Epub 2018 Dec 17. 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]. 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. i came across this in cpt a revision acl reconstruction and i came anterior, price 8 900 cpt code 29888 anterior cruciate ligament reconstruction acl reconstruction is a surgical tissue graft replacement of the anterior cruciate ligament located in the knee to restore its function after anterior cruciate ligament injury the torn ligament is Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. Orthopaedic Specialists of North Carolina. 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? Bone Graft related CPT Codes. endobj Background: The optimal and earliest possible timing of the two-stage procedure is still not clear. 4. reported that the laxity measurements achieved with a two-stage revision ACLR using autograft iliac bone could be similar to those achieved after primary ACLR and clinical improvement [11]. Arthrosc Tech 5:e189e195, Hofbauer M, Muller B, Murawski CD, Baraga M, van Eck CF, Fu FH (2013) Strategies for revision surgery after primary double-bundle anterior cruciate ligament (ACL) reconstruction. - Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. 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. Clifford R. Wheeless, III, M.D. - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); Discover how to save hours each week. [21] evaluated 88 patients who underwent one-stage revision ACLR. Revision ACL surgery: A comprehensive approach - Mayo Clinic 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). Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Results: However, Thomas et al. PubMedGoogle Scholar. Then in that case, yes, I would code this as 29888-52. -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.. The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. registered for member area and forum access. Arthrosc Tech. 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. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. However, methods used to sterilize allograft material (e.g., gamma irradiation and autoclaving), are known to adversely affect the structural and other properties of the graft material [25]. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. BMC Musculoskelet Disord 19:246. In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). In addition, patients who receive revision ACL surgery might have other damaged ligaments. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer [11] noted that this suggestion is unnecessary, as using a two-stage technique ensures that there is good-quality bone around the tunnels, and the initial graft fixation is as secure as in the primary reconstruction. Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Anterior cruciate ligament (ACL) reconstruction rates have increased over the past 20years to roughly 200,000 per year [1]. Manage cookies/Do not sell my data we use in the preference centre. 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. Trojani et al. - historic techniques: 2020 Dec 21;9(12):e1917-e1925. 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. - references: government site. Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. 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. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. 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). J Bone Joint Surg Am 100:9931000, Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. Morphological Changes in the Tibial Tunnel After ACL Reconstruction At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Bone graft substitute for tunnel filling improved ACL reconstruction Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. endobj Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. - tunnel positioning: 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. The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. Similarly, root tears of the lateral meniscus are often missed as well. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). Jul 22, 2009. eCollection 2021 Oct-Dec. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues. Knee Surg Sports Traumatol Arthrosc 18:10591064, Bhatia S, Korth K, Van Thiel GS, Frank RM, Gupta D, Cole BJ et al (2016) Effect of tibial tunnel diameter on femoral tunnel placement in transtibial single bundle ACL reconstruction. 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]. Two-stage revision anterior cruciate ligament reconstruction Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . 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/. Terms and Conditions, performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. stream Punch-biopsy specimens of the augmented tunnels were taken at the two-stage procedure, and histologic examination included quantitative analysis of the area of immature bone formation, lamellar bone, and bone marrow. Thomas et al. The indication for bone grafting and between-stage protocol varied among studies. An official website of the United States government. Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. He did other procedures, but I have the codes for them. 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? Reports suggest that a two-stage procedure is performed in only 8 to 9% of revision ACLRs [6]. To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. <> 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Title: Slide 1 Author: Charles H Brown Created Date: 12/3/2018 11:52:05 AM . Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Bone Marrow Aspirate Concentrate With Two-Staged-Revision ACL Bethesda, MD 20894, Web Policies eCollection 2022 Jul. eCollection 2022 Mar. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. For a better experience, please enable JavaScript in your browser before proceeding. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. 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]. 1). Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. A clinical, prospective, randomized, double-blind study. 110 West Rd., Suite 227 A decision that will often depend on the graft used during the primary ACLR. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. Secure graft fixation is critical in ensuring a successful two-staged ACLR. Disclaimer. 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 . doi: 10.1016/j.eats.2020.08.024. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. [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. 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. ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft Spine (Phila Pa 1976) 35:E1058E1063, Lerner T, Liljenqvist U (2013) Silicate-substituted calcium phosphate as a bone graft substitute in surgery for adolescent idiopathic scoliosis. endstream The results from this group were compared to the results of a matched group of patients with primary ACLR. Bethesda, MD 20894, Web Policies 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 ]. 