACL revision procedures with either autograft or allograft. Thomas et al. Accessibility He did other procedures, but I have the codes for them. CT examinations were performed at 3, 12, and 24weeks after bone grafting. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Comparison of Femoral Tunnel Position and Clinical Results. The goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. 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. JFIF C 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]. The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. There was also a significant improvement in the Lysholm score when comparing preoperative and postoperative values. 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 . The site is secure. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; You must log in or register to reply here. 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. 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. stream I just want to get the basic idea so I can advise him since he keeps a copy of his billing. 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? The https:// ensures that you are connecting to the Clin Radiol 68:e552e559, Marchant MH Jr, Willimon SC, Vinson E, Pietrobon R, Garrett WE, Higgins LD (2010) Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction. 2020 Dec 21;9(12):e1917-e1925. 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. #1. 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. Patrick C. McCulloch MD. Federal government websites often end in .gov or .mil. 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/. - one incision transtibialtechnique registered for member area and forum access. 2015;43:2510. Yoon et al. A Meta-analysis of 47,613 Patients. -increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used Clin Orthop Relat Res 474:827835, Van de Pol GJ, Bonar F, Salmon LJ, Roe JP, Pinczewski LA (2018) Supercritical carbon dioxide-sterilized bone allograft in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction: a histologic evaluation. However, the results of the postoperative side-to-side differences of the Lachman test as well as the pivot-shift test were significantly superior in group A (<12mm). This adds a fair amount of complexity to the procedure. 2023 BioMed Central Ltd unless otherwise stated. Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. government site. [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). official website and that any information you provide is encrypted We want our patients to be able to return to the activities they enjoy. [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. 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. Systematic review. - references: 2022 Jun 21;11(7):e1367-e1372. [40] reported the results of 87 patients who underwent revision ACLR with a follow-up of more than 3 years. %PDF-1.5 I would look at billing 29877 for the debridement of the soft tissue. Disclaimer. Enjoy a guided tour of FindACode's many features and tools. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. 8600 Rockville Pike This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. and transmitted securely. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study These lesions are often difficult to see on MRI. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. Results: - Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? 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. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. The anterior cruciate ligament (ACL) is a ligament that provides stability to the knee joint. An official website of the United States government. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. 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. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Purpose: A 17-year-old female came to see us after two failed ACL surgeries. Two-stage revision anterior cruciate ligament reconstruction. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. An Observational Study Using Navigated Measurements. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. - ref: Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. 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). 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. 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. Am J Sports Med 45:17901798, Diermeier T, Herbst E, Braun S, Saracuz E, Voss A, Imhoff AB et al (2018) Outcomes after bone grafting in patients with and without ACL revision surgery: a retrospective study. 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. - resulting anterior-posterior cruciate ligament impingement near extension caused a persistentfunctional extension deficit of 20; [26] reported the use of a sCO2-sterilized bone allograft to fill tunnel defects as the first stage of a two-stage revision ACLR. - grafts that pass thru femoral tunnels develop more internal pressure at femoral attachment site than those passed over top because of sharp edge of the tunnel; - this technique allows for a more anatomic and precise placement of the femoral tunnel (more reliable posterior placement); 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]. % The bone grafting is an opportune time to do an osteotomy to correct the malalignment. To me it really is a separate issue especially since the debridement was performed first, not as a clean up after the hardware was removed. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings. Knee Surgery & Related Research 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. 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. This video may be inappropriate for some users. Finally, 1 study compared ICBG to a synthetic bone substitute. eCollection 2022 Jun. 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 ]. Approximately 200,000 anterior cruciate ligament (ACL) ruptures occur in the United States annually. The analysis included 7 studies with a total of 234 patients. 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? . endobj - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. I forgot to mention he did an allograft bone graft. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? Autograft bone, either from the iliac crest or anterior tibial plateau, is still considered the gold standard source for grafting because of its osteoconductive, osteoinductive, and osteogenic properties. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. American Journal of Sports Medicine. What other specialized procedures might be performed in conjunction with ACL revision surgery? - 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; Unauthorized use of these marks is strictly prohibited. xMO@; aK]XDZ)r(-w(;.B ~8MG{ Lee et al. A tamp is used to further compress the graft. But an iliac-crest autograft is comparatively invasive with relatively high donor-site morbidity and the potential for insufficient yield quantities [11, 22]. This adds a fair amount of complexity to the procedure. They noted that although additional lateral tenodesis did not influence the International Knee Documentation Committee (IKDC) score in a multicenter study of 163 revision ACLRs, the proportion of negative pivot shifts was 80% with lateral tenodesis plus revision ACLR versus 63% without tenodesis. doi: 10.1016/j.arthro.2006.07.054. 1998-2023 Mayo Foundation for Medical Education and Research. - references: 2. Mosaicplasty. Anterior cruciate ligament reconstruction with patellar tendon: an ex vivo study of wear-related damage and failure at the femoral tunnel, Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension, Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? You are using an out of date browser. The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. PMC A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. In cases like these your going to need to bill out "what you can" which in this case would be 20680. Discover how to save hours each week. CPT codes are grouped into 6 sections: 1. The https:// ensures that you are connecting to the Previous literature has reported that if the tunnel size exceeds 1015mm, two-stage surgery should be performed. Conclusion: 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 . Ki-Cheor Bae. Before PMC Only 44 patients underwent a staged revision ACLR after bone grafting and 10 patients refused to undergo a revision ACLR. 29866 is for autografts (from the patient). Secure graft fixation is critical in ensuring a successful two-staged ACLR. - this restricts flexion of knee if graft remains intact, or it may elongate graft if the range of motion is restored; 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. Data Trace Publishing Company eCollection 2022 Jul. Franceschi et al. 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. 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. registered for member area and forum access. 2022 Feb 28;11(3):e463-e469. Example: 29888 - ACL Repair G0289 - Arthroscopy, knee, surgical, for removal of loose body, Harvesting and inserting the graft is included in code . Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. That would help me to provide some better guidance. - anteromedial portal technique: This site needs JavaScript to work properly. Cite this article. My surgeon disagrees with me and is firm that the harvest of the bone graft is not separately reportable. ",#(7),01444'9=82. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. 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. 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. Meniscal tears are another contributing cause. JavaScript is disabled. Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. 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. MeSH endobj ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. Background: Ligament reconstruction is a common procedure in orthopedic surgery. 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. J Bone Joint Surg Br 89:10511054, Article Arthroscopic knee procedure CPT codes range from 29866 to 29889. [21] evaluated 88 patients who underwent one-stage revision ACLR. - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a 2022 May 11;11(6):e971-e976. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Clipboard, Search History, and several other advanced features are temporarily unavailable. 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].