Griffith TB, et al. 2020;38:1191. Methods: Careers. Telephone: 410.494.4994, Morphology of the Femoral Intercondylar Notch, The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction. I am still awaiting the OP note from the ASC, which takes weeks, so I can't post it. CAS Revision ACL surgery: A comprehensive approach. Outcomes of repeat revision anterior cruciate ligament reconstruction. We focus on many factors including the status of the menisci, cartilage, alignment, tibial slope and other knee ligaments, as well as technical issues from the index surgery, such as the positioning of ACL sockets and tunnels. - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. 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]. Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study. 110 West Rd., Suite 227
Correlation between femoral tunnel length and tunnel position in ACL reconstruction. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 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. 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. A decision that will often depend on the graft used during the primary ACLR. endstream
[33] evaluated 30 patients who underwent two-staged ACLR revision procedure after a traumatic re-rupture of the ACL. Mosaicplasty. Neil Duplantier MD. 8600 Rockville Pike statement and Pre-op imaging shows excessive tunnel and socket widening and no malalignment with normal slope. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Disclaimer. These lesions are often difficult to see on MRI. 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. 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. 1 0 obj
Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. All the patients in the study underwent screw removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. After 6 to 12weeks, failures tend to occur in mid-substance [11]. 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. 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? 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. 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. Unable to load your collection due to an error, Unable to load your delegates due to an error. Few studies report the outcomes of two-stage revision ACLR alone. American Journal of Sports Medicine. TECHNIQUE VIDEO. ",#(7),01444'9=82. The patients were divided into two groups based on the tunnel diameter (group A, <12mm; group B, <12mm). The authors declare that they have no competing interests. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. 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. FOIA Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. The femoral tunnel was easily visualized with flexing the knee beyond 90 degrees. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. Drilling a tibial tunnel at 40 degrees yields an average tunnel length of 45.442.18 mm. PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. At a mean follow-up of 7.9years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. MARS Group. A relatively small but challenging subset of patients requires two-stage revision ACLR. Study design: Systematic review. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? 3. 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. Louis et al. Bone tunnel-related issues are frequently encountered during revision anterior cruciate ligament reconstruction. You must log in or register to reply here. doi: 10.1016/j.eats.2022.03.024. Federal government websites often end in .gov or .mil. Approximately 200,000 anterior cruciate ligament (ACL) ruptures occur in the United States annually. I just want to get the basic idea so I can advise him since he keeps a copy of his billing. Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. - Editorial: The Lateral Intercondylar RidgeA Key to Anatomic Anterior Cruciate Ligament Reconstruction Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. Biomechanical Comparison Between Bashti Bone Plug Technique and PDF ACL reconstruction revision with staged bone grafting endobj
To date, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of primary ACLR. Rehabilitation after the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. Anterior cruciate ligament (ACL) reconstruction rates have increased over the past 20years to roughly 200,000 per year [1]. Resurfacing technique consisting of transplantation of multiple osteochondral grafts to smooth the area. [26] reported the use of a sCO2-sterilized bone allograft to fill tunnel defects as the first stage of a two-stage revision ACLR. Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery. MeSH PMC 2021 Oct 12;11(4):e20.00055. If this is your first visit, be sure to check out the. eCollection 2022 Mar. Often the meniscus hasn't healed after the initial surgery, or lesions might have been overlooked during surgery, in particular meniscal root tears or meniscal ramp lesions. View all the articles associated with any code, right from the code page. %
See our privacy policy. Then in that case, yes, I would code this as 29888-52. CT scans to confirm healing at 3-5months after bone grafting [4, 12, 33, 34]. 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. 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. doi: 10.2106/JBJS.ST.20.00055. A 17-year-old female came to see us after two failed ACL surgeries. Bone Marrow Aspirate Concentrate With Two-Staged-Revision ACL <>
Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Part of [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 . - Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. 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. - A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction ]+yC`6Hd Ql]M 3w7ah;HNdyS*7x-zq^/4%^6eA$m@(,ly}U[N9E(/=iHCL")d6yx]K7!84,q!r~#6mE8dIS69eYn
Bethesda, MD 20894, Web Policies 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. Thomas et al. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. doi: 10.1016/j.eats.2021.11.019. volume31, Articlenumber:10 (2019) Comparison of Femoral Tunnel Position and Clinical Results. American Journal of Sports Medicine. 29866 is for autografts (from the patient). - Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. Correspondence to [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. CPT codes are grouped into 6 sections: 1. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. endobj
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. #1. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. Outcomes of repeat revision anterior cruciate ligament reconstruction. 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. Epub 2018 Feb 23. Autogenous grafts are considered the gold standard, due to their osteoinductive, osteoconductive, and osteogenic properties. - over the top repair tensioned in extension will provide support in terminal extension but may slacken at greater flexion angles; This site needs JavaScript to work properly. Recently, we recognized that patients needing ACL reconstruction who also have significant rotatory instability of the knee may have injuries in the anterolateral complex. xMO@; aK]XDZ)r(-w(;.B ~8MG{ - references: Bone Grafting Tibial and Femoral Tunnels knee Portion of op note reads as follows: ACL was completely absent in mid aspect. I forgot to mention he did an allograft bone graft. [21] evaluated 88 patients who underwent one-stage revision ACLR. endobj
Google Scholar, Group M, Ding DY, Zhang AL, Allen CR, Anderson AF, Cooper DE et al (2017) Subsequent surgery after revision anterior cruciate ligament reconstruction: rates and risk factors from a multicenter cohort. -Femoral Tunnel Drilling From the Anteromedial Portal Using the Figure-4 Position in ACL Reconstruction. Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. Blurring of the tunnel margins, reactive sclerosis, and the presence of bone within the tunnel were used as signs of adequate healing. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision - Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: a cadaveric study Christensen JJ, et al. 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. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Epub 2018 Dec 17. - The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint CT analysis also included the determination of the filling rates of the tunnels. Uchida et al. 2019 Feb;50(2):467-475. doi: 10.1016/j.injury.2018.12.020. 2021 Oct 12;11(4):e20.00055. In cases like these your going to need to bill out "what you can" which in this case would be 20680. registered for member area and forum access. ACL injuries most commonly occur during sports that involve sudden stops and changes in direction such as soccer, football, basketball and volleyball. Conclusion: 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. Bruce A. Data Trace Publishing Company
Epub 2007 Jan 5. Mayo Clinic is a not-for-profit organization. <>>>
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. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. The .gov means its official. Data Trace is the publisher of
doi: 10.2106/JBJS.ST.20.00055. (C) Sagittal magnetic resonance imaging showing insufficiency of the anterior cruciate ligament graft. PDF Acl Reconstruction With Allograft Cpt Code - annualreport.psg.fr Hello, our physician bone grafted the previous ACL tunnels with allograft via arthroscopy. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. sharing sensitive information, make sure youre on a federal To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. 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? 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. They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. In additional analyses, 24% (12/49) of patients were newly found to have concomitant knee injuries (e.g., chondral defects, meniscal lesions) at the time of the second-stage operative procedure. Inferior tendon graft to bone tunnel healing at the tibia compared to that at the femur after anterior cruciate ligament reconstruction. https://doi.org/10.1186/s43019-019-0010-6, DOI: https://doi.org/10.1186/s43019-019-0010-6. - tunnel positioning: If this is your first visit, be sure to check out the. Bookshelf - Discussion: It may not display this or other websites correctly. 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. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. Bone grafting of femur and tibial tunnels - AHA Coding Clinic for HCPCS An Observational Study Using Navigated Measurements. The slope causes the tibia to move forward and the femur to fall backward, putting tremendous strain on the ACL. Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. Bookshelf He is only grafting the bone. - Anteromedial Portal vs Transtibial Drilling Techniques in Anterior Cruciate Ligament Reconstruction: Any Clinical Relevance? Two-stage revisions are rarely performed, but are particularly useful when addressing substantial tunnel-widening, active infection, and concomitant knee pathology (e.g., malalignment, other ligamentous injuries, meniscal or chondral lesions). This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. There are several techniques for bone grafting tunnels in one- or two-staged ACL revision procedures with either autograft or allograft. government site. 