DESCRIPTION
The anterior cruciate ligament (ACL) is located in the center of the knee and holds the femur and the tibia in place. The ACL attaches from the back of the femur to the front of the tibia. The ACL is one of the most important ligaments to athletes because it functions to stabilize the joint during deceleration movements.
ACL reconstruction is generally an arthroscopic procedure. Before the reconstruction, an arthroscope is used to carefully survey the whole joint. Once the injured ACL is removed, the allograft is placed in the same position as the original ACL and fastened securely in place with two "interference fit" screws. The purpose for this procedure is stabilization of the knee.
POLICY
Allograft anterior cruciate ligament reconstruction for the treatment of ACL deficiency is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Policies with similar titles:
MEDICAL APPROPRIATENESS
Allograft ACL reconstruction is considered medically appropriate for an individual who is not a candidate for autogenous transplantation due to ANY ONE of the following:
Autogenous tissue that has been compromised (e.g., by previous surgery, previous injury)
Multi-ligament reconstruction is being performed
Pathology such as chronic patellar tendonitis and hamstring injury exists
ADDITIONAL INFORMATION
According to the American Association of Tissue Banks, allograft tissue (tissue from another person's body) is used by surgeons because of the inadequate amount of available autograft tissue (a person's own bone or soft tissue). Allograft tissue is commonly used in reconstructive surgeries and in cases of bone loss due to trauma or tumors.
Donor-recipient matching is done primarily by size to ensure optimum fit of the allograft; tissue typing is not required since the allograft is only minimally immunogenic. Screening, collection and processing of the donor grafts include the following steps:
Screening of donors using American Association of Tissue Banks (AATB) schema to rule out groups at high risk for human immunodeficiency virus (HIV) infection and systemic disease, including infection, neoplasia and arthritis. Screening of blood for types B and C hepatitis, syphilis, and HIV disease.
Culturing of donor tissues for bacterial and fungal infection.
Lymph node evaluation at autopsy.
Harvesting of the grafts under sterile conditions, preferably within 12 hours of death.
Preservation of the specimens in a tissue culture solution containing antibiotics at 4° C until transplantation. Transplantation usually occurs within 3 days. Although tissue is cryopreserved, most investigators use fresh graft material.
SOURCES
American Academy of Orthopaedic Surgeons. (2002). Multiple ligamentous injuries of the knee in the athlete. Retrieved December 17, 2002 from http://www3.aaos.org/product/prt_item.cfm?code=02574.
American Association of Tissue Banks. (2002). What can you tell me about bone & tissue transplantation? Retrieved January 22, 2003 from http://www.aatb.org/aaosinfo.htm.
BlueCross BlueShield of Tennessee network physicians. December 2002.
Center for Disease Control and Prevention (CDC). (2002). Update: Allograft-associated bacterial Infections - United States, 2002. Morbidity and Mortality Weekly Report, 51 (10), 207-210.
Center for Disease Control and Prevention (CDC). (2003). Invasive streptococcus pyogenes after allograft implantation - Colorado, 2003. Morbidity and Mortality Weekly Report, 52 (48), 1173-1176.
Center for Disease Control and Prevention (CDC). (2006, September). About tissue transplants. Retrieved June 2, 2008 from http://www.cdc.gov/ncidod/dhqp/tissueTransplantsFAQ.html.
Chang, S. K., Egami, D. K., Shaieb, M. D., Kan, D. M., & Richardson, A. B. (2003). Anterior cruciate ligament reconstruction: Allograft versus autograft. Arthroscopy, 19 (5), 453-462. Abstract retrieved November 4, 2004 from PubMed database.
Fuchs, R., Wheatley, W., Uribe, J. W., Hechtman, K. S., Zvijac, J. E., & Schurhoss, M. R. (2002). Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 18 (8), 824-828.
Johnson, D. (2004). AAOS 2004: All about allografts - highlights of the 71st annual meeting of the American Academy of Orthopaedic Surgeons. Medscape General Medicine, 6 (4), 23.
Miller, S.L., & Gladstone, J. N. (2002). Graft selection in anterior cruciate ligament reconstruction. Orthopedic Clinics of North America, 33 (4), 675-673.
National Guideline Clearinghouse. (2004, January). Review criteria for knee surgery. Retrieved August 4, 2006 from http://www.guidelines.gov.
Petrigliano, F. A., & McAllister, D. R. (2006). Tissue engineering for anterior cruciate ligament reconstruction: A review of current strategies. Arthroscopy, 22 (4), 441-451. Abstract retrieved August 4, 2006 from PubMed database.
Poehling, G. G., Curl, W. W., Lee, C. C., Ginn, T. A., Rushing, J. T., Naughton, M. J., et al. (2005). Analysis of outcomes of anterior cruciate ligament repair with 5-year follow-up: Allograft versus autograft. Arthroscopy, 21 (7), 774-785. Abstract retrieved August 4, 2006 from PubMed database.
Tom, J. A., & Rodeo, S. A. (2002). Soft tissue allografts for knee reconstruction in sports medicine. Clinical Orthopedics and Related Research, (402), 135-156.
U. S. Department of Health and Human Services. (2005, May). Federal Register. Eligibility determination for donors of human cells, tissues, and cellular and tissue-based products. Retrieved August 4, 2003 from http://www.fda.gov/CbER/rules/suitdonor.pdf#search=%22www.fda.gov%2Fcber%2Frules%2Fsuitdonor.pdf%22.
ORIGINAL EFFECTIVE DATE: 12/1/2001
MOST RECENT REVIEW DATE: 7/24/2008
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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