JBJS -- Letters to the Editor for Simmons et al., 85 (6) 1018-1029

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Scientific Articles:
Richard Simmons, Stephen M. Howell, and M. L. Hull
Effect of the Angle of the Femoral and Tibial Tunnels in the Coronal Plane and Incremental Excision of the Posterior Cruciate Ligament on Tension of an Anterior Cruciate Ligament Graft: An in Vitro Study
J Bone Joint Surg Am 2003; 85: 1018-1029 [Abstract] [Full text] [PDF]

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Dr. Howell responds to Dr. Arnold: Stephen M. Howell, M.D. (25 November 2003)

Factors Influencing the Tension of Anterior Cruciate Ligament Grafts: M.P. Arnold (25 November 2003)

Dr. Howell responds to Dr. Arnold 25 November 2003

Stephen M. Howell, M.D.,
Physician
University of California
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Re: Dr. Howell responds to Dr. Arnold

sebhowell{at}aol.com Stephen M. Howell, M.D.

> > > We appreciate your letter and your kind comments regarding our recent article.
In the experiment we did not obtain radiographs of each femoral tunnel placement. We only obtained one AP and Lateral radiograph with the tibial guide wire in place BEFORE drilling any of the femoral tunnels. Hence we don't have any radiographic record of the femoral tunnel placement for any of the knees. > > >
As you correctly stated in your letter,the position of the femoral tunnel is defined by the tibial tunnel. We would be interested in learning of a technique that we might use to retrospectively gather the information concerning the placement of the femoral tunnel so that we may fulfill your request.> > > Sincerely, > > > Stephen M. Howell, MD

Factors Influencing the Tension of Anterior Cruciate Ligament Grafts 25 November 2003

M.P. Arnold,
Orthopaedic Surgeon
University Hospital, The Netherlands
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Re: Factors Influencing the Tension of Anterior Cruciate Ligament Grafts

mcarnold{at}planet.nl M.P. Arnold

To the Editor:
We read with great interest "Effect of the angle of the femoral and tibial tunnels in the coronal plane and incremental excision of the posterior cruciate ligament on tension of an anterior cruciate ligament graft: an in vitro study� (2003;85:1018-29) by R. Simmons et al.
We agree with the authors that the most important tunnel in the transtibial tunnel technique is the tibial tunnel. In their paper they clearly show that, once the tibial tunnel is drilled, the place of the femoral tunnel is defined. It is generally accepted that changes in the femoral tunnel position have a more important effect on graft forces than differences in tibial tunnel placement (1-6). In particular femoral tunnels placed too shallow along the Blumensaat�s line may lead to unfavourable high graft forces in flexion (2,4,7).
In their Figure 9, the authors show that different angles of the tibial tunnel in the coronal plane lead to different insertional positions of the femoral graft. We would ask the authors to provide the data regarding the resulting femoral tunnel placements. In our opinion, these data are essential to more easily compare their findings to those of other papers that address tension in ACL grafts.
Marco P. Arnold, MD Albert van Kampen, MD, PhD Department of Orthopaedic Surgery Department of Orthopaedic Surgery University Hospital UMC St. Radboud P.O. Box 30.001 Hanzeplein 1 Th. Craanenlaan 7 NL � 9700 RB Groningen 6700 HB Nijmegen The Netherlands Netherlands m.arnold@orth.azg.nl
1. Amis AA, Beynnon B, Blankevoort L, Chambat P, Christel P, Durselen L, Friederich N, Grood E, Hertel P, Jakob R et al. Proceedings of the ESSKA scientific workshop on reconstruction of the anterior and posterior cruciate ligaments. Knee Surg Sports Traumatol Arthrosc. 1994;2:124-32.
2. Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc. 1998;6:S2- S12.
3. Bylski Austrow DI, Grood ES, Hefzy MS, Holden JP, Butler DL. Anterior cruciate ligament replacements: A mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension. J Orthop Res. 1990;8:522-31.
4. Friederich NF, O'Brien WR. Anterior cruciate ligament graft tensioning versus knee stability. Knee Surg Sports Traumatol Arthrosc. 1998;6:S38-42.
5. Grontvedt T, Pena F, Engebretsen L. Accuracy of femoral tunnel placement and resulting graft force using one- or two-incision drill guides. A cadaver study on ten paired knees. Arthroscopy. 1996;12:187-92.
6. Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. Part ii: The anterior cruciate ligament. Am J Sports Med. 1989;17:208-16.
7. M�ller W: The knee. Form, function and ligament reconstruction. Berlin, Heidelberg, New York: Springer; 1982.