Bordeaux-Mérignac Centre of Orthopaedic and Sports Surgery - 9 rue Jean Moulin - F-33700 Mérignac, France

Reconstructions of the anterior cruciate ligament (ACL) are among the most frequently performed procedures in knee surgery nowadays. Looking at the history of ACL surgery, it is amazing to see how long it took for some diagnostic and management techniques to establish themselves. Long ago, the ACL was a structure that never had a scalpel come near it. However, since the early 20th century, there has been increasing awareness of, and interest in, the ligament and its lesions; and since then, the former Cinderella has moved very much more centre stage.

As far back as 1845, Amédée Bonnet(2,3) of the Lyon school, wrote a treatise on joint disorders causing bloody effusions, in which he analyzed knee injuries. He described three essential signs indicative of acute ACL rupture: “In patients who have not suffered a fracture, a snapping noise, haemarthrosis, and loss of function are characteristic of ligamentous injury in the knee.” His statement was based upon his clinical experience, as well as on cadaver studies in which he produced knee injuries and then dissected the knee to see what lesional pattern had occurred. The paper remained unknown - after all, it was not published in English.

Fig. 1  George K. Noulis

In 1875, Georges K. Noulis (1849-1919)32 (Fig. 1), a brilliant Greek who had studied medicine in Greece and gone to Paris to pursue his research, wrote a thesis entitled Knee Sprains. In it, he very accurately described the role of the ACL, and showed how the integrity of the ligament should be tested with the knee in extension. The test proposed by Noulis was identical with the one now known and used as the Lachman test. Noulis eventually returned to Athens, and then went to Constantinople, where he made a brilliant career, rising to the highest ranks in academia. He was also noted for his great kindness to his patients.

Fig. 2  Paul Segond

In 1879, a Paris surgeon, Paul F. Segond, (1851-1912) (Fig. 2) wrote a most interesting study entitled Clinical an

d experimental research into bloody effusions of the knee joint in sprains, which was published in Progrès Médical47. For this study, Segond had repeated Bonnet’s work, producing lesions in forced extension in 90 knees. In the same paper, he described an avulsion

fracture of the anterolateral margin of the tibial plateau, which he had found to be routinely associated with ACL tears. This fracture now bears his name, and is considered as a pathognomonic feature of ACL tears.

In 1895, A.W. Mayo Robson (Leeds, UK) performed the first cruciate (or, as it was then still called, crucial) ligament repair31 in a 41-year-old miner who had been injured in a fall of earth 36 months previously. The patient had lameness from weakness and instability of the right knee. The two torn cruciate ligaments were stitched in position, at their femoral attachments. Six years later, the patient described his knee as “perfectly strong,”, and was able to walk without a limp and to run; since his discharge from the infirmary, he had never been off work a day on account of his knee. The case was not reported in the literature until 1903. By then, in 1900, another Brit, W.H. Battle, had exhibited to the Clinical Society of London a case of anterior cruciate repair, of which he claimed that it was an all-time first.

In 1903, F. Lange(25) of Munich performed the first ACL replacement, using braided silk attached to the semitendinosus as a ligament substitute. The procedure did not work, leading Lange’s compatriot M. Herz to conclude that the use of silk had been a nice try, but that the attempt to imitate Nature had failed. However, it was not, perhaps, quite such a misguided idea....

Fig. 4  Hey Groves’ technique [18]

In 1917, Ernest W. Hey Groves(17) of Bristol performed the first ACL reconstruction using an iliotibial band transplant. The approach was through a wide anterior horseshoe incision, and involved a tibial tubercle osteotomy, to give excellent exposure of the joint. The incision was extended laterally, to harvest a strip of iliotibial band. In the initial technique, the graft was detached from the tibia and routed through a femoral and a tibial canal. At its exit from the tibial tunnel, the graft was sutured to the periosteum and the fascia. The tibial tubercle was refixed with two ivory nails. The technique was subsequently modified18 as follows: the 20 cm x 8 cm graft was left attached to the tibia. The strip was passed, in a frame pattern, through a tunnel in the lateral condyle, through the joint, and into a tibial tunnel in the anterior part of the tibial spine, exiting at the anteromedial aspect of the tibia. From there, it was routed up the medial aspect of the medial femoral condyle, and attached to the condyle with an ivory nail (Fig. 4). In 1918, Maj. S. Alwyn Smith(44) of Cardiff published a paper reporting on nine cases treated with Hey Groves’ technique, and criticizing the incomplete nature of the construct, which failed to strengthen the medial collateral ligament. He also described his instruments (Fig. 6), and mentioned other techniques practised at the time: plication,  reefing, wire loops, and a ligament substitute made from silk.

