Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. Keep your critical coding and billing tools with you no matter where you work. Arthrosc Tech. Only 44 patients underwent a staged revision ACLR after bone grafting and 10 patients refused to undergo a revision ACLR. An official website of the United States government. 4. MARS Group. MeSH 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). A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. American Journal of Sports Medicine. 2020;48(3):767-777. Physical therapy with muscle-strengthening and proprioceptive training can be performed. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. 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. 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. 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. 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. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Tibial tunnel cyst | Radiology Reference Article | Radiopaedia.org Knee Surg & Relat Res 31, 10 (2019). In active young patients, failed primary ACLR may require a revision ACLR. 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]. eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. 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. Arthrosc Tech. PDF Acl Reconstruction With Allograft Cpt Code - annualreport.psg.fr Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. For assessment of bone-graft incorporation, radiographs are routinely used. 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. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. Epub 2007 Jan 5. I would look at billing 29877 for the debridement of the soft tissue. Then in that case, yes, I would code this as 29888-52. 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. 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. Christensen JJ, et al. 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. Griffith TB, et al. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. The anterior cruciate ligament (ACL) is a ligament that provides stability to the knee joint. 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). In addition, patients who receive revision ACL surgery might have other damaged ligaments. 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. An official website of the United States government. Tunnel orientation and size are the most important causes related to the two-stage procedure, as these enlarged tunnels may complicate graft placement and fixation [11, 12]. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. HHS Vulnerability Disclosure, Help There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. Sci Rep (2016) 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]. - 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. The https:// ensures that you are connecting to the 2002 Richard O'Connor Award paper. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. <> stream 2002 Richard O'Connor Award paper. in 30 deg flexion at the time of final fixation may result inexcessive graft tension when the knee is position in full extension; CT scans to confirm healing at 3-5months after bone grafting [4, 12, 33, 34]. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. It may not display this or other websites correctly. 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. BMC Musculoskelet Disord 19:246. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; 1 0 obj 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. In the immediate postoperative period, the weakest part of any ACLR is the fixation. If no autograft is available for revision surgery, they advise augmentation of the allograft with the lateral extra-articular iliotibial band procedure to reduce the high failure rate associated with the use of the allograft. Epub 2016 Dec 30. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). 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. Philippe C, Marot V, Courtot L, Mesnier T, Reina N, Cavaignac E. Arthrosc Tech. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. 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. PMC Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. 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]. Orthop Traumatol Surg Res 103:S223S2S9, Lee DW, Kim JG, Cho SI, Kim DH (2019) Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. -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.. Careers. Spine J 7:475490, Jenis LG, Banco RJ (2010) Efficacy of silicate-substituted calcium phosphate ceramic in posterolateral instrumented lumbar fusion. We NEVER sell or give your information to anyone. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. 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. - Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? -main criticism is that in some cases a transtibial tunnel will not allow for the exact desiredtunnel placement (you get what you get) 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. registered for member area and forum access. statement and In 4 studies, the authors reported the time interval between first and second surgeries, with an average of 6.1 months for ICBG compared with 8.7 months for allogenic and synthetic grafts. Thomas et al. doi: 10.2106/JBJS.ST.20.00055. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. I forgot to mention he did an allograft bone graft. 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. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. anterior cruciate ligament; bone graft; knee; revision. 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. You are using an out of date browser. Primary ACL reconstruction is recognized as a successful procedure, but failure has been shown to occur in approximately 10% of patients. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. If this is your first visit, be sure to check out the. They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. 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. Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? Abstract The . Reports suggest that a two-stage procedure is performed in only 8 to 9% of revision ACLRs [6]. endobj 7 0 obj 2020 Dec 21;9(12):e1917-e1925. xMO@; aK]XDZ)r(-w(;.B ~8MG{ Epub 2018 Dec 17. TECHNIQUE STEPS. Comparison of Femoral Tunnel Position and Clinical Results. Bone tunnel-related issues are frequently encountered during revision anterior cruciate ligament reconstruction. Bone and Joint Clinic. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Unauthorized use of these marks is strictly prohibited. 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 removed from the knee before the graft is inserted through a hole created by a single hole punch. - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Knee Surgery & Related Research Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. 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. 2022 Jun 21;11(7):e1367-e1372. The optimal and earliest possible timing of the two-stage procedure is still not clear. Background: Ligament reconstruction is a common procedure in orthopedic surgery. 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. 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. The new ligament was fixed to the tibia by a metallic screw and to the femur by a bioabsorbable screw. Tunnel malposition, widening, and interference pose unique challenges that may complicate surgery and compromise outcomes. registered for member area and forum access. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). Correspondence to Neil Duplantier MD. Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. 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]. However, remarkable advances in knowledge of this process have been made based primarly on animal models. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? doi: 10.1016/j.eats.2022.03.024. Am J Sports Med 32:543549, Groves C, Chandramohan M, Chew C, Subedi N (2013) Use of CT in the management of anterior cruciate ligament revision surgery. - one incision transtibialtechnique 2007 May;23(5):558.e1-4. 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 . Two-stage revision ACLR should be considered in cases of tunnel lysis, infection, malalignment, meniscal deficiency, or chondral lesions. Clifford R. Wheeless, III, M.D. 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]. One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior. PDF ACL reconstruction revision with staged bone grafting The site is secure. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. 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. Mayo Clinic has substantial experience with all of these procedures. Learn how to get the most out of your subscription. Get timely coding industry updates, webinar notices, product discounts and special offers. Keywords: - lateral tunnel placement: Currently, the gold standard for measuring tunnel size is the computed tomography (CT) method. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . 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. Tibial Tunnel Bone Allograft Cpt Code For The. Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Louis et al. 2005 Nov;33(11):1701-9. doi: 10.1177/0363546505276759. 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. Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. 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. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. Femoral press-fit fixation versus interference screw fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: 20-year follow-up. A single copy of these materials may be reprinted for noncommercial personal use only. They are benign ganglion cysts that develop in or around the osseous tibial tunnel made during ACL reconstruction using the transtibial technique 1-2. Epub 2005 Aug 10. Springer Nature. % endobj National Library of Medicine Uchida et al. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. Cite this article. . Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. Methods: Accessibility 2021 Nov 16;10(12):e2699-e2708. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. This site complies with the HONcode standard for trustworthy health information: verify here. Bone graft substitute for tunnel filling improved ACL - Healio The surgeon submitted CPT code 25431 alone. MeSH 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%). 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. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. 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 endobj Consistent Indications and Good Outcomes Despite High Variability in Conclusions. Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. - Editorial: The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. My surgeon disagrees with me and is firm that the harvest of the bone graft is not separately reportable. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Not applicable, this is a review article. Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding Unless you probe for a root tear during surgery, you may miss it. That would help me to provide some better guidance. - ACL graft should pull up intotibial tunnel by about 2mm with extension when fixed on femoral side; - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; Secure graft fixation is critical in ensuring a successful two-staged ACLR. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. endobj -increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. This process is repeated until there is full fill of femoral tunnel. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Graft healing in anterior cruciate ligament reconstruction