and transmitted securely. Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. <> 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. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. J Orthop Sci (2010) . The optimal and earliest possible timing of the two-stage procedure is still not clear. A new and innovative procedure. However, many authors prefer using an autograft for revision ACLR when possible. Yoon et al. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. 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. Outcomes of repeat revision anterior cruciate ligament reconstruction. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. Stage I femoral and tibial bone grafting. 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. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. 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]. Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 7 0 obj Levy, M.D., an orthopedic surgeon specializing in sports medicine at Mayo Clinic in Rochester, Minnesota, discusses Mayo's approach to revision ACL surgery. 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. There are several techniques for bone grafting tunnels in one- or two-staged ACL revision procedures with either autograft or allograft. Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. No charge. Louis et al. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. A single copy of these materials may be reprinted for noncommercial personal use only. Our Experience: 2014 - 2018 . A 17-year-old female came to see us after two failed ACL surgeries. - graft that tightens (pulls up into the tibial tunnel) with flexion will have a much higher likelyhood offailure and usually indicates a Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. 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]. I forgot to mention he did an allograft bone graft. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. Ki-Cheor Bae. 2013;41:1296. Few studies report the outcomes of two-stage revision ACLR alone. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. TECHNIQUE STEPS. Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. Please enable it to take advantage of the complete set of features! performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. - tunnel positioning: I wanted to see the history here to better define the stages of reconstruction and see the indication for the procedure being performed in this stage. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction. They observed that an average of 5.8months was needed for healing of the autograft dowel to become visible on CT scans [11]. <>>> 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]. Epub 2018 Dec 17. Sorry. 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. The tibial tunnel looked to be in a good position. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. 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]. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. 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. 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). -Morphology of the Femoral Intercondylar Notch a statistical evaluation. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. Keywords: No restrictions are placed on their range of motion and patients were allowed to weightbear on the affected leg using crutches [17]. BMC Musculoskelet Disord 19:246. eCollection 2020 Dec. ",#(7),01444'9=82. sharing sensitive information, make sure youre on a federal anterior cruciate ligament; bone graft; knee; revision. 2022 Jun 21;11(7):e1367-e1372. Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. -allows the femoral attachment point to overlap the anterolateral and posteromedial bundles insertion site JavaScript is disabled. 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. Previous literature has reported that if the tunnel size exceeds 1015mm, two-stage surgery should be performed. He is only grafting the bone. - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Clipboard, Search History, and several other advanced features are temporarily unavailable. 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. 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]. doi: 10.1016/j.eats.2022.01.004. Phys Ther 85:740749, PubMed The greater the tibial slope, the higher the risk of graft failure as our group found in a 2015 study in American Journal of Sports Medicine. This site needs JavaScript to work properly. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. The new ligament was fixed to the tibia by a metallic screw and to the femur by a bioabsorbable screw. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues. eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. [26] reported the use of a sCO2-sterilized bone allograft to fill tunnel defects as the first stage of a two-stage revision ACLR. 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. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. MeSH 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]. We want our patients to be able to return to the activities they enjoy. View all the articles associated with any code, right from the code page. - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; Would this qualify for CPT 29888 with a 52 mod? What other specialized procedures might be performed in conjunction with ACL revision surgery? It may not display this or other websites correctly. 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. Springer Nature. The goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. J Bone Joint Surg Br 89:10511054, Article Primary ACL reconstruction is recognized as a successful procedure, but failure has been shown to occur in approximately 10% of patients. 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. Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). volume31, Articlenumber:10 (2019) Sci Rep (2016) 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. Outcomes of repeat revision anterior cruciate ligament reconstruction. Your going to need to get very familiar with 2017 CMS NCCI Surgical Policy Manual. Manage cookies/Do not sell my data we use in the preference centre. - Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position . Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). 2020 Dec 21;9(12):e1917-e1925. 8 Therefore, one should avoid angles <40 to 45 . However, the small number of included patients, especially in the group of patients without revision ACLR, is limited. Disclaimer. Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. 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. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. We thank Eun-Ji Jeon and Min-Ji Kim for their support. Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. - 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; 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. 19 Despite favorable outcomes after interference screw fixation, there are concerns related to graft biology, such as graft damage during screw insertion, a small tendon-to-bone contact area for graft integration, the presence of . To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study Learn how to get the most out of your subscription. Before 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%). If this is your first visit, be sure to check out the. Measurements are made perpendicular to the axial plane of the tunnel at the widest point [15]. Comparison of Femoral Tunnel Position and Clinical Results. An Observational Study Using Navigated Measurements. Comparison of Femoral Tunnel Position and Clinical Results. Kim, DH., Bae, KC., Kim, DW. 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). Franceschi et al. When measuring with CT, the axial-plane image is considered incorrect because the plane of cuts is inconsistent. Mayo Clinic has substantial experience with all of these procedures. 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. ACL graft can replicate the normal ligament's tension curve. 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. [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. Cite this article. - consider whether there is an interplay between posterior graft placement and appropriate graft tension; Overview. CT examinations were performed at 3, 12, and 24weeks after bone grafting. Some authors suggest that an accelerated rehabilitation program for revision ACLR is not appropriate because of weaker initial graft fixation [20]. 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. Then in that case, yes, I would code this as 29888-52. Cancel anytime. Example: 29888 - ACL Repair G0289 - Arthroscopy, knee, surgical, for removal of loose body, Harvesting and inserting the graft is included in code . The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. 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 systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Epub 2020 Apr 1. Mayo Clinic has vast experience treating posterior cruciate ligament, lateral collateral ligament, posterolateral and posteromedial corner injuries, as well as medial collateral ligament injuries. Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. in 30 deg flexion at the time of final fixation may result inexcessive graft tension when the knee is position in full extension; American Journal of Sports Medicine. I would look at billing 29877 for the debridement of the soft tissue. endobj Arch Orthop Trauma Surg. [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. 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. eCollection 2022 Jun. Mayo Clinic is a not-for-profit organization. With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. In cases like these your going to need to bill out "what you can" which in this case would be 20680. 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]. 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. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. 3 0 obj A relatively small but challenging subset of patients requires two-stage revision ACLR. 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. Am J Sports Med 40:800807, Article Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Journal of Orthopaedic Research. Study design: Systematic review. The site is secure. - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Epub 2007 Jan 5. Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. i came across this in cpt a revision acl reconstruction and i came anterior, price 8 900 cpt code 29888 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 performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Thomas et al. Clifford R. Wheeless, III, M.D. 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. #1. See our privacy policy. CPT codes are grouped into 6 sections: 1. Preoperative planning is critical to identify and characterize bone tunnel pathology. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. 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. This content does not have an Arabic version. Clin Orthop Relat Res. JavaScript is disabled. Thomas et al. 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. 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 inside punch of the harvester is tapped and this allows delivery of the graft in a controlled manner and its impaction into the tunnel. An official website of the United States government. 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. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . Spine J 7:475490, Jenis LG, Banco RJ (2010) Efficacy of silicate-substituted calcium phosphate ceramic in posterolateral instrumented lumbar fusion. The indication for bone grafting and between-stage protocol varied among studies.