While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. [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 . Bone Tunnel Management in Modern Revision Anterior Cruciate Ligament Bethesda, MD 20894, Web Policies Arthroscopic Delivery of Injectable Bone Graft for Staged Revision a meta-analysis of 32 studies. To minimize the risk of viral and bacterial contamination, allograft bone is sterilized. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? MeSH 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. 4. Sometimes we can perform a biplanar osteotomy to correct both planes of deformity at once. Part of 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. Correlation between femoral tunnel length and tunnel position in ACL reconstruction. With each added degree of inclination, one gains 0.68 mm of tibial tunnel length. ACL Reconstruction with a Bone-Patellar Tendon-Bone (BPTB) Graft 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). Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL surgery. We thank Eun-Ji Jeon and Min-Ji Kim for their support. 2003 Jan;34(1):49-64. doi: 10.1016/s0030-5898(02)00070-6. 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. $.' A common belief of having 20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof. registered for member area and forum access. registered for member area and forum access. Achieving the correct position can be tricky. anterior cruciate ligament; bone graft; knee; revision. They observed that an average of 5.8months was needed for healing of the autograft dowel to become visible on CT scans [11]. 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. 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? - Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o'clock and 10 o'clock femoral tunnel placement. MeSH <> One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior. Tunnel malpositioning and widening remain the most common indications for two-stage revision ACLR. Two-stage revision ACLR should be considered in cases of tunnel lysis, infection, malalignment, meniscal deficiency, or chondral lesions. 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]. doi: 10.1016/j.eats.2020.08.024. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel. The tibial tunnel looked to be in a good position. Disclaimer. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings. Jul 22, 2009. 2018 Apr-Jun;9(2):116-120. doi: 10.1016/j.jcot.2018.02.010. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Ki-Cheor Bae. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. Arthroscopy. - resulting anterior-posterior cruciate ligament impingement near extension caused a persistentfunctional extension deficit of 20; This study aims to identify potential factors for both femoral and tibial tunnel widening (TW) and to investigate the effect of TW on postoperative outcomes after anterior cruciate ligament (ACL) reconstruction with a tibialis anterior allograft. 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). American Journal of Sports Medicine. No, I'm sorry that was my bad, you did say allograft, I just overlooked it. [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. femoral tunnel too far anterior in the notch; However, with precise indications, proper preoperative planning and operative-technique selection, two-stage revision ACLR can achieve favorable outcomes. National Library of Medicine 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]. Mosaicplasty. When aperture fixation is not possible, familiarity with, and use of, all-inside tibial and femoral sockets with cortical suspensory fixation may be necessary [4]. A tamp is used to further compress the graft. 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. They observed that the the failure rate was 10.3% in the one-stage revision group and 6.1% in the two-stage group. Biazzo A, Manzotti A, Motavalli K, Confalonieri N. J Clin Orthop Trauma. A Meta-analysis of 47,613 Patients. The optimal and earliest possible timing of the two-stage procedure is still not clear. Would you like email updates of new search results? A new technique for femoral and tibial tunnel bone grafting using the At Mayo Clinic, we also are evaluating surgical techniques for ACL reconstruction, as well as optimal approaches to multiligament knee reconstruction. Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Femoral press-fit fixation versus interference screw fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: 20-year follow-up. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. 2017 Jun;99-B(6):714-723. doi: 10.1302/0301-620X.99B6.BJJ-2016-0929.R2. 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. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. #1. There was also a significant improvement in the Lysholm score when comparing preoperative and postoperative values. Garcia-Mansilla I, Jones KJ, Kremen TJ Jr. JBJS Essent Surg Tech. Bone graft, any donor area; minor or small eg, dowel or button) (20900) Bone graft, any donor area; major or large (20902) Insertion vascular pedicle into carpal bone (25430) Bone marrow; aspiration only (38220) Bone marrow transplantation; autologous (38241) Microvascular. 1 0 obj - Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? Tunnel widening is generally cavitary, frequently maximal in the mid-zone of the tibial tunnel. - posterior placement or distal to normal site of attachment results in excessive tightening of the graft when knee is extended; and transmitted securely. (D-F) Coronal and axial computed tomography images showing bone tunnel dilatation (femoral, 15.7 mm; tibial, 9.8 mm). National Library of Medicine 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. 