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. 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 . 2022 Feb 28;11(3):e463-e469. The analysis included 7 studies with a total of 234 patients. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. Thomas et al. endobj
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. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. CT analysis also included the determination of the filling rates of the tunnels. Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. It is commonly injured during high-intensity sports. TECHNIQUE STEPS. Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. The AHA Coding Clinic for HCPCS includes: Thank you for choosing Find-A-Code, please Sign In to remove ads. HHS Vulnerability Disclosure, Help All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. 2005 Nov;33(11):1701-9. doi: 10.1177/0363546505276759. J Bone Joint Surg Br 89:10511054, Article Salem HS, Axibal DP, Wolcott ML, et al. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Levy, M.D., an orthopedic surgeon specializing in sports medicine at Mayo Clinic in Rochester, Minnesota, discusses Mayo's approach to revision ACL surgery. advocate that the allograft should not be considered as the first choice of graft for revision surgery [36]. PDF Two-stage revision anterior cruciate ligament reconstruction The optimal and earliest possible timing of the two-stage procedure is still not clear. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. 2013;41:1296. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. 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. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. <>
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]. 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. California Privacy Statement, ACL Reconstruction - BTB Graft - Knee & Sports - Orthobullets Enjoy a guided tour of FindACode's many features and tools. 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. ACL reconstruction - Mayo Clinic - Mayo Clinic - Mayo Clinic If this is your first visit, be sure to check out the. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. In addition, patients who receive revision ACL surgery might have other damaged ligaments. PDF Acl Reconstruction With Allograft Cpt Code - annualreport.psg.fr 7 0 obj
However, Thomas et al. Tibial Tunnel Bone Allograft Cpt Code For The. Bone Tunnel Management in Modern Revision Anterior Cruciate Ligament Similarly, a patient with a loss of more than 5 of extension or 20 of flexion of knee motion should be considered for lysis of adhesions and manipulation under anesthesia followed by rehabilitation [4, 10]. 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. Revision ACL surgery: A comprehensive approach - Mayo Clinic 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. This adds a fair amount of complexity to the procedure. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. - Discussion: Trojani et al. You must log in or register to reply here. A 17-year-old female came to see us after two failed ACL surgeries. 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. [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. 29866 is for autografts (from the patient). To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. Before Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. endobj
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? In the immediate postoperative period, the weakest part of any ACLR is the fixation. Consistent Indications and Good Outcomes Despite High Variability in - historic techniques: I just want to get the basic idea so I can advise him since he keeps a copy of his billing. endobj
Arthrosc Tech. The insertion of an interference screw not only compresses the graft in the tunnel but also leads to an enlargement of the bone tunnel itself [13]. 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. 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]. TECHNIQUE STEPS. The .gov means its official. doi: 10.2106/JBJS.ST.20.00055. Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Diermeier et al. Van de pol et al. endstream
Tibial tunnel cyst | Radiology Reference Article | Radiopaedia.org - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. 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]. These lesions are often difficult to see on MRI. PMC Knee Surg & Relat Res 31, 10 (2019). Conclusions. Epub 2007 Jan 5. doi: 10.1016/j.eats.2020.08.024. We thank Eun-Ji Jeon and Min-Ji Kim for their support. Methods: JavaScript is disabled. Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. Terms and Conditions, Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Arthrosc Tech. Ki-Cheor Bae. a statistical evaluation. What other specialized procedures might be performed in conjunction with ACL revision surgery? - open technique(which might be required with arthroscopy malfunction). Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. This site complies with the HONcode standard for trustworthy health information: verify here. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. 2015;43:2510. Aust N Z J Surg 69:517521, Eagan MJ, McAllister DR (2009) Biology of allograft incorporation. For example, patients may require bone grafting of prior graft tunnels, and then have the ACL revision in a second stage. It does not hit an edit, but be prepared for insurance to deny it. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; Mayo Clinic is a not-for-profit organization. Graft healing in anterior cruciate ligament reconstruction in 30 deg flexion at the time of final fixation may result inexcessive graft tension when the knee is position in full extension; 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 Provided by the Springer Nature SharedIt content-sharing initiative. View all the articles associated with any code, right from the code page. Bethesda, MD 20894, Web Policies Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. 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. But no significant difference was observed between the two groups. The site is secure. - ACL graft should pull up intotibial tunnel by about 2mm with extension when fixed on femoral side; TECHNIQUE VIDEO. According to the result of the multicenter ACL Revision Study (MARS) Group, the risk of graft re-rupture following revision ACLR in patients receiving an autograft is 2.78 times less likely than in those receiving an allograft [35]. There are several procedures that can be performed in the ACL revision setting, such as anterolateral ligament reconstruction and iliotibial band tenodesis, to control that rotation. Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Thomas et al. Bone grafting of femur and tibial tunnels - AHA Coding Clinic for HCPCS 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. Uchida et al. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. The tibial tunnel looked to be in a good position. 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. 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. Bookshelf sharing sensitive information, make sure youre on a federal Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Bone Joint J. We want our patients to be able to return to the activities they enjoy. ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft 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. Careers. American Journal of Sports Medicine. The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior. JavaScript is disabled. 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. FOIA Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. This video may be inappropriate for some users. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. However, remarkable advances in knowledge of this process have been made based primarly on animal models. 2022 Jun 21;11(7):e1367-e1372. ACL Reconstruction - BTB Graft. eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. 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]. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. 1998-2023 Mayo Foundation for Medical Education and Research. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. The .gov means its official. Discover how to save hours each week. 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%). Arthroscopic Delivery of Injectable Bone Graft for Staged Revision - ref: Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. They observed that revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than revision ACLR alone, although there were no significant differences in anterior laxity or functional test results between the two groups. 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. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. 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. - Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Revision ACL surgery: A comprehensive approach. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint The goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. 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). Measurements are made perpendicular to the axial plane of the tunnel at the widest point [15]. PMC Springer Nature. 1 0 obj
See our privacy policy. Lee et al. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. In cases like these your going to need to bill out "what you can" which in this case would be 20680. Bone Grafting tibial and femoral tunnels knee, failed ACL CT scans to confirm healing at 3-5months after bone grafting [4, 12, 33, 34]. Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. A clinical, prospective, randomized, double-blind study. An Observational Study Using Navigated Measurements. Bookshelf Comparing Bone-Tendon Autograft With Bone-Tendon-Bone Autograft for ACL 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. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. 2 0 obj
Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. 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. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. - Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling This site needs JavaScript to work properly. Clifford R. Wheeless, III, M.D. - figure four flexedpositionassist with providing the best femoral target; - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. Overview. 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. An official website of the United States government. The use of allograft material negates the issue of donor-site morbidity but carries the potential risk of disease or infection transmission [23, 24]. Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. Disclaimer. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. statement and Am J Sports Med 36:851860, Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N et al (2013) Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study. 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. This adds a fair amount of complexity to the procedure. anterior cruciate ligament; bone graft; knee; revision. Towson, MD 21204
Unfortunately, the most common cause for failure is related to technical issues from the primary ACL surgery, with malposition of the sockets and tunnels, particularly on the femoral side. 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 ].