2002 Richard O'Connor Award paper. Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. Would this qualify for CPT 29888 with a 52 mod? Conclusions. A relatively small but challenging subset of patients requires two-stage revision ACLR. Sci Rep (2016) Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. 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. 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. CAS The bone grafting is an opportune time to do an osteotomy to correct the malalignment. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint PMC 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]. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). Please enable it to take advantage of the complete set of features! Autologous Dedifferentiated Osteogenic Bone Marrow Mesenchymal Stem Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. National Library of Medicine 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). Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. A tamp is used to further compress the graft. The femoral tunnel was a little high. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. 2020;38:1191. Federal government websites often end in .gov or .mil. et al. 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. doi: 10.1016/j.eats.2020.08.024. Recently, we recognized that patients needing ACL reconstruction who also have significant rotatory instability of the knee may have injuries in the anterolateral complex. 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. 2020;48(3):767-777. A new technique for femoral and tibial tunnel bone grafting using the This video may be inappropriate for some users. Consistent Indications and Good Outcomes Despite High Variability in 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. Unfortunately, both previous reconstructions were performed with allograft (cadaver) tissue, which has been shown to have significantly higher failure rates in young patients compared with autograft (the patient's own tissue). 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 . Achieving the correct position can be tricky. JCM | Free Full-Text | Femoral Tunnel Position Affects Postoperative It is commonly injured during high-intensity sports. Clipboard, Search History, and several other advanced features are temporarily unavailable. National Library of Medicine -increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used Revision ACL surgery: A comprehensive approach. Kim, DH., Bae, KC., Kim, DW. Example: 29888 - ACL Repair G0289 - Arthroscopy, knee, surgical, for removal of loose body, Harvesting and inserting the graft is included in code . Physical therapy with muscle-strengthening and proprioceptive training can be performed. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. - two incision technique (outside in) 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]. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). Patient age and activity level are also important factors when deciding on graft choice for revision procedures. 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. $.' View all the articles associated with any code, right from the code page. Patrick C. McCulloch MD. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. - over the top position: Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Journal of Orthopaedic Research. 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. Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. 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]. 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 . . Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. Graft healing in anterior cruciate ligament reconstruction We thank Eun-Ji Jeon and Min-Ji Kim for their support. An average Lysholm score at 2 years post operation was 96.6 points 2.1 (91100 points). 8600 Rockville Pike Abstract The . JavaScript is disabled. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. 4 0 obj 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. 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. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. [34] evaluated 10 consecutive patients who underwent staged revision ACLR using autogenous bone grafting and reported that all patients had a full range of motion of the knees, a negative Lachmann sign and negative pivot-shift test . Accessibility 2015;43:2510. Purpose: Bone Tunnel Management in Modern Revision Anterior Cruciate Ligament But an iliac-crest autograft is comparatively invasive with relatively high donor-site morbidity and the potential for insufficient yield quantities [11, 22]. ACL reconstruction is surgery to replace a torn anterior cruciate (KROO-she-ate) ligament (ACL) a major ligament in your knee. Conclusion: In the immediate postoperative period, the weakest part of any ACLR is the fixation. No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. The AHA Coding Clinic for HCPCS includes: Thank you for choosing Find-A-Code, please Sign In to remove ads. - 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; bone graft acl tunnel cpt - juliocarmona.com Hi you mentioned this was a staged procedure - any chance you can post the entire operative report without patient info? Bone Graft - KarenZupko&Associates, Inc. TJ!!X`Sz9Q*BeV={=F ' 0y^*2| '! Bone graft substitute for tunnel filling improved ACL - Healio - references: stream - this technique allows for a more anatomic and precise placement of the femoral tunnel (more reliable posterior placement); What other specialized procedures might be performed in conjunction with ACL revision surgery? official website and that any information you provide is encrypted PDF ACL reconstruction revision with staged bone grafting The analysis included 7 studies with a total of 234 patients. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision 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. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; 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. Arthrosc Tech. Part of A clinical, prospective, randomized, double-blind study, Femoral Shaft Frx: Leg Lengths / Nail Lengths, Orthopaedic Specialists of North Carolina. Google Scholar, Group M, Ding DY, Zhang AL, Allen CR, Anderson AF, Cooper DE et al (2017) Subsequent surgery after revision anterior cruciate ligament reconstruction: rates and risk factors from a multicenter cohort. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. a statistical evaluation. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. doi: 10.1016/j.eats.2022.01.004. Study design: Systematic review. #1. TECHNIQUE VIDEO. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning Two-stage revision anterior cruciate ligament reconstruction. Accessibility 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]. 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.
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