% Mayo Clinic is a not-for-profit organization. 2005 Nov;33(11):1701-9. doi: 10.1177/0363546505276759. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. Spine (Phila Pa 1976) 20:10551060, Campbell DG, Li P (1999) Sterilization of HIV with irradiation: relevance to infected bone allografts. government site. 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. PubMedGoogle Scholar. JavaScript is disabled. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. A new harvest site for bone graft in anterior cruciate ligament revision surgery. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. Arthrosc Tech. Is it appropriate to assign codes for both the arthroscopic and open portions of the procedure? Hi you mentioned this was a staged procedure - any chance you can post the entire operative report without patient info? All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? 1). Bone Graft - KarenZupko&Associates, Inc. xMO@; aK]XDZ)r(-w(;.B ~8MG{ No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. 2013;41:1296. 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]. - 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; Inferior tendon graft to bone tunnel healing at the tibia compared to that at the femur after anterior cruciate ligament reconstruction. There are several techniques for bone grafting tunnels in one- or two-staged ACL revision procedures with either autograft or allograft. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. You are using an out of date browser. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. - tunnel positioning: - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); Preoperative Patient Care. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. Get timely coding industry updates, webinar notices, product discounts and special offers. Resurfacing technique consisting of transplantation of multiple osteochondral grafts to smooth the area. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. 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. Background: Ligament reconstruction is a common procedure in orthopedic surgery. To me it really is a separate issue especially since the debridement was performed first, not as a clean up after the hardware was removed. Clin Orthop Relat Res. An Observational Study Using Navigated Measurements. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . The analysis included 7 studies with a total of 234 patients. Unauthorized use of these marks is strictly prohibited. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Clin Sports Med 28:203214 vii, Islam A, Chapin K, Moore E, Ford J, Rimnac C, Akkus O (2016) Gamma radiation sterilization reduces the high-cycle fatigue life of allograft bone. Bruce A. Among these potential scenarios requiring a two-stage revision, tunnel-widening is the most common cause; the first stage involves graft removal, tunnel curettage, and bone grafting, followed by revision ACL reconstruction in the second stage. He did other procedures, but I have the codes for them. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint Learn how to get the most out of your subscription. Arch Orthop Trauma Surg 132:12991313, Thomas NP, Kankate R, Wandless F, Pandit H (2005) Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. et al. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. - figure four flexedpositionassist with providing the best femoral target; What Is the Minimum Length of An Anterior Cruciate Ligament Autograft Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). 1998-2023 Mayo Foundation for Medical Education and Research. 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). ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. Arthroscopic Bone Graft Technique for Two-Stage Revision Anterior Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. Clifford R. Wheeless, III, M.D. American Journal of Sports Medicine. sharing sensitive information, make sure youre on a federal a statistical evaluation. In cases like these your going to need to bill out "what you can" which in this case would be 20680. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. 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. doi: 10.1016/j.arthro.2006.07.054. 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]. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. 6 0 obj 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. This adds a fair amount of complexity to the procedure. 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. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Stage I femoral and tibial bone grafting. doi: 10.1016/j.eats.2020.08.024. JFIF C ACL Reconstruction - BTB Graft - Knee & Sports - Orthobullets 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. 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. 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. 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. doi: 10.2106/JBJS.ST.20.00055. We thank Eun-Ji Jeon and Min-Ji Kim for their support. 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. Optimal outcomes require a precise picture of how the ACL reconstruction failed. 8 Therefore, one should avoid angles <40 to 45 . Comparison of Femoral Tunnel Position and Clinical Results. Overview. A decision that will often depend on the graft used during the primary ACLR. Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. Femoral Tunnel for ACL Reconstruction - Wheeless' Textbook of Orthopaedics Please enable it to take advantage of the complete set of features! Abstract The . You must log in or register to reply here. MeSH 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. Autologous Dedifferentiated Osteogenic Bone Marrow Mesenchymal Stem 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. 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]. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Some authors suggest that an accelerated rehabilitation program for revision ACLR is not appropriate because of weaker initial graft fixation [20]. Unless you probe for a root tear during surgery, you may miss it. Remaining soft tissue was debrided along tibia. Knee Surg & Relat Res 31, 10 (2019). Cookies policy. If this is your first visit, be sure to check out the. 2022 May 11;11(6):e971-e976. Systematic review. Journal of Orthopaedic Research. 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. Arch Orthop Trauma Surg. - references: The second stage of the revision ACLR was performed a minimum of 3 months later, after obtaining a CT demonstrating adequate filling of the tunnels using a hamstring autograft though a transtibial drilling technique. 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. Graft healing in anterior cruciate ligament reconstruction [11] reported the results of 49 consecutive two-stage revision ACLRs in which the tibial tunnel was grafted (the bone graft was taken from the ipsilateral iliac crest) during the first stage, followed by an ACLR using various grafts and fixation methods for the second stage. Root tears also put tremendous forces on the ACL graft and can lead to rotational instability and graft failure. Meniscal tears are another contributing cause. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. There are numerous challenges to revision ACL surgery with regard to graft selection, timing of surgery, and whether or not the surgery can be performed in a single operation or multiple-staged surgeries. Bone grafting of femur and tibial tunnels - AHA Coding Clinic for HCPCS sharing sensitive information, make sure youre on a federal [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. You must log in or register to reply here. 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. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. PDF ACL reconstruction revision with staged bone grafting Bone Graft related CPT Codes. Consistent Indications and Good Outcomes Despite High Variability in A relatively small but challenging subset of patients requires two-stage revision ACLR. PMC But no significant difference was observed between the two groups. American Journal of Sports Medicine. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. Her alignment, tibial slope and cartilage were all normal. 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 ]. Tibial tunnel cysts, including pretibial cysts , are occasional complications of autologous or synthetic anterior cruciate ligament (ACL) reconstruction surgeries. - Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. My surgeon disagrees with me and is firm that the harvest of the bone graft is not separately reportable. Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. -notchplasty ACL graft can replicate the normal ligament's tension curve. This study aims to identify potential factors for both femoral and tibial tunnel widening (TW) and to investigate the effect of TW on postoperative outcomes after anterior cruciate ligament (ACL) reconstruction with a tibialis anterior allograft. Epub 2020 Apr 1. NPI Look-Up Tool (National Provider Identifier), The official publication for Level I HCPCS (CPT-4 codes) for hospital providers, Also specific Level II HCPCS codes for hospitals, physicians and other health professionals, Fully searchable through Find-A-Code's Comprehensive Search, Codes mentioned in articles are linked to Code Information pages, Code Information page link back to related articles. Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding proprioceptive reflex leading to a functional extension loss while the patient is awake. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. 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. 4 0 obj See our privacy policy. An official website of the United States government. 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. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). endobj Anterior cruciate ligament (ACL) reconstruction rates have increased over the past 20years to roughly 200,000 per year [1]. California Privacy Statement, - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. 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. Revision ACL surgery: A comprehensive approach - Mayo Clinic Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. The AHA Coding Clinic for HCPCS includes: Thank you for choosing Find-A-Code, please Sign In to remove ads. The https:// ensures that you are connecting to the Then in that case, yes, I would code this as 29888-52. It may not display this or other websites correctly. One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior. and transmitted securely. - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Excessive tibial slope also puts patients at much higher risk of early ACL reconstruction failure. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction.
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