8 Therefore, one should avoid angles <40 to 45 . Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. Cookies policy. 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 . In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). - under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a eCollection 2021 Dec. Abdel-Aziz A, Waly MR, Abdel-Aziz MA, Sherif MM, Elhaddad H, Mostafa Zaky Abdelrazek BH. doi: 10.1016/j.eats.2022.01.004. % A 17-year-old female came to see us after two failed ACL surgeries. We NEVER sell or give your information to anyone. <> Bethesda, MD 20894, Web Policies Arthroscopy 33:819827, Diamantopoulos AP, Lorbach O, Paessler HH (2008) Anterior cruciate ligament revision reconstruction: results in 107 patients. Femoral and Tibial Tunnel Bone Grafting for Stage 1 Revision ACL Federal government websites often end in .gov or .mil. 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]. ACL reconstruction - Mayo Clinic - Mayo Clinic - Mayo Clinic statement and For assessment of bone-graft incorporation, radiographs are routinely used. Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results. stream However, the small number of included patients, especially in the group of patients without revision ACLR, is limited. 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. Bone graft substitute for tunnel filling improved ACL - Healio 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. Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Bone Joint J. Yoon et al. Orthopedics 39:e456e464, Noyes FR, Barber-Westin SD (2006) Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. doi: 10.1016/j.eats.2021.11.019. Preoperative planning for revision ACL surgery is essential for a successful outcome. 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. JCM | Free Full-Text | Femoral Tunnel Position Affects Postoperative 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. Knee-laxity measurements were elevated in the without-revision group, but the difference was not significant. 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). 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). What other specialized procedures might be performed in conjunction with ACL revision surgery? According to the result of the multicenter ACL Revision Study (MARS) Group, the risk of graft re-rupture following revision ACLR in patients receiving an autograft is 2.78 times less likely than in those receiving an allograft [35]. - ACL position is lower and more horizontal than that achieved when performing the transtibial (TT) procedure. In active young patients, failed primary ACLR may require a revision ACLR. An official website of the United States government. Terms and Conditions, Arthroscopic Bone Graft Technique for Two-Stage Revision Anterior 2017 Apr;33(4):819-827. doi: 10.1016/j.arthro.2016.10.007. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. endobj There are numerous challenges to revision ACL surgery with regard to graft selection, timing of surgery, and whether or not the surgery can be performed in a single operation or multiple-staged surgeries. A Retrospective Comparative Study In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted bone tunnels. - this technique allows for a more anatomic and precise placement of the femoral tunnel (more reliable posterior placement); American Journal of Sports Medicine. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). bone graft acl tunnel cpt - juliocarmona.com 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. 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. endobj 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. 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? - Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting. The results from this group were compared to the results of a matched group of patients with primary ACLR. Prall WC, Kusmenkov T, Frmetz J, Haasters F, Mayr HO, Bcker W, Grote S. Injury. ]+yC`6Hd Ql]M 3w7ah;HNdyS*7x-zq^/4%^6eA$m@(,ly}U[N9E(/=iHCL")d6yx]K7!84,q!r~#6mE8dIS69eYn Anterior cruciate ligament (ACL) reconstruction rates have increased over the past 20years to roughly 200,000 per year [1]. Revision ACL surgery: A comprehensive approach - Mayo Clinic government site. Ligaments are strong bands of tissue that attach one bone to . Privacy This adds a fair amount of complexity to the procedure. Knee Surg Sports Traumatol Arthrosc 18:10591064, Bhatia S, Korth K, Van Thiel GS, Frank RM, Gupta D, Cole BJ et al (2016) Effect of tibial tunnel diameter on femoral tunnel placement in transtibial single bundle ACL reconstruction. Orthopaedic Specialists of North Carolina. Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. 2002 Richard O'Connor Award paper. You are using an out of date browser. 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 . 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 3. They recommended that two-stage reconstruction could be safely performed at 24weeks after bone grafting by the iliac-bone block-grafting technique. Make a donation. 6 0 obj ",#(7),01444'9=82. There is no code for bone grafting. Background: Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. 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. endstream The prior skin incision is typically used to expose the distal portion of the tibial tunnel. 