- tunnel positioning: 2002 Richard O'Connor Award paper. Uchida et al. Bone tunnel-related issues are frequently encountered during revision anterior cruciate ligament reconstruction. 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%). A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. 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. 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. You must log in or register to reply here. If no autograft is available for revision surgery, they advise augmentation of the allograft with the lateral extra-articular iliotibial band procedure to reduce the high failure rate associated with the use of the allograft. 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. You are using an out of date browser. eCollection 2020 Dec. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. 2013;41:1296. A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction. - most common error is non isometric anterior tunnel placement within intercondylar notch rather than at its normal posterior insertion; Some authors suggest that an accelerated rehabilitation program for revision ACLR is not appropriate because of weaker initial graft fixation [20]. - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. A new harvest site for bone graft in anterior cruciate ligament revision surgery. registered for member area and forum access. Preoperative planning for revision ACL surgery is essential for a successful outcome. - Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. - one incision transtibialtechnique 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. Resurfacing technique consisting of transplantation of multiple osteochondral grafts to smooth the area. Anterior cruciate ligament (ACL) reconstruction remains the gold-standard treatment for young active patients with functional instability after an ACL injury. 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. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. You must log in or register to reply here. 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. Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. Disclaimer. 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. Two-stage revision anterior cruciate ligament reconstruction. % 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]. The analysis included 7 studies with a total of 234 patients. 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. TECHNIQUE VIDEO. - open technique(which might be required with arthroscopy malfunction). 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]. For an allograft, a single bone dowel approximately 1mm larger than the diameter of the tunnel is used and placed using a bone tamp for a press-fit technique, ensuring that the entire tunnel is filled [4]. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. 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. An official website of the United States government. BMC Musculoskelet Disord 19:246. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. Arthrosc Tech. Uchida et al. No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. Bone and Joint Clinic. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). Arthroscopic knee procedure CPT codes range from 29866 to 29889. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. 2022 Feb 28;11(3):e463-e469. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. - Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. A clinical, prospective, randomized, double-blind study. 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. For example, patients may require bone grafting of prior graft tunnels, and then have the ACL revision in a second stage. Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). 8 Therefore, one should avoid angles <40 to 45 . Thomas et al. What code(s) would be reported for the open removal of retained deep hardware, along with placement of bone graft to the femur and tibial tunnels? endobj 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]. 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]. For a better experience, please enable JavaScript in your browser before proceeding. - Discussion: Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. Stage I femoral and tibial bone grafting. After 6 to 12weeks, failures tend to occur in mid-substance [11]. volume31, Articlenumber:10 (2019) Terms and Conditions, doi: 10.1016/j.arthro.2006.07.054. 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]. We routinely obtain hip-to-ankle AP X-rays to assess for any coronal plane malalignment. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). - w/a right knee, place the tunnel at about the 9:30 to 10 oclock position; Thomas et al. [34] evaluated 10 consecutive patients who underwent staged revision ACLR using autogenous bone grafting and reported that all patients had a full range of motion of the knees, a negative Lachmann sign and negative pivot-shift test . All rights reserved. These lesions are often difficult to see on MRI. Mayo Clinic is a not-for-profit organization. Outcomes of repeat revision anterior cruciate ligament reconstruction. 3 0 obj xMO@; aK]XDZ)r(-w(;.B ~8MG{ Please enable it to take advantage of the complete set of features! doi: 10.1016/j.eats.2020.08.024. 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. Given our prior assumption of the STC being 45 mm, the graft-50 rule suggests a 45-mm tibial tunnel if using 25-mm bone plugs. 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 . There is ongoing debate about how best to reconstruct the anterior cruciate ligament (ACL) to restore knee kinematics, including which is the best fixation method. Ligaments are strong bands of tissue that attach one bone to . Recently, we recognized that patients needing ACL reconstruction who also have significant rotatory instability of the knee may have injuries in the anterolateral complex. Thomas et al. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. [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. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. 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. - Surgical Technique: - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. 2020;38:1191. Am J Sports Med 45:17901798, Diermeier T, Herbst E, Braun S, Saracuz E, Voss A, Imhoff AB et al (2018) Outcomes after bone grafting in patients with and without ACL revision surgery: a retrospective study. 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. 2021 Nov 16;10(12):e2699-e2708. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Springer Nature. <> -notchplasty Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Diermeier et al. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. Phys Ther 85:740749, PubMed Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. Two-stage revision anterior cruciate ligament reconstruction, https://doi.org/10.1186/s43019-019-0010-6, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. 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. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. J Bone Joint Surg Br 89:10511054, Article Two years after the surgery, she resumed all activities and plays collegiate volleyball. Excessive tibial slope also puts patients at much higher risk of early ACL reconstruction failure. Ki-Cheor Bae. - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a My surgeon disagrees with me and is firm that the harvest of the bone graft is not separately reportable. Not applicable, this is a review article. Griffith TB, et al. A Retrospective Comparative Study. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. Preoperative planning is critical to identify and characterize bone tunnel pathology. Epub 2020 Apr 1. By using this website, you agree to our Accessibility Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. Orthop Clin North Am. 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]. 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. This content does not have an English version. A total 75 patients (75 knees) who underwent ACL reconstruction with tibialis anterior allografts were investigated between February 2015 and October . - two incision technique (outside in) - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. - Editorial: The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction [21] evaluated 88 patients who underwent one-stage revision ACLR. JavaScript is disabled. endobj 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. You must log in or register to reply here. Bookshelf - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. 2022 May 11;11(6):e971-e976. 2020 Dec 21;9(12):e1917-e1925. a meta-analysis of 32 studies. [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. However, remarkable advances in knowledge of this process have been made based primarly on animal models. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. - surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. 1998-2023 Mayo Foundation for Medical Education and Research. in 30 deg flexion at the time of final fixation may result inexcessive graft tension when the knee is position in full extension; If this is your first visit, be sure to check out the. Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. 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. Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. - consider whether there is an interplay between posterior graft placement and appropriate graft tension; 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]. Study design: Background: 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 ]. 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. They noted that although additional lateral tenodesis did not influence the International Knee Documentation Committee (IKDC) score in a multicenter study of 163 revision ACLRs, the proportion of negative pivot shifts was 80% with lateral tenodesis plus revision ACLR versus 63% without tenodesis. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. - ACL graft should pull up intotibial tunnel by about 2mm with extension when fixed on femoral side;
