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. doi: 10.1016/j.eats.2022.03.024. No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. Uchida et al. 1 0 obj [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. However, Thomas et al. The indication for bone grafting and between-stage protocol varied among studies. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. Achieving the correct position can be tricky. Uchida et al. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. Department of Orthopaedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, 1035 Dalgubul-ro, Dalseo-gu, Daegu, 42601, South Korea, Du-Han Kim,Ki-Cheor Bae,Dong-Wan Kim&Byung-Chan Choi, You can also search for this author in - makesure that interference screws are less than 25 mm in length; American Journal of Sports Medicine. - 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. 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. Bone Graft related CPT Codes. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. He did other procedures, but I have the codes for them. For example, patients may require bone grafting of prior graft tunnels, and then have the ACL revision in a second stage. 8600 Rockville Pike With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. - resulting anterior-posterior cruciate ligament impingement near extension caused a persistentfunctional extension deficit of 20; 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]. 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]. This site needs JavaScript to work properly. Franceschi et al. A new harvest site for bone graft in anterior cruciate ligament revision surgery. Tibial tunnel cysts, including pretibial cysts , are occasional complications of autologous or synthetic anterior cruciate ligament (ACL) reconstruction surgeries. $.' When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. 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]. 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. The authors declare that they have no competing interests. 6 0 obj Jul 22, 2009. If any of those ligaments were missed in the initial knee surgery, they can be treated in the revision setting. Preoperative Patient Care. and transmitted securely. 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 . https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. Levy, M.D., an orthopedic surgeon specializing in sports medicine at Mayo Clinic in Rochester, Minnesota, discusses Mayo's approach to revision ACL surgery. JavaScript is disabled. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Researchers randomly assigned 40 patients undergoing two-stage revision ACL reconstruction to receive either autologous iliac crest cancellous bone graft for tunnel grafting (control group; n=20) or silicate-substituted calcium phosphate in the form of sculptable microgranules (Actifuse MIS System, Baxter) as a bone graft substitute . - historic techniques: No charge. 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. Orthop Clin North Am. Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. Federal government websites often end in .gov or .mil. 8600 Rockville Pike Arch Orthop Trauma Surg. 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, Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF (2017) Outcomes after 1-stage versus 2-stage revision anterior cruciate ligament reconstruction. 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]. - references: Biazzo A, Manzotti A, Motavalli K, Confalonieri N. J Clin Orthop Trauma. - anteromedial portal technique: Inferior tendon graft to bone tunnel healing at the tibia compared to that at the femur after anterior cruciate ligament reconstruction. FOIA 4 0 obj Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study Is it appropriate to assign codes for both the arthroscopic and open portions of the procedure? This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. The .gov means its official. Preoperative planning for revision ACL surgery is essential for a successful outcome. 2022 Jun 21;11(7):e1367-e1372. Biomaterials 27:50145026, Hing KA, Wilson LF, Buckland T (2007) Comparative performance of three ceramic bone graft substitutes. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). 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. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning endstream Conclusions. American Journal of Sports Medicine. Comparison of Femoral Tunnel Position and Clinical Results. National Library of Medicine 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. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). 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]. JavaScript is disabled. 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. Your going to need to get very familiar with 2017 CMS NCCI Surgical Policy Manual. A single copy of these materials may be reprinted for noncommercial personal use only. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . It may not display this or other websites correctly. - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. 2007 May;23(5):558.e1-4. -allows the femoral attachment point to overlap the anterolateral and posteromedial bundles insertion site Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Neil Duplantier MD. J Orthop Sci (2010) . Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? Mayo Clinic has vast experience treating posterior cruciate ligament, lateral collateral ligament, posterolateral and posteromedial corner injuries, as well as medial collateral ligament injuries. This adds a fair amount of complexity to the procedure. Spine J 7:475490, Jenis LG, Banco RJ (2010) Efficacy of silicate-substituted calcium phosphate ceramic in posterolateral instrumented lumbar fusion. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. 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. Tibial Tunnel Bone Allograft Cpt Code For The. volume31, Articlenumber:10 (2019) Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. Title: Slide 1 Author: Charles H Brown Created Date: 12/3/2018 11:52:05 AM . Manage cookies/Do not sell my data we use in the preference centre. 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]. 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). -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. A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction. 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. TECHNIQUE VIDEO. 2020 Dec 21;9(12):e1917-e1925. Lateral tibial posterior slope is increased in patients with early graft failure after 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. MeSH eCollection 2022 Jul. 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. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. - one incision transtibialtechnique - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 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. CPT codes are grouped into 6 sections: 1. Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. The https:// ensures that you are connecting to the - Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation doi: 10.2106/JBJS.ST.20.00055. The tibial tunnel looked to be in a good position. Wheeless' Textbook of Orthopaedics. The https:// ensures that you are connecting to the 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 ]. Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. This content does not have an English version. 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 Mayo Clinic sports medicine surgeons routinely perform revision surgery for patients who have undergone one or more ACL reconstructions elsewhere, and have published extensively on this topic. Sci Rep (2016) - open technique(which might be required with arthroscopy malfunction). Data Trace Publishing Company Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. To read the full article, sign in and subscribe to the AHA Coding Clinic for HCPCS. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. There was also a significant improvement in the Lysholm score when comparing preoperative and postoperative values. (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. They observed that an average Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. Diermeier et al. Sorry. [38] have reported the outcomes of revision ACLR with and without lateral extra-articular tenodesis. Yoon et al. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. J Bone Joint Surg Br 89:10511054, Article Typically, a staged procedure requires an average delay of 4 to 6months to allow for the bone defect to heal [11, 18], likely subjecting patients to a prolonged period of knee instability and thus adding to the risk of meniscal injury, additional deterioration of muscle strength, and osteochondrosis [32]. He is only grafting the bone. Journal of Orthopaedic Research. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. - Surgical Technique: endobj A relatively small but challenging subset of patients requires two-stage revision ACLR. 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. - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. 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. Purpose: Reports suggest that a two-stage procedure is performed in only 8 to 9% of revision ACLRs [6]. 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. 2015;43:2510. 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]. It may not display this or other websites correctly. Am J Sports Med 45:20682076, Erickson BJ, Cvetanovich G, Waliullah K, Khair M, Smith P, Bach B Jr et al (2016) Two-stage revision anterior cruciate ligament reconstruction. 2020;48(3):767-777. 4. Background: Ligament reconstruction is a common procedure in orthopedic surgery. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. Example: 29888 - ACL Repair G0289 - Arthroscopy, knee, surgical, for removal of loose body, Harvesting and inserting the graft is included in code . Comparison of Femoral Tunnel Position and Clinical Results. However, the small number of included patients, especially in the group of patients without revision ACLR, is limited. Disclaimer. statement and Provided by the Springer Nature SharedIt content-sharing initiative. They found that a sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution. Springer Nature. By using this website, you agree to our 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). There is no code for bone grafting. Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. - Discussion: Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. femoral tunnel too far anterior in the notch; Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. Salem HS, Axibal DP, Wolcott ML, et al. 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? Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. ACL graft can replicate the normal ligament's tension curve. MARS Group. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues. [40] reported the results of 87 patients who underwent revision ACLR with a follow-up of more than 3 years. Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. %PDF-1.5 Federal government websites often end in .gov or .mil. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? - Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Epub 2005 Aug 10. 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. 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. doi: 10.1016/j.eats.2020.08.024. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. He did other procedures, but I have the codes for them. 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. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. 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. Thomas et al. The optimal and earliest possible timing of the two-stage procedure is still not clear.