The goal of revision ACLR is to improve knee stability and activity levels, but the outcomes are reported to be inferior to those of primary ACLR [3]. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. [34] reported 10 consecutive patients (four female and six male patients with a mean age of 28years) who underwent autogenous bone grafting prior to ACLR revision. Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. 4 0 obj PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. - Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? American Journal of Sports Medicine. TECHNIQUE VIDEO. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. The goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. statement and It is commonly injured during high-intensity sports. JavaScript is disabled. Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. Not applicable, this is a review article. They found that a sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution. There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. Thomas et al. Unable to load your collection due to an error, Unable to load your delegates due to an error. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. 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. 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. If any of those ligaments were missed in the initial knee surgery, they can be treated in the revision setting. Improved muscle strength may be the decisive factor; however, changes in functional movement patterns after intensive physical therapy are also important to consider [41]. 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. For assessment of bone-graft incorporation, radiographs are routinely used. - some create a trough in the femur to bring graft closer to anatomical position, or they fix graft in place w/ knee in full extension; Varying Femoral Tunnels Between the Anatomical Footprint and Isometric Positions: Effect on Kinematics of the Anterior Cruciate Ligament-Reconstructed Knee. Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. Bone Grafting Tibial and Femoral Tunnels knee Portion of op note reads as follows: ACL was completely absent in mid aspect. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. 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. Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. 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]. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. It may not display this or other websites correctly. Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. stream 2013;41:1296. A new harvest site for bone graft in anterior cruciate ligament revision surgery. Some authors suggest that an accelerated rehabilitation program for revision ACLR is not appropriate because of weaker initial graft fixation [20]. Louis et al. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning An official website of the United States government. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery. - most common error is non isometric anterior tunnel placement within intercondylar notch rather than at its normal posterior insertion; TECHNIQUE STEPS. 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. Then in that case, yes, I would code this as 29888-52. 2020 Dec 21;9(12):e1917-e1925. Preoperative Patient Care. eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. The inside punch of the harvester is tapped and this allows delivery of the graft in a controlled manner and its impaction into the tunnel. But no significant difference was observed between the two groups. FOIA Yoon et al. 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. endobj Correspondence to 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. A Meta-analysis of 47,613 Patients. 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. The analysis included 7 studies with a total of 234 patients. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); We want our patients to be able to return to the activities they enjoy. Uchida et al. The initial rehabilitation emphasis is focused on restoring tibiofemoral and patellofemoral passive range of motion, restoring quadriceps activation, and controlling and resolving any joint effusion. Clipboard, Search History, and several other advanced features are temporarily unavailable. JavaScript is disabled. Stage I femoral and tibial bone grafting. anterior cruciate ligament; bone graft; knee; revision. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. 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. 2021 Oct 12;11(4):e20.00055. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. Tunnel malposition, widening, and interference pose unique challenges that may complicate surgery and compromise outcomes. You must log in or register to reply here. Terms and Conditions, 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. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. Clin Orthop Relat Res. 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). Background: - this restricts flexion of knee if graft remains intact, or it may elongate graft if the range of motion is restored; They observed that an average doi: 10.1016/j.eats.2020.08.024. 2022 May 11;11(6):e971-e976. [26] reported the use of a sCO2-sterilized bone allograft to fill tunnel defects as the first stage of a two-stage revision ACLR. Comparison of Femoral Tunnel Position and Clinical Results. JavaScript is disabled. An Observational Study Using Navigated Measurements - makesure that interference screws are less than 25 mm in length; 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]. - graft that tightens (pulls up into the tibial tunnel) with flexion will have a much higher likelyhood offailure and usually indicates a National Library of Medicine doi: 10.1016/j.eats.2021.11.019. Unauthorized use of these marks is strictly prohibited. Mosaicplasty. Make a donation. Conclusions. Bruce A. Failed ACL with Tunnel Enlargement: How I Bone Graft & Stage It Charles H. Brown Jr.,MD Director Abu Dhabi, United Arab Emirates . An average Lysholm score at 2 years post operation was 96.6 points 2.1 (91100 points). Anterior cruciate ligament (ACL) reconstruction rates have increased over the past 20years to roughly 200,000 per year [1]. 2015;43:2510. Would this qualify for CPT 29888 with a 52 mod? Lee et al. 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. In active young patients, failed primary ACLR may require a revision ACLR. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Careers. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. Towson, MD 21204 Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . Arthrosc Tech. HHS Vulnerability Disclosure, Help Unable to load your collection due to an error, Unable to load your delegates due to an error. Two years after the surgery, she resumed all activities and plays collegiate volleyball. BMC Musculoskelet Disord 19:246. 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. Two-stage revision anterior cruciate ligament reconstruction. The authors declare that they have no competing interests. You are using an out of date browser. A Retrospective Comparative Study PubMedGoogle Scholar. -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.. