Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. Anterior cruciate ligament (ACL) reconstruction rates have increased over the past 20years to roughly 200,000 per year [1]. 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. Privacy Bone Tunnel Management in Modern Revision Anterior Cruciate Ligament I forgot to mention he did an allograft bone graft. American Journal of Sports Medicine. I wanted to see the history here to better define the stages of reconstruction and see the indication for the procedure being performed in this stage. Bookshelf The results from this group were compared to the results of a matched group of patients with primary ACLR. The femoral tunnel was a little high. Manage cookies/Do not sell my data we use in the preference centre. J Orthop Sci (2010) . Biazzo A, Manzotti A, Motavalli K, Confalonieri N. J Clin Orthop Trauma. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. At Mayo Clinic, we have the imaging, surgical and physical therapy teams to manage extremely complex knee issues. Arthroscopy 21:767, Wilson TC, Kantaras A, Atay A, Johnson DL (2004) Tunnel enlargement after anterior cruciate ligament surgery. This adds a fair amount of complexity to the procedure. The AHA Coding Clinic for HCPCS includes: Thank you for choosing Find-A-Code, please Sign In to remove ads. - surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; %PDF-1.5 Not applicable, this is a review article. Learn how to get the most out of your subscription. TECHNIQUE VIDEO. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. Unless you probe for a root tear during surgery, you may miss it. Orthop Clin North Am. 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. You are using an out of date browser. 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). 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. - one incision transtibialtechnique - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. He did other procedures, but I have the codes for them. Patrick C. McCulloch MD. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. 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? 6 0 obj MeSH The indication for bone grafting and between-stage protocol varied among studies. MARS Group. Arthroscopic knee procedure CPT codes range from 29866 to 29889. <> Philippe C, Marot V, Courtot L, Mesnier T, Reina N, Cavaignac E. Arthrosc Tech. J Bone Joint Surg Br 89:10511054, Article Bone Grafting Tibial and Femoral Tunnels knee Portion of op note reads as follows: ACL was completely absent in mid aspect. doi: 10.1016/j.eats.2021.11.019. 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]. Comparison of Femoral Tunnel Position and Clinical Results. 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 Graft related CPT Codes. official website and that any information you provide is encrypted Am J Sports Med 40:800807, Article [21] evaluated 88 patients who underwent one-stage revision ACLR. 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. - w/a right knee, place the tunnel at about the 9:30 to 10 oclock position; HHS Vulnerability Disclosure, Help Trojani et al. 1 0 obj Thomas et al. View all the articles associated with any code, right from the code page. 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 Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Bone Joint J. 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%). An official website of the United States government. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). Disclaimer. - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; Christensen JJ, et al. Bone Grafting tibial and femoral tunnels knee, failed ACL JavaScript is disabled. JavaScript is disabled. Knee Surg Sports Traumatol Arthrosc 20:15651570, Louis ML, D'Ingrado P, Ehkirch FP, Bertiaux S, Colombet P, Sonnery-Cottet B et al (2017) Combined intra- and extra-articular grafting for revision ACL reconstruction: a multicentre study by the French Arthroscopy Society (SFA). 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. This site complies with the HONcode standard for trustworthy health information: verify here. #1. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint An Observational Study Using Navigated Measurements 2020;38:1191. <> Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. Clin Orthop Relat Res. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. 2020 Sep;140(9):1211-1219. doi: 10.1007/s00402-020-03421-7. Lee et al. 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 . 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. At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. 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 tunnel placement in single-bundle anterior cruciate ligament reconstruction: a cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. - Discussion: In cases like these your going to need to bill out "what you can" which in this case would be 20680. 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? Disclaimer. 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. Arch Orthop Trauma Surg. Cite this article. [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. 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]. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. - this restricts flexion of knee if graft remains intact, or it may elongate graft if the range of motion is restored; Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. 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. This site needs JavaScript to work properly. Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. Would you like email updates of new search results? Von recum et al. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. - tunnel positioning: ACL Reconstruction - BTB Graft. This adds a fair amount of complexity to the procedure. -notchplasty Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. - this represents the closest reconstitution of the ACL's "physiometry"; (see: isometry); Am J Sports Med 43:121127, Carson EW, Anisko EM, Restrepo C, Panariello RA, O'Brien SJ, Warren RF (2004) Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results. - most common error is non isometric anterior tunnel placement within intercondylar notch rather than at its normal posterior insertion; Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. ACL Reconstruction - BTB Graft - Knee & Sports - Orthobullets They observed that revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than revision ACLR alone, although there were no significant differences in anterior laxity or functional test results between the two groups. Bookshelf 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]. -allows the femoral attachment point to overlap the anterolateral and posteromedial bundles insertion site The https:// ensures that you are connecting to the registered for member area and forum access. CT scans to confirm healing at 3-5months after bone grafting [4, 12, 33, 34]. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. 2. anterior cruciate ligament; bone graft; knee; revision. - historic techniques: endobj <>>> eCollection 2020 Dec. A decision that will often depend on the graft used during the primary ACLR. 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. Purposes: We sought to introduce our new technique of Bashti bone plug for fixation of soft tissue graft in anterior cruciate ligament (ACL) reconstruction and to compare . 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). 