Fig. 6  Alwyn Smith’s technique

By then, the stage had been set for everything that was to happen over the next eighty years.

Fig. 7  Hey Groves’ test

In 1920, Hey Groves18, in the British Journal of Surgery, reported his anatomical and physiological findings in the cruciate ligaments, and described their ruptures and repair. In particular, he noted the presence of forward displacement of the tibia, which the patient could induce by putting weight on one leg with the knee slightly flexed. He had found the tibia to slip forward with a jerk in some cases, but failed to mention the earlier work done by G. Noulis. All the references in his paper were English- or German-language ones. Perhaps there was a problem of communication.... Hey Groves also used the anteroposterior instability in slight flexion observed in his patients as a clinical test (Fig. 7). The paper dealt with his first 14 cases operated on since 1917. None of the patients had been made worse by the operation; four showed no benefit; four benefited to some degree; and four were cured, and able to return to their former activities. Two were still undergoing rehabilitation at the time of writing.

In 1935, Willis C. Campbell5, of Memphis, Tennessee, reported the first use of a tibia-based graft of the medial one-third of the patellar tendon, the prepatellar retinaculum, and a portion of the quadriceps tendon (Fig. 8). The technique involved drilling two tunnels, one in the tibia and one in the femur. The graft was stitched to the periosteum at the femoral tunnel exit. The operation was followed by posterior-splint fixation for a period of 3 weeks. The technique did not become widespread until MacIntosh reintroduced it, many years later.

Fig. 8  Campbell’s procedure Fig. 12  Harry B. Macey’s procedure

Campbell’s paper was published in Surgery, Gynecology and Obstetrics. It dealt with 17 ACL reconstruction cases, most of whom were athletes. Nine patients had an excellent outcome, and were able to return to playing football from 6 to 10 months after operation. Campbell felt that, while the need for reconstruction was more urgent in athletes, restoration of the ruptured ligaments would materially improve the end-results in about 10 per cent of all traumatic knees, especially if the procedures employed could be carried out rapidly and without undue intra- and extra-articular reaction.

In 1939, Harry B. Macey29, of Rochester, Minnesota, described the first technique using the semitendinosus tendon (Fig. 12). The tendon was left attached to the tibia, then passed through a tibial and a femoral tunnel, and sutured to the periosteum. The joint was approached via an anterior oblique parapatellar incision. (The same principle was used for posterior cruciate repair, with exposure of the popliteal space for accurate placing of the posterior tibial drill hole.) Only the tendinous portion of the semitendinosus was harvested, stopping short of the musculotendinous junction. The tunnels were 4.7 mm in diameter, and the graft was attached with the knee in full extension. A plaster of Paris cast was applied and worn for 4 weeks; full activity was permitted at the end of 8 weeks.

Fig. 9  Robert W. Augustine’s technique

The period from 1940 to 1950 was the “black hole” (probably because of WWII). The breath-taking speed with which ACL surgery had developed before 1940 had given rise to the hope that further rapid progress would be made around the middle of the century.  However, the 40s and 50s turned out to be the Dark Ages. All that was achieved were techniques of active stabilization and collateral ligament retensioning, as reported by Robert W. Augustine1, of Madisonville, Kentucky, in 1956. Augustine’s paper concerned a technique devised by the German K. Lindemann(27) (1950), who had used semitendinosus tendon detached from the tibia and re-routed, with the muscle belly, through the popliteal space. From this position, it was taken through the notch, and into an anterior tibial tunnel. The graft was attached using a wire suture tied around a “boat nail” (Fig. 9). Augustine also described how a slack collateral ligament could be retensioned by detaching its femoral origin, with a bone block, and reinserting it more proximally with a boat nail. For posterior cruciate ligament (PCL) lesions, he also proposed a dynamic stabilization technique which involved detaching one third of the patellar tendon from the tibial tubercle, passing it back into the joint, and out through a tunnel in the tibia (Fig. 9).

