<> Keywords: 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. The anterior cruciate ligament (ACL) is a ligament that provides stability to the knee joint. 7 0 obj 8600 Rockville Pike The site is secure. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). 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]. 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. Thomas et al. Towson, MD 21204 4. Tibial tunnel was found to be anterior, perhaps more inferior than would be in an anatomic ACL insertion. Houston Methodist Orthopedics & Sports Medicine. Improved muscle strength may be the decisive factor; however, changes in functional movement patterns after intensive physical therapy are also important to consider [41]. Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. 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]. The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. They explained that because a bone tunnel of 15mm diameter with 45 of inclination resulted in a tibial tunnel aperture of >20mm, a 20-mm tunnel aperture was regarded as a candidate for grafting. endobj Primary ACL reconstruction is recognized as a successful procedure, but failure has been shown to occur in approximately 10% of patients. Outcomes of repeat revision anterior cruciate ligament reconstruction. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. Get timely coding industry updates, webinar notices, product discounts and special offers. eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Outcomes of repeat 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]. [38] have reported the outcomes of revision ACLR with and without lateral extra-articular tenodesis. The .gov means its official. He is only grafting the bone. National Library of Medicine 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]. For assessment of bone-graft incorporation, radiographs are routinely used. These lesions are often difficult to see on MRI. Van de pol et al. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. Purpose: Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. When measuring with CT, the axial-plane image is considered incorrect because the plane of cuts is inconsistent. Physical therapy with muscle-strengthening and proprioceptive training can be performed. Orthopaedic Specialists of North Carolina. - Editorial: The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction 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]. - resulting anterior-posterior cruciate ligament impingement near extension caused a persistentfunctional extension deficit of 20; Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. There was also a significant improvement in the Lysholm score when comparing preoperative and postoperative values. American Journal of Sports Medicine. [40] reported the results of 87 patients who underwent revision ACLR with a follow-up of more than 3 years. CPT codes are grouped into 6 sections: 1. For a better experience, please enable JavaScript in your browser before proceeding. The analysis included 7 studies with a total of 234 patients. 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. Results: Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. Comparison of Femoral Tunnel Position and Clinical Results. 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/. JavaScript is disabled. [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. 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. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. - this technique allows for a more anatomic and precise placement of the femoral tunnel (more reliable posterior placement); An official website of the United States government. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; Clin Sports Med 36:173187, Trojani C, Beaufils P, Burdin G, Bussiere C, Chassaing V, Djian P et al (2012) Revision ACL reconstruction: influence of a lateral tenodesis. Levy, M.D., an orthopedic surgeon specializing in sports medicine at Mayo Clinic in Rochester, Minnesota, discusses Mayo's approach to revision ACL surgery. endobj Accessibility - Discussion: - over the top position: Aust N Z J Surg 69:517521, Eagan MJ, McAllister DR (2009) Biology of allograft incorporation. Unauthorized use of these marks is strictly prohibited. CAS If any of those ligaments were missed in the initial knee surgery, they can be treated in the revision setting. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. Preoperative planning for revision ACL surgery is essential for a successful outcome. It may not display this or other websites correctly. Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. Neil Duplantier MD. TJ!!X`Sz9Q*BeV={=F ' 0y^*2| '! Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. Mayo Clinic has vast experience treating posterior cruciate ligament, lateral collateral ligament, posterolateral and posteromedial corner injuries, as well as medial collateral ligament injuries. 2007 May;23(5):558.e1-4. For example, patients may require bone grafting of prior graft tunnels, and then have the ACL revision in a second stage. 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 . J Bone Joint Surg Br 89:10511054, Article It does not hit an edit, but be prepared for insurance to deny it. Spine (Phila Pa 1976) 20:10551060, Campbell DG, Li P (1999) Sterilization of HIV with irradiation: relevance to infected bone allografts. 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. 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). -main criticism is that in some cases a transtibial tunnel will not allow for the exact desiredtunnel placement (you get what you get) Trojani et al. HHS Vulnerability Disclosure, Help MeSH [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 . Enjoy a guided tour of FindACode's many features and tools. 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. After 6 to 12weeks, failures tend to occur in mid-substance [11]. - Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. endstream Arthrosc Tech. This case required a two-stage approach: Stage 1 consisted of bone grafting, followed by second-stage repeat revision ACL reconstruction with patellar tendon autograft, lateral meniscal root repair and iliotibial band tenodesis. Sci Rep (2016) 2023 BioMed Central Ltd unless otherwise stated. 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. 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. - 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; Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Then in that case, yes, I would code this as 29888-52. 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]. registered for member area and forum access. The femoral tunnel was a little high. This site complies with the HONcode standard for trustworthy health information: verify here. ACL graft can replicate the normal ligament's tension curve. Knee Surg & Relat Res 31, 10 (2019). Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. Telephone: 410.494.4994, Morphology of the Femoral Intercondylar Notch, The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction. Bethesda, MD 20894, Web Policies Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation, Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study, The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint, Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling, Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? Discover how to save hours each week. At Mayo Clinic, we frequently perform osteotomies to correct both sagittal plane and coronal plane deformity. - consider whether there is an interplay between posterior graft placement and appropriate graft tension; 2022 Jun 21;11(7):e1367-e1372. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. This adds a fair amount of complexity to the procedure. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. PMC Please enable it to take advantage of the complete set of features! He did other procedures, but I have the codes for them. 2005 Nov;33(11):1701-9. doi: 10.1177/0363546505276759. eCollection 2022 Jun. A Retrospective Comparative Study. Arthrosc Tech. