Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. CAS ACL Reconstruction - BTB Graft. 1998-2023 Mayo Foundation for Medical Education and Research. Arthrosc Tech. Conclusions. Unauthorized use of these marks is strictly prohibited. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study - makesure that interference screws are less than 25 mm in length; - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; Thomas et al. Morphological Changes in the Tibial Tunnel After ACL Reconstruction If this is your first visit, be sure to check out the. Aust N Z J Surg 69:517521, Eagan MJ, McAllister DR (2009) Biology of allograft incorporation. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. Anterior cruciate ligament reconstruction, Ohly NE, Murray IR, Keating JF (2007) Revision anterior cruciate ligament reconstruction: timing of surgery and the incidence of meniscal tears and degenerative change. 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. ACL reconstruction - Mayo Clinic - Mayo Clinic - Mayo Clinic This site needs JavaScript to work properly. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Preoperative planning is critical to identify and characterize bone tunnel pathology. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. - graft that tightens (pulls up into the tibial tunnel) with flexion will have a much higher likelyhood offailure and usually indicates a Christensen JJ, et al. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. If this is your first visit, be sure to check out the. Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. 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. 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. - tunnel positioning: <>
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. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? - Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling 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. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. 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). - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Femoral Tunnel for ACL Reconstruction - Wheeless' Textbook of Orthopaedics Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Bone Tunnel Management in Modern Revision Anterior Cruciate Ligament 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. 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). Uchida et al. Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding 2021 Nov 16;10(12):e2699-e2708. (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. Knee Surg & Relat Res 31, 10 (2019). The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. Franceschi et al. Only 44 patients underwent a staged revision ACLR after bone grafting and 10 patients refused to undergo a revision ACLR. You are using an out of date browser. Discover how to save hours each week. Outcomes of repeat revision anterior cruciate ligament reconstruction. We thank Eun-Ji Jeon and Min-Ji Kim for their support. 2021 Oct 12;11(4):e20.00055. 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? To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Correspondence to Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. 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. <>
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. I added CPT code 20902 after reviewing the operative note, because the surgeon obtained the bone graft from a distant site via a separate incision. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. A single copy of these materials may be reprinted for noncommercial personal use only. PDF ACL reconstruction revision with staged bone grafting J Bone Joint Surg Br 89:10511054, Article [38] have reported the outcomes of revision ACLR with and without lateral extra-articular tenodesis. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. Similarly, root tears of the lateral meniscus are often missed as well. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. However, many authors prefer using an autograft for revision ACLR when possible. The surgeon submitted CPT code 25431 alone. At Mayo Clinic, we also are evaluating surgical techniques for ACL reconstruction, as well as optimal approaches to multiligament knee reconstruction. PDF Acl Reconstruction With Allograft Cpt Code - annualreport.psg.fr I would look at billing 29877 for the debridement of the soft tissue. Mayo Clinic has substantial experience with all of these procedures. 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. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. Enjoy a guided tour of FindACode's many features and tools. MeSH Mayo Clinic is a not-for-profit organization. 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. 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. #1. A tamp is used to further compress the graft. The optimal and earliest possible timing of the two-stage procedure is still not clear. 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). eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. California Privacy Statement, (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). 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. eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. 2002 Richard O'Connor Award paper. 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. eCollection 2022 Jul. Bruce A. Tibial tunnel cyst | Radiology Reference Article | Radiopaedia.org Consistent Indications and Good Outcomes Despite High Variability in 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. An official website of the United States government. - Discussion: One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. 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. Arthrosc Tech. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. You must log in or register to reply here. -increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. Ki-Cheor Bae. 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]. Measurements are made perpendicular to the axial plane of the tunnel at the widest point. . Accessibility Epub 2018 Feb 23. JavaScript is disabled. Femoral press-fit fixation versus interference screw fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: 20-year follow-up. JavaScript is disabled. Unable to load your collection due to an error, Unable to load your delegates due to an error. A new technique for femoral and tibial tunnel bone grafting using the [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. HHS Vulnerability Disclosure, Help 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. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. endobj
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]. Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. doi: 10.1016/j.eats.2022.01.004. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Yoon et al. 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. It does not hit an edit, but be prepared for insurance to deny it. For an allograft, a single bone dowel approximately 1mm larger than the diameter of the tunnel is used and placed using a bone tamp for a press-fit technique, ensuring that the entire tunnel is filled [4]. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. 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]. doi: 10.1016/j.eats.2022.03.024. - open technique(which might be required with arthroscopy malfunction). 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]. For assessment of bone-graft incorporation, radiographs are routinely used. <>
- references: 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. Journal of Orthopaedic Research. 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. 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]. A patient with a left knee anterior cruciate ligament tear, torn lateral meniscus and retained hardware from a previous anterior cruciate ligament reconstruction presented for a left knee arthroscopic anterior cruciate ligament repair, open removal of retained hardware and bone grafting of the distal femur and tibial tunnels.Following the arthroscopic anterior cruciate ligament repair, a tibial incision was made through subcutaneous tissue to access the tibial tunnel in order to remove the deep hardware. You must log in or register to reply here. Two-stage revision anterior cruciate ligament reconstruction. Make a donation. 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. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. 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. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. However, Thomas et al. Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. These lesions are often difficult to see on MRI. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. A new harvest site for bone graft in anterior cruciate ligament revision surgery. This process is repeated until there is full fill of femoral tunnel. Comparison of Femoral Tunnel Position and Clinical Results. The .gov means its official. xMO@; aK]XDZ)r(-w(;.B ~8MG{ Article | Outpatient Surgery Magazine - Association of periOperative Telephone: 410.494.4994, Morphology of the Femoral Intercondylar Notch, The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction. Comparison of Femoral Tunnel Position and Clinical Results. 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%). When measuring with CT, the axial-plane image is considered incorrect because the plane of cuts is inconsistent. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? They observed that an average 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. When aperture fixation is not possible, familiarity with, and use of, all-inside tibial and femoral sockets with cortical suspensory fixation may be necessary [4]. 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 ]. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. [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. JCM | Free Full-Text | Femoral Tunnel Position Affects Postoperative 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]. The anterior cruciate ligament (ACL) is a ligament that provides stability to the knee joint. All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. Bethesda, MD 20894, Web Policies 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. 6 0 obj
You must log in or register to reply here. 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). A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. Cite this article. 8600 Rockville Pike Am J Sports Med 40:800807, Article The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. Epub 2005 Aug 10. - 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;