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. 1 0 obj ACL reconstruction is surgery to replace a torn anterior cruciate (KROO-she-ate) ligament (ACL) a major ligament in your knee. 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? -Morphology of the Femoral Intercondylar Notch sharing sensitive information, make sure youre on a federal Recently, we recognized that patients needing ACL reconstruction who also have significant rotatory instability of the knee may have injuries in the anterolateral complex. Study design: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. 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. 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. volume31, Articlenumber:10 (2019) 8600 Rockville Pike Data Trace Publishing Company California Privacy Statement, Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. endstream Thomas et al. Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. 2021 Nov 16;10(12):e2699-e2708. doi: 10.1016/j.eats.2022.03.024. 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. Franceschi et al. Inferior tendon graft to bone tunnel healing at the tibia compared to that at the femur after anterior cruciate ligament reconstruction. In cases like these your going to need to bill out "what you can" which in this case would be 20680. After 6 to 12weeks, failures tend to occur in mid-substance [11]. 1). 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. See our privacy policy. stream One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior. 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. doi: 10.2106/JBJS.ST.20.00055. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. It does not hit an edit, but be prepared for insurance to deny it. Thomas et al. - anteromedial portal technique: Systematic review. The https:// ensures that you are connecting to the 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. If this is your first visit, be sure to check out the. This site needs JavaScript to work properly. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. For a better experience, please enable JavaScript in your browser before proceeding. 2020;48(3):767-777. The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. - ref: Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. 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. To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. 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. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . $.' Telephone: 410.494.4994, Morphology of the Femoral Intercondylar Notch, The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction. a meta-analysis of 32 studies. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. Hi you mentioned this was a staged procedure - any chance you can post the entire operative report without patient info? This case required a two-stage approach: Stage 1 consisted of bone grafting, followed by second-stage repeat revision ACL reconstruction with patellar tendon autograft, lateral meniscal root repair and iliotibial band tenodesis. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. - lateral tunnel placement: - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. For a better experience, please enable JavaScript in your browser before proceeding. 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. A single copy of these materials may be reprinted for noncommercial personal use only. - 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; (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. When measuring with CT, the axial-plane image is considered incorrect because the plane of cuts is inconsistent. Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Preoperative planning for revision ACL surgery is essential for a successful outcome. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. A tamp is used to further compress the graft. official website and that any information you provide is encrypted (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. 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]. Learn how to get the most out of your subscription. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; To read the full article, sign in and subscribe to the AHA Coding Clinic for HCPCS. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. 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. - references: These lesions are often difficult to see on MRI. % We routinely obtain hip-to-ankle AP X-rays to assess for any coronal plane malalignment. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. <> Wheeless' Textbook of Orthopaedics. Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. 2022 Jun 21;11(7):e1367-e1372. Federal government websites often end in .gov or .mil. Kim, DH., Bae, KC., Kim, DW. Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Bone Joint J. 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. 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. We thank Eun-Ji Jeon and Min-Ji Kim for their support. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. 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. 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? J Bone Joint Surg Br 89:10511054, Article 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]. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. In the immediate postoperative period, the weakest part of any ACLR is the fixation. Am J Sports Med 40:800807, Article By using this website, you agree to our Thomas et al. 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]. Please enable it to take advantage of the complete set of features! - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. 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]. Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. 8600 Rockville Pike Enjoy a guided tour of FindACode's many features and tools. We NEVER sell or give your information to anyone. 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]. MeSH Only 44 patients underwent a staged revision ACLR after bone grafting and 10 patients refused to undergo a revision ACLR. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. 2 0 obj Her alignment, tibial slope and cartilage were all normal. eCollection 2020 Dec. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. Meniscal tears are another contributing cause. Biomaterials 27:50145026, Hing KA, Wilson LF, Buckland T (2007) Comparative performance of three ceramic bone graft substitutes. [38] have reported the outcomes of revision ACLR with and without lateral extra-articular tenodesis. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; Root tears also put tremendous forces on the ACL graft and can lead to rotational instability and graft failure. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. 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.
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