8600 Rockville Pike 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. Unable to load your collection due to an error, Unable to load your delegates due to an error. Orthopaedic Specialists of North Carolina. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? 2023 BioMed Central Ltd unless otherwise stated. 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. 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]. What other specialized procedures might be performed in conjunction with ACL revision surgery? At Mayo Clinic, we also are evaluating surgical techniques for ACL reconstruction, as well as optimal approaches to multiligament knee reconstruction. 3 0 obj doi: 10.1016/j.arthro.2006.07.054. National Library of Medicine 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. endobj Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. - resulting anterior-posterior cruciate ligament impingement near extension caused a persistentfunctional extension deficit of 20; The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); - Editorial: The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction Epub 2007 Jan 5. If this is your first visit, be sure to check out the. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. BMC Musculoskelet Disord 19:246. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. The appropriately sized OATS harvester is chosen 1 mm larger than the tunnel size and is used to harvest bone graft from the iliac crest through a percutaneous approach. - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. The site is secure. A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Remaining soft tissue was debrided along tibia. Meniscal tears are another contributing cause. If this is your first visit, be sure to check out the. Abstract The . The inside punch of the harvester is tapped and this allows delivery of the graft in a controlled manner and its impaction into the tunnel. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. - historic techniques: endobj Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. 29866 is for autografts (from the patient). Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? A single copy of these materials may be reprinted for noncommercial personal use only. Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-tendon-bone (BTB) autograft is associated with increased postoperative anterior knee pain and pain with kneeling and has the risk of intra- and postoperative patellar fracture. registered for member area and forum access. 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]. - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a - 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; Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . Make a donation. 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). doi: 10.1016/j.eats.2020.08.024. endobj performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. 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. They observed that an average Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. 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. The .gov means its official. Currently, the gold standard for measuring tunnel size is the computed tomography (CT) method. Tibial tunnel was found to be anterior, perhaps more inferior than would be in an anatomic ACL insertion. - this technique allows for a more anatomic and precise placement of the femoral tunnel (more reliable posterior placement); doi: 10.2106/JBJS.ST.20.00055. 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. No charge. 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. Journal of Orthopaedic Research. Her alignment, tibial slope and cartilage were all normal. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. Cancel anytime. In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). 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. With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. - one incision transtibialtechnique Conclusions. National Library of Medicine This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. Disclaimer. The results from this group were compared to the results of a matched group of patients with primary ACLR. - Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position . This adds a fair amount of complexity to the procedure. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; Sci Rep (2016) 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. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. For a better experience, please enable JavaScript in your browser before proceeding. Mayo Clinic has substantial experience with all of these procedures. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. Unauthorized use of these marks is strictly prohibited. MeSH - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. 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. Outcomes of repeat revision anterior cruciate ligament reconstruction. 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. The new ligament was fixed to the tibia by a metallic screw and to the femur by a bioabsorbable screw. 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]. The analysis included 7 studies with a total of 234 patients. The tibial tunnel looked to be in a good position. 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]. My surgeon disagrees with me and is firm that the harvest of the bone graft is not separately reportable. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. endobj 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. You are using an out of date browser. The AHA Coding Clinic for HCPCS includes: Thank you for choosing Find-A-Code, please Sign In to remove ads. Would you like email updates of new search results? advocate that the allograft should not be considered as the first choice of graft for revision surgery [36]. endobj 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. statement and 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. A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction. - Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? HHS Vulnerability Disclosure, Help 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. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. Careers. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. Federal government websites often end in .gov or .mil. J Bone Joint Surg Br 89:10511054, Article Would you like email updates of new search results? 