[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. I forgot to mention he did an allograft bone graft. 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 Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. 2021 Oct 12;11(4):e20.00055. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. A new harvest site for bone graft in anterior cruciate ligament revision surgery. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. National Library of Medicine Orthopaedic Specialists of North Carolina. PDF Failed ACL with Tunnel Enlargement: How I Bone Graft & Stage It official website and that any information you provide is encrypted If this is your first visit, be sure to check out the. An Observational Study Using Navigated Measurements. Lee et al. 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. 2021 Nov 16;10(12):e2699-e2708. Franceschi et al. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. Study design: Systematic review. Results: What other specialized procedures might be performed in conjunction with ACL revision surgery? A relatively small but challenging subset of patients requires two-stage revision ACLR. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. 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]. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 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. Graft healing in anterior cruciate ligament reconstruction - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Remaining soft tissue was debrided along tibia. You are using an out of date browser. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Orthop Clin North Am. Clin Orthop Relat Res. Bruce A. - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Epub 2018 Feb 23. Bone grafting is commonly reported using iliac crest autograft and allograft bone chips and dowels, while hamstring autograft and BPTB autograft were the most utilized grafts during the second-stage definitive reconstruction. - makesure that interference screws are less than 25 mm in length; doi: 10.2106/JBJS.ST.20.00055. You must log in or register to reply here. Thomas et al. 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). Biomaterials 27:50145026, Hing KA, Wilson LF, Buckland T (2007) Comparative performance of three ceramic bone graft substitutes. To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. The femoral tunnel was easily visualized with flexing the knee beyond 90 degrees. 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. Data Trace is the publisher of 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]. Improved muscle strength may be the decisive factor; however, changes in functional movement patterns after intensive physical therapy are also important to consider [41]. J Orthop Sci (2010) . 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. The surgeon submitted CPT code 25431 alone. Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. National Library of Medicine Conclusions. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. doi: 10.1016/j.eats.2022.01.004. Jul 22, 2009. Unable to load your collection due to an error, Unable to load your delegates due to an error. Houston Methodist Orthopedics & Sports Medicine. 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. Optimal outcomes require a precise picture of how the ACL reconstruction failed. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. 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. and transmitted securely. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. A decision that will often depend on the graft used during the primary ACLR. Towson, MD 21204 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. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer 2 0 obj - with a posteriorly positioned femoral tunnel consider final tibial graft fixation in full extension ratherthan 30 deg flexion, since positioning 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]. This process is repeated until there is full fill of femoral tunnel. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . Article | Outpatient Surgery Magazine - Association of periOperative 1). He did other procedures, but I have the codes for them. 1998-2023 Mayo Foundation for Medical Education and Research. 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). See our privacy policy. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. registered for member area and forum access. Preoperative planning is critical to identify and characterize bone tunnel pathology. The AHA Coding Clinic for HCPCS includes: Thank you for choosing Find-A-Code, please Sign In to remove ads. <> Correlation between femoral tunnel length and tunnel position in ACL reconstruction. A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Bone Marrow Aspirate Concentrate With Two-Staged-Revision ACL Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. Comparison of Femoral Tunnel Position and Clinical Results. 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%). eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; My surgeon disagrees with me and is firm that the harvest of the bone graft is not separately reportable. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. 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. % While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. 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 . Arthrosc Tech. - ACL graft should pull up intotibial tunnel by about 2mm with extension when fixed on femoral side; Am J Sports Med 38:19791986, Dye SF (1996) The future of anterior cruciate ligament restoration. 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. [21] evaluated 88 patients who underwent one-stage revision ACLR. Recently, we recognized that patients needing ACL reconstruction who also have significant rotatory instability of the knee may have injuries in the anterolateral complex. A tamp is used to further compress the graft. a meta-analysis of 32 studies. For a better experience, please enable JavaScript in your browser before proceeding. Griffith TB, et al. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? Patient age and activity level are also important factors when deciding on graft choice for revision procedures. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; 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. 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. Arthrosc Tech. xMO@; aK]XDZ)r(-w(;.B ~8MG{ Patients who underwent ACL reconstruction (Current Procedural Terminology (CPT) code 29888) between 20 were identified using the PearlDiver database. Additionally, Brown and Carson [20] regarded patients with a bone tunnel of <15mm diameter as good candidates for grafting. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. However, Thomas et al. All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. 29866 is for autografts (from the patient). 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]. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. 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. (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Bone Graft related CPT Codes. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. Secure graft fixation is critical in ensuring a successful two-staged ACLR. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. 8600 Rockville Pike Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. - Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling Methods: 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/. Measurements are made perpendicular to the axial plane of the tunnel at the widest point. doi: 10.2106/JBJS.ST.20.00055. Aust N Z J Surg 69:517521, Eagan MJ, McAllister DR (2009) Biology of allograft incorporation. -allows the femoral attachment point to overlap the anterolateral and posteromedial bundles insertion site Provided by the Springer Nature SharedIt content-sharing initiative. A Retrospective Comparative Study and transmitted securely. This video may be inappropriate for some users. 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. statement and Primary ACL reconstruction is recognized as a successful procedure, but failure has been shown to occur in approximately 10% of patients. <> He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. 2022 Feb 28;11(3):e463-e469. Federal government websites often end in .gov or .mil. 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]. 2023 BioMed Central Ltd unless otherwise stated. The https:// ensures that you are connecting to the 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. 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. - open technique(which might be required with arthroscopy malfunction). Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Background: - figure four flexedpositionassist with providing the best femoral target; -Morphology of the Femoral Intercondylar Notch endobj Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. 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]. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. We NEVER sell or give your information to anyone. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Use of silicate-substituted calcium phosphate bone substitute had equivalent knee laxity and clinical function outcomes compared with autologous bone graft 3 years after two-stage ACL . This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. 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. American Journal of Sports Medicine. femoral tunnel too far anterior in the notch; 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. HHS Vulnerability Disclosure, Help Consistent Indications and Good Outcomes Despite High Variability in Epub 2018 Dec 17. Background: Ligament reconstruction is a common procedure in orthopedic surgery. What Is the Minimum Length of An Anterior Cruciate Ligament Autograft To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. You must log in or register to reply here. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). Bone Graft of both bone tunnels (Knee) | Medical Billing and Coding 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 ]. CT analysis also included the determination of the filling rates of the tunnels. Clinically, many authors have reported good results for two-staged revision ACLR using autograft bone [4, 11]. Wheeless' Textbook of Orthopaedics. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . If this is your first visit, be sure to check out the. (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. Finally, 1 study compared ICBG to a synthetic bone substitute. However, remarkable advances in knowledge of this process have been made based primarly on animal models. Bone grafting of femur and tibial tunnels - AHA Coding Clinic for HCPCS Knee Surgery & Related Research performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Federal government websites often end in .gov or .mil. There was also a significant improvement in the Lysholm score when comparing preoperative and postoperative values. Is it appropriate to assign codes for both the arthroscopic and open portions of the procedure? 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 ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. In addition, patients who receive revision ACL surgery might have other damaged ligaments. 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. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. Arthroscopic Bone Graft Technique for Two-Stage Revision Anterior This site needs JavaScript to work properly. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. JavaScript is disabled. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. Uchida et al. doi: 10.1016/j.eats.2021.11.019. Unauthorized use of these marks is strictly prohibited. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. This adds a fair amount of complexity to the procedure. 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. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. 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]. doi: 10.1016/j.arthro.2006.07.054. 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. There has been a long-standing debate as to whether an autograft or an allograft should be used for revision ACLR. Manage cookies/Do not sell my data we use in the preference centre. 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. 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. 2022 May 11;11(6):e971-e976. 2017 Oct;475(10):2459-2468. doi: 10.1007/s11999-017-5278-9. Achieving the correct position can be tricky. 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. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Two years after the surgery, she resumed all activities and plays collegiate volleyball. 2021 Oct 12;11(4):e20.00055. 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 . Arthroscopic knee procedure CPT codes range from 29866 to 29889. 2020 Dec 21;9(12):e1917-e1925. California Privacy Statement, After 6 to 12weeks, failures tend to occur in mid-substance [11]. Preoperative Patient Care. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. 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). Unauthorized use of these marks is strictly prohibited. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study <> Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. official website and that any information you provide is encrypted government site. PDF Two-stage revision anterior cruciate ligament reconstruction PMC The indication for bone grafting and between-stage protocol varied among studies. Thomas et al. The .gov means its official. Mayo Clinic has substantial experience with all of these procedures. 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. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. 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. This content does not have an English version. Systematic review. Unless the surgeon looks specifically for a ramp lesion at the time of ACL surgery, the lesion can be missed. Bethesda, MD 20894, Web Policies An official website of the United States government. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. The results from this group were compared to the results of a matched group of patients with primary ACLR. American Journal of Sports Medicine. [26] reported the use of a sCO2-sterilized bone allograft to fill tunnel defects as the first stage of a two-stage revision ACLR. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. - Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? 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]. In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). BMC Musculoskelet Disord 19:246. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL - tunnel positioning: At a mean follow-up of 6years, the laxity measurements achieved with a two-stage revision ACLR can be similar to those achieved after primary ACLR, although the IKDC rating is lower. 2015;43:2510. We thank Eun-Ji Jeon and Min-Ji Kim for their support. HHS Vulnerability Disclosure, Help Cookies policy. 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]. - some create a trough in the femur to bring graft closer to anatomical position, or they fix graft in place w/ knee in full extension; Varying Femoral Tunnels Between the Anatomical Footprint and Isometric Positions: Effect on Kinematics of the Anterior Cruciate Ligament-Reconstructed Knee.
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