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. - surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; Clinically, many authors have reported good results for two-staged revision ACLR using autograft bone [4, 11]. doi: 10.1016/j.eats.2022.01.004. CT analysis also included the determination of the filling rates of the tunnels. 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. Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. This content does not have an English version. Louis et al. Unable to load your collection due to an error, Unable to load your delegates due to an error. 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. As this number has continued to increase, the incidence of revision ACL reconstruction (ACLR) has also grown to a rate of between 4.1 and 13.3% of all primary ACLRs performed [2]. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. 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. Arthrosc Tech. Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. statement and Revision ACL surgery: A comprehensive approach. They found that a sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution. 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]. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. 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. TECHNIQUE STEPS. We routinely obtain hip-to-ankle AP X-rays to assess for any coronal plane malalignment. Tunnel malposition, widening, and interference pose unique challenges that may complicate surgery and compromise outcomes. Knee Surgery & Related Research 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. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. Patients who have lost a meniscus or have a significant cartilage defect and have a failed ACL can, in some circumstances, require a meniscus transplant or cartilage replacement surgery. - one incision transtibialtechnique Numerous studies have reported that additional procedures (e.g., extra-articular tenodesis, anatomical anterolateral ligament (ALL) reconstruction) could be a meaningful option in cases of revision ACLR to improved rotatory stability which is associated with re-injury. Preoperative Patient Care. Learn how to get the most out of your subscription. View all the articles associated with any code, right from the code page. 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 removed from the knee before the graft is inserted through a hole created by a single hole punch. doi: 10.2106/JBJS.ST.20.00055. The tibial tunnel looked to be in a good position. 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. They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. 2020;38:1191. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. 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. 2020 Dec 21;9(12):e1917-e1925. - historic techniques: 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. endobj Am J Sports Med 38:19791986, Dye SF (1996) The future of anterior cruciate ligament restoration. [21] evaluated 88 patients who underwent one-stage revision ACLR. At a mean follow-up 6.7years postoperatively, 66.7% of patients had returned to their preoperative sports activity level, 23.3% had changed to lower, non-impact sports, and 10% had given up any sports activity. Title: Slide 1 Author: Charles H Brown Created Date: 12/3/2018 11:52:05 AM . Study design: 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. 29866 is for autografts (from the patient). Arthrosc Tech. 2. The .gov means its official. new ACL graft. It may not display this or other websites correctly. Therefore, the coronal and sagittal images (four-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. <> Thomas et al. Epub 2016 Dec 30. Before Epub 2018 Dec 17. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. Preoperative planning is critical to identify and characterize bone tunnel pathology. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. Hi you mentioned this was a staged procedure - any chance you can post the entire operative report without patient info? Bone and Joint Clinic. ACL reconstruction is surgery to replace a torn anterior cruciate (KROO-she-ate) ligament (ACL) a major ligament in your knee. 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%). Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. You must log in or register to reply here. - lateral tunnel placement: - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint Example: 29888 - ACL Repair G0289 - Arthroscopy, knee, surgical, for removal of loose body, Harvesting and inserting the graft is included in code . - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. -increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used 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. All rights reserved. -Morphology of the Femoral Intercondylar Notch However, remarkable advances in knowledge of this process have been made based primarly on animal models. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. 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. <> - most common error is non isometric anterior tunnel placement within intercondylar notch rather than at its normal posterior insertion; -allows the femoral attachment point to overlap the anterolateral and posteromedial bundles insertion site - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning Finally, 1 study compared ICBG to a synthetic bone substitute. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. 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]. - references: 3. 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. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Federal government websites often end in .gov or .mil. A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. Clin Orthop Relat Res 325:130139, Andernord D, Desai N, Bjornsson H, Ylander M, Karlsson J, Samuelsson K (2015) Patient predictors of early revision surgery after anterior cruciate ligament reconstruction: a cohort study of 16,930 patients with 2-year follow-up. That would help me to provide some better guidance. The indication for bone grafting and between-stage protocol varied among studies. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. 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. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Clipboard, Search History, and several other advanced features are temporarily unavailable. Philippe C, Marot V, Courtot L, Mesnier T, Reina N, Cavaignac E. Arthrosc Tech. J Bone Joint Surg Am 100:9931000, Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. 2002 Richard O'Connor Award paper. Bruce A. However, the results of the postoperative side-to-side differences of the Lachman test as well as the pivot-shift test were significantly superior in group A (<12mm). Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. Thomas et al. 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. 2022 Feb 28;11(3):e463-e469. Current studies report an average-low failure rate of 3.6% (wide range of 08.1%) for utilizing two-stage revision ACLR [11, 33, 34, 42, 43] (Table2). 3 0 obj BMC Musculoskelet Disord 19:246. 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. Spine (Phila Pa 1976) 35:E1058E1063, Lerner T, Liljenqvist U (2013) Silicate-substituted calcium phosphate as a bone graft substitute in surgery for adolescent idiopathic scoliosis. Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. Privacy Patient age and activity level are also important factors when deciding on graft choice for revision procedures. A new harvest site for bone graft in anterior cruciate ligament revision surgery. Comparison of Femoral Tunnel Position and Clinical Results. JFIF C Epub 2020 Apr 1. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. Reports suggest that a two-stage procedure is performed in only 8 to 9% of revision ACLRs [6]. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. Background: Ligament reconstruction is a common procedure in orthopedic surgery. 2021 Oct 12;11(4):e20.00055. 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. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. Epub 2007 Jan 5. Thomas et al. The site is secure. anterior cruciate ligament; bone graft; knee; revision. 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 .
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