8600 Rockville Pike Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. Knee Surg Sports Traumatol Arthrosc 21:20722080, Magnussen RA, Debieux P, Benjamin B, Lustig S, Demey G, Servien E et al (2012) A CT-based classification of prior ACL femoral tunnel location for planning revision ACL surgery. eCollection 2022 Jul. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Get timely coding industry updates, webinar notices, product discounts and special offers. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the hosts bone marrow [26]. 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]. 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. Data Trace is the publisher of Two-stage revision ACLR should be considered in cases of tunnel lysis, infection, malalignment, meniscal deficiency, or chondral lesions. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL - Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling Am J Sports Med 38:19791986, Dye SF (1996) The future of anterior cruciate ligament restoration. 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. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. You are using an out of date browser. Clin Sports Med 18:109171, Yoon KH, Kim JS, Park SY, Park SE (2018) One-stage revision anterior cruciate ligament reconstruction: results according to preoperative bone tunnel diameter: five to fifteen-year follow-up. Mosaicplasty. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. 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. - ref: Correlation between femoral tunnel length and tunnel position in ACL reconstruction. No restrictions are placed on their range of motion and patients were allowed to weightbear on the affected leg using crutches [17]. PubMedGoogle Scholar. 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. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. 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]. -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.. 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. Preoperative planning is critical to identify and characterize bone tunnel pathology. 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]. Two-stage revision anterior cruciate ligament reconstruction. Sci Rep (2016) An Observational Study Using Navigated Measurements. Am J Sports Med 33:17011709, Battaglia TC, Miller MD (2005) Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. We NEVER sell or give your information to anyone. Background: new ACL graft. Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. Epub 2005 Aug 10. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. Preoperative Patient Care. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. A new technique for femoral and tibial tunnel bone grafting using the - two incision technique (outside in) 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. [38] have reported the outcomes of revision ACLR with and without lateral extra-articular tenodesis. 4. Stage II lateral root tear, lateral root repair and repeat revision back-to-back ACL repair. 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. 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. Department of Orthopaedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, 1035 Dalgubul-ro, Dalseo-gu, Daegu, 42601, South Korea, Du-Han Kim,Ki-Cheor Bae,Dong-Wan Kim&Byung-Chan Choi, You can also search for this author in Currently, the gold standard for measuring tunnel size is the computed tomography (CT) method. 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. 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. Tibial tunnel cysts, including pretibial cysts , are occasional complications of autologous or synthetic anterior cruciate ligament (ACL) reconstruction surgeries. This video may be inappropriate for some users. 4 0 obj Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. Punch-biopsy specimens of the augmented tunnels were taken at the two-stage procedure, and histologic examination included quantitative analysis of the area of immature bone formation, lamellar bone, and bone marrow. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. 3. - 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. Achieving the correct position can be tricky. Arthrosc Tech. % Unauthorized use of these marks is strictly prohibited. Knee Surg Sports Traumatol Arthrosc 20:12981306, Brown CH Jr, Carson EW (1999) Revision anterior cruciate ligament surgery. Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. Hi you mentioned this was a staged procedure - any chance you can post the entire operative report without patient info? We routinely obtain hip-to-ankle AP X-rays to assess for any coronal plane malalignment. Tibial Tunnel Bone Allograft Cpt - toyoulalar - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; 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. - lateral tunnel placement: <> doi: 10.2106/JBJS.ST.20.00055. It may not display this or other websites correctly. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction. 2022 Jun 21;11(7):e1367-e1372. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. Ramp tears can lead to rotational instability and put excessive strain on the ACL graft, causing it to fail. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. PMC Ligaments are strong bands of tissue that attach one bone to . 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. PDF Two-stage revision anterior cruciate ligament reconstruction There are several techniques for bone grafting tunnels in one- or two-staged ACL revision procedures with either autograft or allograft. a meta-analysis of 32 studies. Secure graft fixation is critical in ensuring a successful two-staged ACLR. The .gov means its official. xMO@; aK]XDZ)r(-w(;.B ~8MG{ JavaScript is disabled. If any of those ligaments were missed in the initial knee surgery, they can be treated in the revision setting. 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. endobj Purpose: I would look at billing 29877 for the debridement of the soft tissue. 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. Epub 2018 Feb 23. Patient age and activity level are also important factors when deciding on graft choice for revision procedures. Careers. Enjoy a guided tour of FindACode's many features and tools. A total 75 patients (75 knees) who underwent ACL reconstruction with tibialis anterior allografts were investigated between February 2015 and October . et al. 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. Autologous Dedifferentiated Osteogenic Bone Marrow Mesenchymal Stem Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? They are benign ganglion cysts that develop in or around the osseous tibial tunnel made during ACL reconstruction using the transtibial technique 1-2. Your going to need to get very familiar with 2017 CMS NCCI Surgical Policy Manual. Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. Kim, DH., Bae, KC., Kim, DW. 2020 Dec 21;9(12):e1917-e1925. Outcomes of repeat revision anterior cruciate ligament reconstruction. Tibial Tunnel Bone Allograft Cpt Code For The. Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. Revision ACL surgery: A comprehensive approach - Mayo Clinic 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). Uchida et al. Methods: Successful revision surgery requires an understanding of the cause of failure, careful preoperative planning, meticulous surgical execution, proper postoperative rehabilitation, and appropriate patient counseling [4].
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