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. It does not hit an edit, but be prepared for insurance to deny it. - Reflex extension loss afteranterior cruciate ligamentreconstruction due to femoral "high noon" graft placement. [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. Systematic review. 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. JavaScript is disabled. He did other procedures, but I have the codes for them. Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. - one incision transtibialtechnique Get timely coding industry updates, webinar notices, product discounts and special offers. A clinical, prospective, randomized, double-blind study, Femoral Shaft Frx: Leg Lengths / Nail Lengths, Orthopaedic Specialists of North Carolina. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Autologous Dedifferentiated Osteogenic Bone Marrow Mesenchymal Stem (A, B) Anteroposterior and lateral knee radiographs showing bone tunnel positioning, widening, and retained biocomposite screw. Would this qualify for CPT 29888 with a 52 mod? 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]. doi: 10.2106/JBJS.ST.20.00055. 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. Overview. Arthroscopic knee procedure CPT codes range from 29866 to 29889. Enhancement of tendon-to-bone healing after anterior cruciate ligament reconstruction using bone marrow-derived mesenchymal stem cells genetically modified with bFGF/BMP2. Conclusion: 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. Biomechanical Comparison Between Bashti Bone Plug Technique and a statistical evaluation. PDF Two-stage revision anterior cruciate ligament reconstruction Federal government websites often end in .gov or .mil. Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. Abstract The . 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. 2020;38:1191. Few studies report the outcomes of two-stage revision ACLR alone. eCollection 2020 Dec. Prall WC, Kusmenkov T, Schmidt B, Frmetz J, Haasters F, Naendrup JH, Bcker W, Shafizadeh S, Mayr HO, Pfeiffer TR. - A Comparison of 2 Drilling Techniques on the Femoral Tunnel for Anterior Cruciate Ligament Reconstruction Careers. Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. Preoperative planning is critical to identify and characterize bone tunnel pathology. <> One of the main factors associated with tunnel enlargement is malposition of the tibial tunnel, which likely leads to graft micromotion. Bone Graft related CPT Codes. Some authors have described the additional use of CT scans to confirm healing at 35months after bone grafting [4, 12, 33, 34]. 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. - graft was placed on the femoral site in the high noon position combined with a slight medial tibial tunnel placement; For example, patients may require bone grafting of prior graft tunnels, and then have the ACL revision in a second stage. 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. 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]. Bone Marrow Aspirate Concentrate With Two-Staged-Revision ACL <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Diermeier et al. - Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. He is only grafting the bone. Tibial tunnel cyst | Radiology Reference Article | Radiopaedia.org 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. 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]. Journal of Orthopaedic Research. - anterior graft placement (relative to normal anatomical insertion of ACL) results in high strain on graft as knee is flexed; Cite this article. doi: 10.2106/JBJS.ST.20.00055. For a better experience, please enable JavaScript in your browser before proceeding. Mayo Clinic is a not-for-profit organization. This content does not have an English version. Tibial tunnel cysts, including pretibial cysts , are occasional complications of autologous or synthetic anterior cruciate ligament (ACL) reconstruction surgeries. -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.. They found that a sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution. Noyes et al. Clipboard, Search History, and several other advanced features are temporarily unavailable. [31] used Si-CaP for a bone-graft substitute for tunnel augmentation in two-stage revision ACLR. - consider whether there is an interplay between posterior graft placement and appropriate graft tension; 2020 Dec 21;9(12):e1917-e1925. Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. In the immediate postoperative period, the weakest part of any ACLR is the fixation. Epub 2018 Feb 23. Improved muscle strength may be the decisive factor; however, changes in functional movement patterns after intensive physical therapy are also important to consider [41]. Bone Graft related CPT Codes - eatonhand.com Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Revision ACLR surgeries can be mainly divided into one-stage and two-stage procedures. However, remarkable advances in knowledge of this process have been made based primarly on animal models. Unable to load your collection due to an error, Unable to load your delegates due to an error. 2022 Feb 28;11(3):e463-e469. 3 0 obj At Mayo Clinic, we sometimes correct the alignment before performing revision ACL surgery, to prevent graft failure. Lateral tibial posterior slope is increased in patients with early graft failure after anterior cruciate ligament reconstruction. - graft that tightens (pulls up into the tibial tunnel) with flexion will have a much higher likelyhood offailure and usually indicates a Thomas et al.
Casualty Actors Who Have Died In Real Life, Effects Of Urban Sprawl In Bristol, Articles B