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When we submitted our cover photograph, taken in 2007, the concept was already out of date. The thought behind submitting this picture was just for it to be on the cover of Arthroscopy; however, obeying the “on the cover” instructions, we sent a summary of the patient history. We have to agree with the comments of Fu et al., especially when they say that phrases such as “we placed the tunnels in an ideal position,” “we performed an anatomic anterior cruciate ligament (ACL) reconstruction,” or “we performed surgery in a routine fashion” should no longer be used in the modern literature.
Another important point is the imprecise position of the femoral tunnel compared with a clock-face location; however, once again, because we only submitted one picture, this seemed to be the fastest and most practical way to define this position. To be honest, it is important to state that this patient had an intact meniscus and an intact secondary restraint, and for this reason, we did not see a need to perform a more complex procedure to correct the issue.
At the end of this athlete's rehabilitation process, he was given an International Knee Documentation Committee rating of “A”, and he resumed his activities with the same intensity and frequency as before he was injured.
Functional disability in the anterior cruciate insufficient knee syndrome Review of knee rating systems and projected risk factors in determining treatment.
He also presented with a 3-mm difference on KT-2000 evaluation (MEDmetric, San Diego, CA), which justifies his stability for anterior translation and external rotation.
Once again, the idea was just to show this picture and not to compare techniques. At the time, we did not submit a description of our present anatomic and biomechanical approach. With the Editor's permission, we would like to make some important points. First, we would like to describe technically how we positioned the graft in the femur: we used a single-bundle graft and anatomic ACL placement. The guide pin was placed on the lateral notch at the midpoint of the proximal to distal length of the ACL attachment, just above this location (Fig 1) and about 7 to 8 mm from the posterior cortex. To achieve this, we have been using a special guide and flexible drill system through the anterior medial portal and with the knee in flexion.
With regard to the literature, it is also necessary to point out that when we talk about double-bundle reconstruction, we still lack conclusive data on where to place the tunnels during surgery, and we still cannot conclude that we have a better result when we compare both techniques. From the biomechanical point of view
Knee stability and graft function after anterior cruciate ligament reconstruction: A comparison of a lateral and an anatomical femoral tunnel placement.
It is important to point out that, in various comparative studies, the patients with a single bundle had their grafts positioned on the roofs of the intercondylar notch, which surely affects the control of rotation.
Reconstruction of the ACL with a semitendinosus tendon graft: A prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes.
We are not against double-bundle reconstruction, but currently, there are still many controversies that need to be clarified before we decide to use a more complex surgery routinely in our practice, especially in cases in which future revision may be necessary. This does not mean that after the publishing of good objective and subjective results, the double-bundle reconstruction cannot be used to treat ACL tears, unless there are indications that a single-bundle reconstruction is superior. We understand that the concerns of Fu et al. are pertinent, especially for future publications involving ACL reconstruction, with better-described landmarks. Once again, we could not have described all of these details with a single cover image.
References
Noyes F.R.
McGinniss G.H.
Mooar L.A.
Functional disability in the anterior cruciate insufficient knee syndrome.
Knee stability and graft function after anterior cruciate ligament reconstruction: A comparison of a lateral and an anatomical femoral tunnel placement.
Reconstruction of the ACL with a semitendinosus tendon graft: A prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes.
In the February 2009 Arthroscopy “Cover Image” by Rene J. Abdalla and Andrea Forgas,1 the authors present a single-bundle anterior cruciate ligament (ACL) reconstruction case with “ideal” femoral tunnel placement. Their description of the performed procedure is very concise with limited information on the technical details of the surgery—the cover shows the end result. The information provided by the authors is insufficient to determine whether tunnel placement was “ideal” or anatomic.
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