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]. Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. - Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. By using this website, you agree to our 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. But an iliac-crest autograft is comparatively invasive with relatively high donor-site morbidity and the potential for insufficient yield quantities [11, 22]. Comparing Bone-Tendon Autograft With Bone-Tendon-Bone Autograft for ACL - one incision transtibialtechnique Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous . Would you like email updates of new search results? Systematic review. - w/a right knee, place the tunnel at about the 9:30 to 10 oclock position; Unfortunately, the most common cause for failure is related to technical issues from the primary ACL surgery, with malposition of the sockets and tunnels, particularly on the femoral side. Knee Surg Sports Traumatol Arthrosc 24:5157, Chahla J, Dean CS, Cram TR, Civitarese D, OBrien L, Moulton SG et al (2016) Two-stage revision anterior cruciate ligament reconstruction: bone grafting technique using an allograft bone matrix. PubMedGoogle Scholar. eCollection 2021 Oct-Dec. von Recum J, Schwaab J, Guehring T, Grtzner PA, Schnetzke M. Arthroscopy. Guide pins were placed in the tibial tunnel and next putty and dowels (grafts) were placed in the tibial and femoral tunnels. Arthroscopic knee procedure CPT codes range from 29866 to 29889. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. eCollection 2020 Dec. - surgeon will also note more perpendicular drill angle to bone surface with AM vs TransTibial drilling; 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. For a better experience, please enable JavaScript in your browser before proceeding. Drilling the Femoral Tunnel During ACL Reconstruction: Transtibial Versus Anteromedial Portal Techniques. Root tears also put tremendous forces on the ACL graft and can lead to rotational instability and graft failure. The two-stage group contained significantly more patients with meniscal and chondral pathology compared with the primary ACLR group. 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. Morphological Changes in the Tibial Tunnel After ACL Reconstruction The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. Arthrosc Tech. 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. Accessibility Unauthorized use of these marks is strictly prohibited. Cancel anytime. They observed that an average Tibial tunnel was found to be anterior, perhaps more inferior than would be in an anatomic ACL insertion. Bone Grafting tibial and femoral tunnels knee, failed ACL The bone graft is deployed, and plunger can be used to gently pack graft into tunnel. 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]. 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]. Our Experience: 2014 - 2018 . 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. The site is secure. Uchida et al. performed a CT scan at 4months to assess healing of the bone graft in the tibial tunnel. Patients were divided into the isolated revision ACLR group (n=45) and the revision ACLR group in combination with ALL reconstruction (n=42). ACL reconstruction - Mayo Clinic - Mayo Clinic - Mayo Clinic Bone Graft related CPT Codes. Predictors of clinical outcome following revision anterior cruciate ligament reconstruction. Trojani et al. Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute. For assessment of bone-graft incorporation, radiographs are routinely used. The results from this group were compared to the results of a matched group of patients with primary ACLR. 2022 Jun 21;11(7):e1367-e1372. 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. Patrick C. McCulloch MD. Von recum et al. eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. The goal is to ensure patients of all activity levels, from professional to recreational, have the surgeries that meet their individual needs. eCollection 2022 Jul. Two years after the surgery, she resumed all activities and plays collegiate volleyball. Autologous Dedifferentiated Osteogenic Bone Marrow Mesenchymal Stem Before -notchplasty This content does not have an Arabic version. TJ!!X`Sz9Q*BeV={=F ' 0y^*2| '! 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. - Anatomic femoral tunnel drilling in anterior cruciate ligament reconstruction: use of an accessory medial portal versus traditional transtibial drilling A Retrospective Comparative Study A single copy of these materials may be reprinted for noncommercial personal use only. A two-stage revision involves an initial bone grafting procedure to fill the tunnels, followed at least . Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Jul 22, 2009. Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft. In addition, patients who receive revision ACL surgery might have other damaged ligaments. Optimal outcomes require a precise picture of how the ACL reconstruction failed. 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 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. Comparison of Femoral Tunnel Position and Clinical Results. - resulting anterior-posterior cruciate ligament impingement near extension caused a persistentfunctional extension deficit of 20;