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. Ideally, the goal is for patients to come out of surgery with far less pain, fewer hindrances, and a quick recovery time. Dr. Leo Pinczewski, an Australian surgeon, has devised an innovative technique for ACL reconstruction, bringing him to the forefront of this crusade. Uniquely, Dr. Pinczewski’s technique uses a bioabsorbable screw to fix the tendon graft to the knee joint, providing the 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 in North Sydney and also practices at the Castlecrag Private Hospital in North Sydney.
Over the course of his career, Dr. Pinczewski has conducted more than 5,300 anterior cruciate ligament reconstructions and currently performs about 450 reconstructions per year. Dr. Pinczewaski handles approximately 5% of the anterior cruciate reconstructions in Australia.
Knee1: How did you become interested in the area of anterior cruciate ligament reconstruction?
Dr. Pinczewski: I got into ACL reconstruction by default because I was trained in joint replacement surgery. When I started in 1984, a political dispute started in our country that prohibited me from taking an appointment in a joint replacement unit. So, I joined a surgeon, Mervin J. Cross, who invited me to give him a hand with his clinic. Within my first two years at the clinic, I had operated on 150 anterior cruciate ligament/medial co-lateral ligament ruptures. These operations were open surgery. That’s how I learned all about knee ligaments. Then I went on and I did 700 open reconstructions. In 1988 we started doing arthroscopic ACL reconstruction with the middle third patella tendon and I did 1800 of those.
Knee1: Did you find it advantageous to be trained in performing open knee surgeries rather than immediately starting with arthroscopic surgery?
Dr. Pinczewski: Absolutely. This training is one of the reasons why I think I have a big advantage over many surgeons who are starting out in the 90’s. My experience comes from 700 operations in which I actually cut the knee open and pulled it apart before I put it back together again. This experience gave me an intimate working knowledge of the normal and abnormal structures of the knee.
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 with utilizing the middle third patella tendon—and I saw more problems than most people because I did more operations— I started using the hamstring tendons. The difference between the hamstring technique and the patella tendon is exactly the same as the difference between open surgery and arthroscopic surgery. There is a quantum leap in patient and surgeon satisfaction. I don’t think many people will return to patella tendons once they have used hamstring tendons.
We just presented our five-year results of the longest clinical prospective study comparing patella tendons and hamstring tendons in ACL reconstruction. The major difference between the two is in what we call the morbidity. In other words, around the operation it appears that the patella tendons have a lot more trouble than the hamstring tendons. With the hamstring tendon, we’ve actually got an operation that’s minimally invasive and it is a true day surgery. In another study I did, out of 1800 patients, my average bed day stay for a patella tendon was two days due to pain and swelling. As for the hamstring tendon, even though we weren’t trying to kick them out, seven out of 10 patients in our hospital left the same day. Out of the other thirty percent, 28 percent were either from a long distance away, so there was a geographic reason why they didn’t leave hospital.
Furthermore, I’ve done 2800 hamstring grafts and the problems and complications of harvesting the hamstring tendon are miniscule in comparison to patella tendons. This background has allowed me to do my surgery faster, because it’s technically quicker and it’s easier, with the same success rate as patella tendon.
Speed of recovery is another advantage. My hamstring tendon cases tend to progress faster than the patella tendons. Hamstring patients are on crutches from only one day to one week and we don’t have to use a brace. For patella tendon reconstruction, patients normally use crutches ranging from ten days to two weeks. By two weeks, hamstring patients should be walking normally. Because using the patella tendon interferes with your quadriceps mechanism so much, patella tendon patients are not walking normally until four to six weeks.
A final advantage of the hamstring tendons is that the tendons re-grow. They’ve been shown to re-grow in many studies. The patella tendons do not re-grow very well and not reproducibly.
Knee1: Surgeons have been using hamstring tendons in ACL reconstruction for a while now, what is innovative about your technique?
Dr. Pinczewski: My big breakthrough came when I decided the best way to fix the hamstring tendon to the knee joint was with an interference screw, which no one had done before. Traditionally, the Americans have used what’s called the Endobutton, which is a button that hooks on the external cortex of the femur, to fix their hamstring tendons. When I first used a screw for fixation, I came under quite a bit of criticism because putting a metal screw against tendon had a lot of risks involved. The risks were that the tendon would die under pressure from the screw; the screw could damage the tendon when you’re putting it in thereby making the operation fail. If it did go in, with the screw over the tendon, there was the risk of it fritting and breaking the graft. However, with the actual technique we had devised, none of those problems had occurred.
In 1991 we had devised a special shaped interference screw that was called the RCI screw. This screw was designed for use in patella tendon reconstruction so as to not damage the patella tendon graft, but in the back of my mind it was always the type of screw that could be used for soft tissue fixation. One of the first guys I used the RCI screw on for hamstring tendon fixation was an Australian international water-ski champion. He had enormous quadriceps, the largest I’ve ever seen, and these muscles supported him when he was skiing. He told me that I could do any operation to fix the instability in his knee, but I had to leave his quadriceps mechanism alone, which meant I couldn’t use patella tendons. So I put a hamstring tendon graft into him using an interference screw. He’s been running around for nine years now and still has no knee problems.
In my technique we prepare the hamstring graft into a four-strand graft, where we suture the tendons into a plug at either end. Then we pull that graft through the tunnels we drilled in the joint and we use and RCI screw to fix the graft at the top end and the bottom end. Smith and Nephew recently introduced the bioabsorbable RCI screw. Basically, the body slowly reabsorbs this screw. Our studies show that the tendon is securely fixed to bone at six weeks, and at twelve weeks, it has all the features of a normal ligament attachment to bone at the attachment site. If you could then remove the screw, you probably wouldn’t be doing much harm. So at three months, you probably don’t need the screws, although it is nice to have them there for a little longer. Certainly at one year, you don’t need the screw. This RCI screw is reabsorbed over a few years, so it gives us the advantages of a screw that disappears, in addition to holding up long enough for the graft to mature.
Knee1: Now that you’ve been successful with the RCI screw, what new projects are you working on?
Dr. Pinczewski: Just before Easter, I signed a confidentiality agreement with Smith and Nephew on 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. We perform this surgery through a small incision measuring about five centimeters long. Unicompartmentals have been done before, there’s nothing new about it, except that in the past, people have had to make a total knee replacement incision with a dislocation of the kneecap to approach the joint to do the unicompartmental replacement. That technique does not have as good a success rate in the literature as the total knee replacement; therefore in Australia and in the United States, unicompartmentals are rarely done. But, if you look closely, the unicompartmentals generally failed because of poor technique. In other words, surgeons were using a total knee replacement technique for the unicompartmental operation. We devised a new instrumentation technique that firstly allows the operation to be done through a small incision, and secondly allows the ligament to be balanced perfectly which should increase the lifespan of these prostheses. We know that in the best cases, the lifespan of a unicompartmental is the same as the lifespan of a total replacement. We hope to create this best-case scenario as a routine. Our instrumentation will allow us to accurately prepare the joint for unicompartmental replacement through a minimally invasive technique. Because it’s a minimally invasive technique, it is going to be done with a day or so in hospital with a far more rapid recovery.
To contact Dr. Pinczewski, send e-mails to [email protected]