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Letters to the Editor |
Cincinnati, Ohio
Dear Editor:
I would like to provide a few comments and raise some questions in regard to the article by Stannard et al., "Anatomic Reconstruction of the Posterior Cruciate Ligament after Multiligament Knee Injuries. A Combination of the Tibial-Inlay and Two-Femoral Tunnel Techniques" (March/April 2003, pages 196–202). The authors stated they were describing a new and novel operative procedure in using a double-bundle PCL tibial inlay technique and stated, "We are not aware of any other descriptions of this anatomic PCL reconstruction technique." Their operative cases occurred from 1998 to 2000.
In fact, I have used this technique since 1995 and have discussed it in detail at numerous AAOS and AOSSM instructional courses. The development of this technique included production of instruments by a commercial company (Smith & Nephew), which also produced a technical manual, PCL Reconstruction with the Acufex Director Drill Guide, Featuring Noyes All-Inside and Tibial Inlay Techniques With a Double-Bundle Quadriceps Tendon Graft. This manual was first distributed to the orthopaedic community at the 1998 annual meeting of the AAOS and continues to be distributed to date. We note many similarities of the authors’ Figure 1 and figures that appear in that manual.
The technique was described in detail and published in 2000.6 We presented for the first time, on February 6, 2003, at the AAOS annual meeting, clinical data on patients who received this operation.5
As the old adage goes, it is always risky to claim being innovative enough to arrive at a new operative technique. Being first is not the real issue though; more importantly, the orthopaedic community needs to know if the technique works and provides for more reliable PCL reconstruction results.
In our AAOS presentation, on our series of 27 knees followed a mean of 39 months after a quadriceps tendon-patellar bone double-bundle reconstruction, we reported a high success rate in the restoration of stability. Several of the knees in our study had multiple ligament ruptures, such as those in the study by Stannard et al., with multiple ligament reconstructions performed in 15 cases. Thus, it would appear, based on two clinical series, that the double-bundle technique may provide an advantage over single-bundle reconstructions previously used for PCL deficiency. To this end, we congratulate the authors on their contribution.
In our study, we compared 15 knees that had the tibial inlay technique with 12 knees that had an all-inside arthroscopic procedure in which the bone portion of the graft was placed into the femur and the two bundles of the graft were brought out through the tibia. We found no difference in results in terms of stability or other variables. Ours was a small series, but suggested that the all-inside technique may be used with equal results, avoiding the necessity for the separate posterior approach.
I would like to ask the authors to more precisely define the placement of the second bundle of their graft construct. If the second bundle is placed 8 mm from the articular cartilage edge, as the article describes, then that bundle should be tightened in 90° of knee flexion, and not 20°, as stated in their article. This statement is based on the biomechanics of a double-bundle PCL reconstruction that we and other authors have published.3,4 Any graft placed in the distal and middle portions of the native PCL will elongate with progressive knee flexion. Only the most proximal part of the PCL footprint contains fibers that function in knee extension. Did the authors locate the second bundle in the distal and middle portions or in the proximal portion? A graft placed in the proximal portion should be tightened in knee extension (20°).
The concept of where to place the two bundles has been extensively studied. In short, the placement in a proximal and distal reference point determines the function of that bundle. It is too simplistic, in our view, to characterize the PCL as having two functional bundles: anterolateral that tightens in flexion and posteromedial that tightens in extension. The PCL has a much more complex pattern that must be duplicated in which the distal fibers tighten in flexion and the most proximal fibers tighten in extension, based on the location of the PCL fibers and the center of knee rotations.2,7 This literally means that within the so-called anterolateral bundle, the distal fibers tighten in flexion and the proximal fibers would tighten in extension, and the same applies for the so-called posteromedial bundle. A better nomenclature, proposed by Covey et al.,1 is to divide the PCL into anterior, middle, and posterior thirds (including the oblique posterolateral fibers). We further divide the PCL into proximal, middle, and distal thirds. In fact, this is the same nomenclature for the anterior, middle, and posterior thirds of a meniscus. This allows the surgeon the ability to precisely define the placement of the bundles. The PCL functions proximal-to-distal in fiber function with knee flexion, not anterior-to-posterior.
As a final note, the posterior tibial inlay approach does require marked familiarity with the anatomic variations of the neurovascular structures. We prefer, in complex reconstructions and dislocations, to use the all-inside approach, believing this lessens the morbidity and potential complications.
REFERENCES
Birmingham, Alabama
The letter from Dr. Noyes discusses two primary issues. The first issue is regarding our statement that we were not aware of any other descriptions of the combination of the tibial inlay and double-bundle anatomic PCL reconstruction technique. I agree wholeheartedly that being first to describe this combination is not the real issue—the real issue is whether it works and represents a step forward in the care of these complex injuries. I did not state that we were not aware of other descriptions of this combination in an attempt to draw attention to ourselves as being "innovative enough to arrive at a new operative technique," as Dr. Noyes has suggested. Our article makes it clear that the innovators regarding this technique are Clancy, Harner, Berg, and others who have developed the two techniques that are being combined. I hope we made it clear that we did not develop any of these techniques, but only combined two well thought-out techniques.
One may ask why I made the statement that we were not aware of other descriptions of the technique. It was to allow readers to know that there were no other references with published results using the technique or descriptions of our exact technique, to the best of our knowledge. There are so many journals and books currently being published that there is a very real risk of missing a description of a similar technique, despite a literature search. That is the reason that we stated that "we are not aware of any other descriptions . . .," rather than stating that there have not been any other descriptions of the technique. If Noyes and colleagues published this technique in the textbook edited by Insall and Scott in 2000, then clearly their description precedes ours.
I do not believe that their presentation of clinical results in 2003 at the AAOS meeting (our results were presented in 2001 at the AOSSM meeting) would change our statement. I also do not believe that either lectures given at national meetings or technique manuals from orthopaedic implant companies can be considered in the same category as textbook and journal publications. I have never had the pleasure of hearing Dr. Noyes’ lecture on this topic, and have not used or been exposed to the Smith & Nephew technique guide. I can also assure Dr. Noyes that any similarities in our figures and those in the technique manual result from the fact that we are both combining techniques described by others, as already noted. The figures with our article are original art, drawn by a medical illustrator at our institution, who was well compensated for his efforts. He based his drawing on my descriptions, pictures taken in the operating room, and from an operative case.
I am very happy to hear that Dr. Noyes has employed a similar technique with good results because the technique is only valuable if good results can be obtained by different surgeons at different sites. Again, I acknowledge that the published reference by Noyes in 2000 precedes ours.
The second issue regards the placement of the femoral tunnels. Our tunnel techniques are very similar to technique descriptions by Sekiya et al.2 They describe their anterolateral bundle in the 11-o’clock or 1-o’clock position, approximately 6 mm off the articular surface, and tensioned at 90° of flexion. Their second bundle is described at approximately the 2:30-o’clock position and tensioned at 15° of flexion. We have differed slightly in that we place the anterolateral bundle approximately 8 mm off the articular surface, and tension in approximately 70° of flexion, as described in the article. The second bundle has been tensioned at 20° of flexion, which is very similar. We also strive for a 4- to 5-mm bone bridge between the two tunnels, as they describe. The picture in the text on page 84 is very similar to that of our placement, except that our second bundle is slightly further posteriorly. Clancy and Bisson1 have published a technique article that also describes the position well. Figure 2 on page 113, showing their tunnel placement, is very similar to our tunnel placement. Their tensioning is very similar to what is described in our article as well as that in the article by Sekiya et al.2 Our anterolateral bundle is placed 8 mm from the articular cartilage and it is tightened in flexion (we have used approximately 70°). We agree that the concept of the PCL being two functional bundles, one anterolateral and the other posteromedial, is probably too simplistic when compared with an intact PCL. However, that concept is what we used in our technique and series. Again, it is very similar to what is published in the two technique papers cited here.1,2
My coauthors and I appreciate Dr. Noyes’ letter and look forward to the publication of his series. It is very gratifying to know that he is using a similar technique and obtaining excellent results.
REFERENCES
This article has been cited by other articles:
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  R. B. Campbell, A. Torrie, A. Hecker, and J. K. Sekiya Comparison of Tibial Graft Fixation Between Simulated Arthroscopic and Open Inlay Techniques for Posterior Cruciate Ligament Reconstruction Am. J. Sports Med., October 1, 2007; 35(10): 1731 - 1738. [Abstract] [Full Text] [PDF]
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