- surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; Improved muscle strength may be the decisive factor; however, changes in functional movement patterns after intensive physical therapy are also important to consider [41]. Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. However, remarkable advances in knowledge of this process have been made based primarly on animal models. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. 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. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. An average Lysholm score at 2 years post operation was 96.6 points 2.1 (91100 points). They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. 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 . Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. 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. CAS Arthrosc Tech. official website and that any information you provide is encrypted - tunnel positioning: To read the full article, sign in and subscribe to the AHA Coding Clinic for HCPCS. 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). TECHNIQUE STEPS. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft Uchida et al. doi: 10.1016/j.eats.2022.03.024. - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a 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]. Bethesda, MD 20894, Web Policies 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%). 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 goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. 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. 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. To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. Previous literature has reported that if the tunnel size exceeds 1015mm, two-stage surgery should be performed. PDF Failed ACL with Tunnel Enlargement: How I Bone Graft & Stage It Study design: Systematic review. Spine (Phila Pa 1976) 20:10551060, Campbell DG, Li P (1999) Sterilization of HIV with irradiation: relevance to infected bone allografts. CT analysis also included the determination of the filling rates of the tunnels. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. Measurements are made perpendicular to the axial plane of the tunnel at the widest point. Revision ACL surgery: A comprehensive approach. government site. 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. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. 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. Federal government websites often end in .gov or .mil. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. 8 Therefore, one should avoid angles <40 to 45 . Mayo Clinic has substantial experience with all of these procedures. PMC - Discussion: - 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; J Bone Joint Surg Br 89:10511054, Article 2 0 obj Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. 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. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). proprioceptive reflex leading to a functional extension loss while the patient is awake. 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. 3. The site is secure. anterior cruciate ligament; bone graft; knee; revision. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. 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? This site complies with the HONcode standard for trustworthy health information: verify here. - Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation View all the articles associated with any code, right from the code page. Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. MARS Group. doi: 10.2106/JBJS.ST.20.00055. Results: endobj No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. a statistical evaluation. 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. Femoral press-fit fixation versus interference screw fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: 20-year follow-up. There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. 2002 Richard O'Connor Award paper. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Stage I femoral and tibial bone grafting. Am J Sports Med 38:19791986, Dye SF (1996) The future of anterior cruciate ligament restoration. official website and that any information you provide is encrypted However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. - A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament 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. 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. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? Bethesda, MD 20894, Web Policies Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Unfortunately, the most common cause for failure is related to technical issues from the primary ACL surgery, with malposition of the sockets and tunnels, particularly on the femoral side. and transmitted securely. Clin Orthop Relat Res 325:130139, Andernord D, Desai N, Bjornsson H, Ylander M, Karlsson J, Samuelsson K (2015) Patient predictors of early revision surgery after anterior cruciate ligament reconstruction: a cohort study of 16,930 patients with 2-year follow-up. 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. <> Secure graft fixation is critical in ensuring a successful two-staged ACLR. Two-stage revision anterior cruciate ligament reconstruction. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. It may not display this or other websites correctly. ACL Reconstruction - BTB Graft. - w/a right knee, place the tunnel at about the 9:30 to 10 oclock position; Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. A tamp is used to further compress the graft. However, Thomas et al. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. Careers. A 17-year-old female came to see us after two failed ACL surgeries. American Journal of Sports Medicine. 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]. Arthrosc Tech. The authors declare that they have no competing interests. - two incision technique (outside in) Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. CPT codes are grouped into 6 sections: 1. 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. 2. PDF Two-stage revision anterior cruciate ligament reconstruction #1. <> TECHNIQUE VIDEO. In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. 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]. Federal government websites often end in .gov or .mil. At Mayo Clinic, we frequently perform osteotomies to correct both sagittal plane and coronal plane deformity. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? There is ongoing debate about how best to reconstruct the anterior cruciate ligament (ACL) to restore knee kinematics, including which is the best fixation method. 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. - lateral tunnel placement: 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. doi: 10.1016/j.eats.2021.08.013. Springer Nature. The results from this group were compared to the results of a matched group of patients with primary ACLR. Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. American Journal of Sports Medicine. Then in that case, yes, I would code this as 29888-52. You must log in or register to reply here. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. statement and Would this qualify for CPT 29888 with a 52 mod? 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. 2021 Oct 12;11(4):e20.00055. a meta-analysis of 32 studies. 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. Correspondence to The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. Thomas et al. In cases like these your going to need to bill out "what you can" which in this case would be 20680. Trojani et al. 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. - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ.