Epub 2005 Aug 10. Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. Careers. This site needs JavaScript to work properly. Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. - tunnel positioning: and transmitted securely. Am J Sports Med 40:800807, Article A Retrospective Comparative Study. FOIA An official website of the United States government. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Disclaimer. doi: 10.1016/j.eats.2021.11.019. Epub 2018 Dec 17. Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery. 2022 Feb 28;11(3):e463-e469. It is commonly injured during high-intensity sports. The prior skin incision is typically used to expose the distal portion of the tibial tunnel. 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). If this is your first visit, be sure to check out the. - lateral tunnel placement: The bone grafting is an opportune time to do an osteotomy to correct the malalignment. The authors declare that they have no competing interests. [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. 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. Spine (Phila Pa 1976) 20:10551060, Campbell DG, Li P (1999) Sterilization of HIV with irradiation: relevance to infected bone allografts. Provided by the Springer Nature SharedIt content-sharing initiative. 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). Bruce A. 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. Meniscal tears are another contributing cause. Federal government websites often end in .gov or .mil. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. 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. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Reconstruction 10,878 views Apr 25, 2017 NewYorkOrtho 25K subscribers Notice. - Native Anterior Cruciate Ligament Obliquity Versus Anterior Cruciate Ligament Graft Obliquity. Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. 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. 1 0 obj This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. doi: 10.1016/j.eats.2022.03.024. Part of 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]. The .gov means its official. Tibial Tunnel Bone Allograft Cpt Code For The. Make a donation. However, Thomas et al. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). Study design: Systematic review. 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. endobj Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. They observed that an average Background: Previous literature has reported that if the tunnel size exceeds 1015mm, two-stage surgery should be performed. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. a meta-analysis of 32 studies. 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. The optimal and earliest possible timing of the two-stage procedure is still not clear. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? Comparison of Femoral Tunnel Position and Clinical Results. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. Some authors suggest that an accelerated rehabilitation program for revision ACLR is not appropriate because of weaker initial graft fixation [20]. doi: 10.1016/j.eats.2020.08.024. American Journal of Sports Medicine. Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? 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. Thomas NP, Kankate R, Wandless F, Pandit H. Am J Sports Med. National Library of Medicine doi: 10.1016/j.eats.2021.08.013. endobj Root tears also put tremendous forces on the ACL graft and can lead to rotational instability and graft failure. Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. An average Lysholm score at 2 years post operation was 96.6 points 2.1 (91100 points). The use of allograft material negates the issue of donor-site morbidity but carries the potential risk of disease or infection transmission [23, 24]. MeSH A clinical, prospective, randomized, double-blind study. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. 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. eCollection 2022 Jul. 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. It may not display this or other websites correctly. The initial rehabilitation emphasis is focused on restoring tibiofemoral and patellofemoral passive range of motion, restoring quadriceps activation, and controlling and resolving any joint effusion. Before Currently, the gold standard for measuring tunnel size is the computed tomography (CT) method. - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study 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]. Von recum et al. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). - Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position . To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. [33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. What other specialized procedures might be performed in conjunction with ACL revision surgery? You are using an out of date browser. - makesure that interference screws are less than 25 mm in length; This process is repeated until there is full fill of femoral tunnel. 7 0 obj Disclaimer. You are using an out of date browser. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. Additionally, Brown and Carson [20] regarded patients with a bone tunnel of <15mm diameter as good candidates for grafting. volume31, Articlenumber:10 (2019) - two incision technique (outside in) Preoperative planning for revision ACL surgery is essential for a successful outcome. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; 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. Stage I femoral and tibial bone grafting. Please enable it to take advantage of the complete set of features! The https:// ensures that you are connecting to the Epub 2018 Feb 23. They observed that an average of 5.8months was needed for healing of the autograft dowel to become visible on CT scans [11]. Telephone: 410.494.4994, Morphology of the Femoral Intercondylar Notch, The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction. -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.. 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. Kim, DH., Bae, KC., Kim, DW. Surgery is often recommended to restore knee strength and function by reconstructing a damaged ACL with a graft. Orthop Clin North Am. However, many authors prefer using an autograft for revision ACLR when possible. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean SD of 4.2 2.1 years. PMC They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. TECHNIQUE STEPS. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. The bone grafting is an opportune time to do an osteotomy to correct the malalignment. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Coronal (a) and sagittal (b) view of computed tomography (CT) images demonstrate widening of the tibial tunnel in the setting of a failed anterior cruciate ligament reconstruction. Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. Knee Surgery & Related Research Mayo Clinic is a not-for-profit organization. 1). 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]. Enjoy a guided tour of FindACode's many features and tools. Uchida et al. 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]. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. Biazzo A, Manzotti A, Motavalli K, Confalonieri N. J Clin Orthop Trauma. For a better experience, please enable JavaScript in your browser before proceeding. Keywords: Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. 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. - A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction The patient also had an unrecognized complete disruption of her lateral meniscal root and excessively widened tunnels and sockets. - over the top position: Orthopaedic Specialists of North Carolina. JavaScript is disabled. eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. eCollection 2021 Oct-Dec. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. An official website of the United States government. a statistical evaluation. Reports suggest that a two-stage procedure is performed in only 8 to 9% of revision ACLRs [6]. No charge. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. An Observational Study Using Navigated Measurements Am J Sports Med. PMC A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. 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]. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; 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 . 2021 Oct 12;11(4):e20.00055. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. In the immediate postoperative period, the weakest part of any ACLR is the fixation. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Thomas et al. MARS Group. 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. Bone and Joint Clinic. (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. Anterior cruciate ligament reconstruction with patellar tendon: an ex vivo study of wear-related damage and failure at the femoral tunnel, Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension, Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? Uchida et al. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. In addition, patients who receive revision ACL surgery might have other damaged ligaments. 5 0 obj performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Phys Ther 85:740749, PubMed 2013;41:1296. After 6 to 12weeks, failures tend to occur in mid-substance [11]. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. - ref: Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Arch Orthop Trauma Surg. - w/a right knee, place the tunnel at about the 9:30 to 10 oclock position; Wheeless' Textbook of Orthopaedics. Data Trace Publishing Company The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. 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. The site is secure. A decision that will often depend on the graft used during the primary ACLR. <> sharing sensitive information, make sure youre on a federal 29866 is for autografts (from the patient). The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. Please enable it to take advantage of the complete set of features! Bone tunnel-related issues are frequently encountered during revision anterior cruciate ligament reconstruction. The indication for bone grafting and between-stage protocol varied among studies. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). Preoperative Patient Care. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. 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]. eCollection 2022 Mar. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. For assessment of bone-graft incorporation, radiographs are routinely used. Achieving the correct position can be tricky. Sci Rep (2016) 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. statement and $.' Philippe C, Marot V, Courtot L, Mesnier T, Reina N, Cavaignac E. Arthrosc Tech. 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. This content does not have an English version. eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. Clipboard, Search History, and several other advanced features are temporarily unavailable. Mayo Clinic sports medicine surgeons routinely perform revision surgery for patients who have undergone one or more ACL reconstructions elsewhere, and have published extensively on this topic. J Knee Surg 17:127132, Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R (2012) Revision anterior cruciate ligament reconstruction: an update. 2007 May;23(5):558.e1-4. We describe a new technique for femoral and tibial tunnel impaction grafting in 2-stage ACL revisions, using the OATS grafting instruments (Osteochondral Autologous Transfer System; Arthrex, Naples, FL). But no significant difference was observed between the two groups. View all the articles associated with any code, right from the code page. Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. 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. Arch Orthop Trauma Surg 132:12991313, Thomas NP, Kankate R, Wandless F, Pandit H (2005) Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. 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. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. 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. JavaScript is disabled. See our privacy policy. Allograft bone grafting femoral an Tibial Tunnels, with Debridement of Tunnels The previous ACL graft was debrided with the use of a shaver. The femoral tunnel was easily visualized with flexing the knee beyond 90 degrees. Van de pol et al. I forgot to mention he did an allograft bone graft. Patrick C. McCulloch MD. American Journal of Sports Medicine. Cite this article. - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. Your going to need to get very familiar with 2017 CMS NCCI Surgical Policy Manual. At Mayo Clinic, we frequently perform osteotomies to correct both sagittal plane and coronal plane deformity. eCollection 2022 Jun. 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. TECHNIQUE VIDEO. Study design: - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); 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. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. 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. Diermeier et al. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. 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 is the great debate in ortho coding. Then in that case, yes, I would code this as 29888-52. There is no code for bone grafting. A Meta-analysis of 47,613 Patients. Not applicable, this is a review article. It may not display this or other websites correctly. Anterior cruciate ligament (ACL) reconstruction remains the gold-standard treatment for young active patients with functional instability after an ACL injury. stream 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. A total 75 patients (75 knees) who underwent ACL reconstruction with tibialis anterior allografts were investigated between February 2015 and October . CAS Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Noyes et al. Houston Methodist Orthopedics & Sports Medicine. - references: You must log in or register to reply here. The surgeon submitted CPT code 25431 alone. 110 West Rd., Suite 227 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. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint 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? 2022 May 11;11(6):e971-e976. Excessive tibial slope also puts patients at much higher risk of early ACL reconstruction failure. This content does not have an Arabic version. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. That would help me to provide some better guidance. Conclusions. 1998-2023 Mayo Foundation for Medical Education and Research. endobj - historic techniques: Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. Data Trace is the publisher of Am J Sports Med 38:19791986, Dye SF (1996) The future of anterior cruciate ligament restoration. FOIA Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. The tibial tunnel looked to be in a good position. 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. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. xMO@; aK]XDZ)r(-w(;.B ~8MG{ By using this website, you agree to our -allows the femoral attachment point to overlap the anterolateral and posteromedial bundles insertion site 4. Revision ACL surgery: A comprehensive approach. 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. 2022 Jun 21;11(7):e1367-e1372. Learn how to get the most out of your subscription. Results: Battaglia and Miller [12] indicated that bone grafting should be performed in cases with a tunnel diameter of 1015mm. CT analysis also included the determination of the filling rates of the tunnels. - most common error is non isometric anterior tunnel placement within intercondylar notch rather than at its normal posterior insertion; With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues.