Dr. Leo Pinczewski: Innovator in ACL Reconstruction
April 26, 2000
Dr. Leo Pinczewski: Innovator in ACL Reconstruction
By Neal Patel, Knee1/Body1 Staff
The movement today in anterior cruciate ligament reconstruction is towards accelerated rehabilitation with a rapid return to normal function. Ideally, the goal for patients is to come out of surgery with less pain, fewer hindrances and a quicker recovery time. Dr. Leo Pinczewski, an Australia surgeon, has devised an innovative technique for ACL reconstruction, bringing him to the forefront of this field. Uniquely, Dr. Pinczewski’s technique uses an interference fit screw to fix the tendon graft to the knee joint, providing immediate stability needed for a quick and unrestricted recovery.
Dr. Pinczewski received his medical degree from Sydney University in 1976. After completing his advanced surgical training, also at Sydney University, he received his Fellowship of the Royal Australian College of Surgeons in 1983. Currently, Dr. Pinczewski serves as a consultant orthopedic surgeon at the Mater Misericordiae Hospital and the Castlecrag Private Hospital, both in North Sydney and he also practices at the North Sydney Orthopaedic & Sports Medicine Centre in Crows Nest, Sydney.
Over the course of his career, Dr. Pinczewski has conducted over 5,300 anterior cruciate ligament reconstructions and currently performs about 450 reconstructions per year. Amazingly, the North Sydney Orthopaedic & Sports Medicine Centre manages approximately 10 percent of the anterior cruciate reconstructions in the whole of Australia. Patients and surgeons alike visit the clinic from all over the world.
Knee1: How did you become interested in the area of anterior cruciate ligament reconstruction?
Dr. Pinczewski: I commenced knee ligament reconstructive surgery by default having originally been trained in joint replacement surgery of the hip and knee. When I began consultant practice in 1984, a political dispute in our State prohibited my taking up an appointment in a joint replacement unit. Therefore, I joined in private practice with Dr. Mervin J. Cross OAM. This was the beginning of a partnership which has lasted over fifteen years and has seen the development of a multi-disciplinary orthopedics and sports medicine center which at present has nine orthopedic surgeons, five sports medicine physicians, two physiotherapy practices as well as radiology and sports related dieticians. Within my first two years at the clinic, being responsible for the acute knee injuries that could not be seen by my senior partner due to time constraints, I had operated on 150 combined ligamentous injuries of the knee joint relating to sporting trauma. These operations were open surgery. That’s how I learned much about knee ligaments and the anatomy of the knee joint. I went on to perform 700 open anterior cruciate ligament reconstructions with lateral extra capsular augmentation. These procedures required approximately five days hospitalization and initially necessitated a long leg plaster cast for six weeks and a prolonged rehabilitation. In 1988 anterior cruciate ligament reconstructive surgery became possible with the use of the arthroscope and our clinic decided upon the middle third patellar tendon graft. Subsequently, I have repaired or reconstructed 1800 anterior cruciate ligaments with that technique.
Knee1: Did you find it advantageous to be trained in performing open knee surgeries rather than immediately starting with arthroscopic surgery?
Dr. Pinczewski: Absolutely. Having a large experience with open knee surgery is one of the reasons that I think surgeons of my generation have a great advantage over the young surgeons who are training today. The 700 operations in which I laid the knee open, essentially pulling it apart before putting it back together again, gave us an intimate working knowledge of the normal and abnormal structures of the knee joint.
Knee1: Why do you prefer to use the hamstring tendon instead of the more conventional patella tendon in ACL reconstruction surgery?
Dr. Pinczewski: Because of the problems that I saw from my patients who had undergone middle third patella tendon reconstruction—and I saw more problems than most people because I carried out more operations. The main problems were patellar tendonitis and pain and tenderness from the patellar tendon donor site. This led us to begin using the hamstring tendon in selected cases. It soon became apparent that the comparison between the hamstring tendon graft technique and the patellar tendon graft technique was enormous, like comparing arthroscopic surgery to open surgery. There was a quantum leap in patient and surgeon satisfaction. I don’t think many people will return to patella tendon graft reconstruction of the ACL once they have successfully utilized hamstring tendon grafts.
As we initiated a new technique with hamstring tendon fixation, a prospective study was commenced comparing ninety isolated ACL patients who had undergone patellar tendon reconstruction and an overlapping number of ninety patients who underwent hamstring tendon reconstructions. This is probably the longest prospective clinical study of its kind and we have just reported the five-year results. Amazingly, if one utilizes interference screw fixation for both grafts, the only difference between the two is in what we call donor site morbidity. Patellar tendon patients have a lot more trouble in the immediate post operative period with pain and swelling. With the hamstring tendon graft, we have an operation that is minimally invasive and is true day surgery. In my 1800 patients who underwent patellar tendon reconstruction, their average bed day stay was two days before they could mobilize comfortably and be discharged from hospital. With the hamstring tendon graft, even though we were not trying to discharge patients, seven out of ten patients left our hospital on the same day of surgery since they rapidly mobilized with comfort. An analysis of the remaining 30 percent of patients revealed that most were from a long distance away or had nausea and vomiting following the anesthetic. Recent advances in anesthetic technique have allowed 98 percent of patients to comfortably undergo hamstring tendon reconstruction of the ACL as a day only procedure.
In the past six years, I have carried out 2800 hamstring tendon ACL reconstructions. The problems and complications of harvesting the hamstring tendon are miniscule in both frequency and severity in comparison with patellar tendon harvest. Therefore, hamstring tendon harvest has allowed me to carry out my surgery technically quicker and with greater ease, translating to a less morbid procedure for the patient. Our five year study has confirmed that the success rate of the hamstring tendon surgery fixed with the interference screws is the same as the success rate for patellar graft reconstructions fixed with interference screws.
Speed of recovery is another advantage. Hamstring tendon patients progress faster than patellar tendons towards normal daily activities. For example, hamstring patients are on crutches from one day to one week and a brace or support is not required. By two weeks, hamstring tendon graft patients should be walking normally and jogging usually commences at about six weeks post operatively. Patients are utilizing an exercise bike two or three days following their surgery.
A final advantage of the hamstring tendons is that the tendons re-grow and have little or no effect on the long-term strength of the leg. Patellar tendons did not re-grow very well and the scar tissue in the front of the knee was prone to causing recurrent tendonitis.
Knee1: Surgeons have been using hamstring tendons in ACL reconstruction for a while now, what is innovative about your technique?
Dr. Pinczewski:The big breakthrough came when I decided to fix the hamstring tendon into the hole drilled for the graft with a specially designed interference screw. Interference screws had been used with patellar tendon grafts with great clinical success, but techniques for hamstring tendon fixation required fixing the graft with staples external to the joint (requiring an extra incision) or suspending the hamstring tendons on sutures within the joint. In North America, an Endobutton was typically used which hooked on the external cortex of the femur and then pulled back to tension the hamstring tendon grafts within the joint. I was unhappy with this form of fixation as it brought in an added variable of the suture material and the knots required to fix it. As any fisherman will tell you, knots slip and the suture material does not respond well to the cyclic loading of early knee joint movements When I first used a screw for fixation of the hamstring tendons, I came under quite a lot of criticism because of the potential risk of putting a metal screw against tendon in bone. The risks were that the tendon would die under pressure from the screw or the screw could damage the tendon during insertion thereby making the operation fail. If it did go into the hole with the tendon, there was the risk of it fretting to rupture the graft. However, with the technique we had devised, none of those problems have occurred. Rather, the compression in the tunnel allowed for a rapid healing of the tendon graft to bone and the location of the fixation proved to have a great advantage in post-operative stability to externally fixed techniques.
In 1991 we devised a special interference screw, the RCI screw. This screw was designed for use in patellar tendon reconstruction so as not to damage the patella tendon graft, but in the back of my mind when designing the screw was the thought of using this for soft tissue fixation. One of my first patients to receive this technique was an Australian international level water-ski champion. He had enormous quadriceps, the largest I’ve ever seen, and these muscles supported him when he was skiing at over 100 miles per hour. He told me that I could do any operation to fix his knee instability, but I had to leave his quadriceps muscle alone, which meant I couldn’t use patellar tendon. So, I harvested a hamstring tendon graft and inserted it using RCI interference screws. He’s been running around for nine years now, competing and still has a stable knee joint.
In my technique we prepare the hamstring tendon graft into a four-strand construct, where we suture the tendons into a plug at either end. These plugs are then pulled through the tunnels drilled in the joint and we use RCI screws to interference fix the graft at the top and bottom ends. Smith and Nephew recently introduced the bioresorbable RCI screw (BioRCI). Basically, the body slowly reabsorbs this screw. Studies have shown that the tendon is securely fixed to bone at twelve weeks so a metal screw could safely be removed after that time. Clinical studies overseas have shown that a screw that resorbs within three months is probably resorbing too quickly for the biology and it would be nice to have them there for a little longer. The BioRCI has been made out of PLLA that is resorbed over a few years so it gives us the advantages of a metal screw as well as the advantages of a bioresorbable screw. It certainly holds up long enough for the graft to mature within the joint.
An interesting discovery that we have made while using the interference screws for soft tissue fixation in ligament reconstruction is that a reverse thread screw is required for right knee femoral fixation. Normal screws are inserted in a clockwise rotation. In a left knee this tends to push the tendon graft to the back of the joint, which is the preferred position for graft fixation. We found that in using a normal clockwise rotation screw for femoral fixation in a right knee the graft rotated anteriorly, hindering visualization and resulting in an anterior placement of the graft. This is not desirable and it is readily apparent that we are performing two different operations between the left and right sides. A right knee requires a mirror image procedure, thus, a reverse thread screw needs to be utilized. This concept is so simple, but initially difficult to grasp. The reverse thread screw in a right knee for femoral fixation pushes the graft posteriorly and allows complete visualization for screw insertion. So, it removed the side to side difference in laxity which is measurable when utilizing only clockwise screws. A reverse thread screw is now recommended for all right knee femoral fixation in ACL surgery.
Knee1: Now that you’ve been successful with the RCI screw, what new projects are you working on?
Dr. Pinczewski: My current projects involve a new minimally invasive technique of unicompartmental knee replacement. In a unicompartmental knee replacement, we are replacing just the worn part of the knee rather than the total joint. This operation will be performed through a small incision measuring about five cm. Unicompartmental replacements have been done before, there’s nothing new about them, except that in the past, surgeons have had to make a total knee replacement incision to adequately implant the joint. Because of instrument considerations, unicompartmental replacements did not have as good a long term success rate as total knee replacements. Therefore in Australia and in the United States, unicompartmental replacements were rarely done. But, if you look closely, the unicompartmental replacements generally failed because of poor technique. We have devised a new instrumentation technique that firstly allows an accurate reproducible placement of the components and secondly allows the procedure to be carried out through a small incision with a lower morbidity and with a more rapid recovery. The instrumentation allows perfect ligament balance, which should increase the life span of these prostheses. We know that in the best cases, the life span of a unicompartmental replacement is the same as the life span for a total knee replacement. What we are hoping to create with this instrumentation is this best case scenario as a routine procedure.
To contact Dr. Pinczewski, send e-mails to [email protected]
Last updated: 26-Apr-00