2 0 obj - surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. No restrictions are placed on their range of motion and patients were allowed to weightbear on the affected leg using crutches [17]. The .gov means its official. An average Lysholm score at 2 years post operation was 96.6 points 2.1 (91100 points). The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. ACL reconstruction is surgery to replace a torn anterior cruciate (KROO-she-ate) ligament (ACL) a major ligament in your knee. 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). The bone grafting is an opportune time to do an osteotomy to correct the malalignment. At a mean period of 33.9months, there was an improvement in the Lysholm score (77.215.5 vs 72.918.7), IKDC score (69.013.4 vs 69.313.4) and Tegner activity score (4.11.5 vs 4.61.2) for both groups. a meta-analysis of 32 studies. 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. Thomas et al. Purpose: The use of allograft material negates the issue of donor-site morbidity but carries the potential risk of disease or infection transmission [23, 24]. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. The indication for bone grafting and between-stage protocol varied among studies. Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. The mean time between the two stages was 8.8months and in the second stage, bone-biopsy specimens were taken from the tibia. 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]. Franceschi et al. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Failed ACL with Tunnel Enlargement: How I Bone Graft & Stage It Charles H. Brown Jr.,MD Director Abu Dhabi, United Arab Emirates . 2007 May;23(5):558.e1-4. - Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation Privacy 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. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. Tibial tunnel cysts, including pretibial cysts , are occasional complications of autologous or synthetic anterior cruciate ligament (ACL) reconstruction surgeries. volume31, Articlenumber:10 (2019) Bethesda, MD 20894, Web Policies 8 Therefore, one should avoid angles <40 to 45 . Stage I femoral and tibial bone grafting. - tunnel positioning: Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. After 6 to 12weeks, failures tend to occur in mid-substance [11]. ACL graft can replicate the normal ligament's tension curve. 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]. You are using an out of date browser. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. - 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; Louis et al. - two incision technique (outside in) Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. Am J Sports Med 40:800807, Article 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. Accessibility 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. CAS All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. Mayo Clinic has vast experience treating posterior cruciate ligament, lateral collateral ligament, posterolateral and posteromedial corner injuries, as well as medial collateral ligament injuries. [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. 1998-2023 Mayo Foundation for Medical Education and Research. Part of 3. Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. 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. J Orthop Sci (2010) . 2002 Richard O'Connor Award paper. - references: Van de pol et al. #1. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. - consider whether there is an interplay between posterior graft placement and appropriate graft tension; Arch Orthop Trauma Surg. Arthrosc Tech. Two-stage revision ACLR should be considered in cases of tunnel lysis, infection, malalignment, meniscal deficiency, or chondral lesions. Cite this article. CT examinations were performed at 3, 12, and 24weeks after bone grafting. A decision that will often depend on the graft used during the primary ACLR. This site needs JavaScript to work properly. Then in that case, yes, I would code this as 29888-52. [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. 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 . We NEVER sell or give your information to anyone. A clinical, prospective, randomized, double-blind study, Femoral Shaft Frx: Leg Lengths / Nail Lengths, Orthopaedic Specialists of North Carolina. Uchida et al. Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. 4 0 obj Measurements are made perpendicular to the axial plane of the tunnel at the widest point. Epub 2020 Apr 1. 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. ]+yC`6Hd Ql]M 3w7ah;HNdyS*7x-zq^/4%^6eA$m@(,ly}U[N9E(/=iHCL")d6yx]K7!84,q!r~#6mE8dIS69eYn - references: -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Epub 2016 Dec 30. 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]. The authors declare that they have no competing interests. There are several techniques for bone grafting tunnels in one- or two-staged ACL revision procedures with either autograft or allograft. 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. 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). Similarly, root tears of the lateral meniscus are often missed as well. For a better experience, please enable JavaScript in your browser before proceeding. To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. - ref: Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. That would help me to provide some better guidance. Thomas et al. 6 0 obj They found that a sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution. Optimal outcomes require a precise picture of how the ACL reconstruction failed. We describe a new technique for femoral and tibial tunnel impaction grafting in 2-stage ACL revisions, using the OATS grafting instruments (Osteochondral Autologous Transfer System; Arthrex, Naples, FL). 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 . 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. 7 0 obj They observed that an average of 5.8months was needed for healing of the autograft dowel to become visible on CT scans [11]. FOIA 2020 Dec 21;9(12):e1917-e1925. -notchplasty Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Approximately 200,000 anterior cruciate ligament (ACL) ruptures occur in the United States annually. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? stream - Discussion: Unable to load your collection due to an error, Unable to load your delegates due to an error. Thomas et al. This site needs JavaScript to work properly. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. [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. 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. Two-stage revision anterior cruciate ligament reconstruction. - lateral 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. In addition, patients who receive revision ACL surgery might have other damaged ligaments.

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