In 1948, Albert Trillat taught that the knee should be examined in extension, and very accurately described the “give” felt as the tibia was moved slightly forwards and backwards. He considered this to be the most sensitive diagnostic sign in ACL injuries. His work and teachings put the Lyon school on the international map.

In 1960, J. Ritchey39, a colonel in the US Armed Forces, gave a detailed description, in the Armed Forces Medical Journal, of a test of anterior knee instability in near extension. Sixteen years later, this diagnostic procedure came to be officially known as the Lachman test.

Fig. 5  The Jones procedure (early version)

In 1963, Kenneth G. Jones22,23, of Little Rock, Arkansas, revived the idea of using a central one-third of patellar tendon graft with an attached patellar bone block. However, the technique described in his paper differed from the one used nowadays. The tendon was left attached to the tibia; there was no tibial tunnel; and because of the shortness of the graft, the author had to drill the femoral tunnel from the anterior margin of the notch (Fig. 5). The ligament was secured to the periosteum at the superolateral exit site on the femur. Jones reported on 11 cases that had been operated on successfully. In the discussion of the article,  Don H. O’Donoghue made the point that the femoral tunnel was in the wrong place; however, the technique was simple and caused minimal operative trauma, which made it a distinct improvement.

Fig. 11  Helmut Brückner’s procedure

In 1966, Helmut Brückner4, a German surgeon, described a similar technique, using the medial one-third of the patellar tendon. The graft, harvested with a patellar bone block,  was left attached to the tibia, then passed through a tibial tunnel, so as to obtain more length. After being passed through the joint, the graft was placed in a socket in the femur; the sutures were then fastened to a button on the lateral aspect of the lateral femoral condyle (Fig. 11).

In 1968, Donald B. Slocum and Robert L. Larson43 (Eugene, Oregon) introduced the concept of rotational instability of the knee, stressing the role of external tibial rotation in the anterior drawer at 90 degrees of flexion, in medial capsuloligamentous lesions. They also noted that the test was much more positive when the ACL was injured, and proposed ways in which to remedy the rotational instability.

In 1969, Kurt Franke (Berlin) pioneered the use of a free bone-tendon-bone graft consisting of one quarter of the patellar tendon and attached patellar and tibial bone blocks. The graft was fixed with a wedge-like piece of bone anchored in the tibial plate, and a shell-like piece implanted into the femoral condyle. The technique derived from the procedures proposed by Brückner and by Jones; however, unlike the previous authors, Franke had the very novel idea of using a free graft. At a 1976 Symposium on Ski Trauma and Skiing Safety13, he reported on nearly 100 cases of ACL repair, mainly in soccer players. One of his patients went on to take part in the Olympic Games, as a wrestler, 5 months after cruciate ligament replacement. Franke recommended that the procedure be performed as early as possible, before cartilage damage had occurred; he had found cartilage damage to be associated with postoperative pain on knee loading, in 10 per cent. of his patients. Also, the procedure should not be used in patients over 50.

It all looked as if major progress had been made.

The Seventies
Extra-articular Reconstructions

In the 70s, everything was back in the melting pot. This was the heyday of non-anatomical extra-articular reconstruction techniques.

In 1972, D. L. MacIntosh15, of Toronto, went back to the phenomenon described by Hey Groves back in 1920, calling it the pivot shift. To remedy the instability, he described a technique using a fascia lata graft pedicled on the tibia, then passed under the lateral collateral ligament, and attached to the intermuscular septum (MacIntosh 1 - the extra-articular MacIntosh). In a subsequent modification (MacIntosh 2), the graft was be brought back intra-articularly (with its weakest portion traversing the joint) and passed into a tibial tunnel. However, the salient feature of the technique was the extra-articular routing of the graft.

Fig. 10  Lemaire’s extra-articular reconstruction

In 1975, M. Lemaire26 described his exclusively extra-articular ligament reconstruction techniques. Medially, gracilis was used for the management of the medial collateral ligament injuries; while, laterally, fascia lata was employed for the reconstruction of the torn ACL. The ACL reconstruction (Fig. 10) was referred to as the Lateral Lemaire. The original technique had been published in 1967, as a procedure for “the control of the ill effects of ACL rupture.” The author stated that the technique was “sound” and “offered a better prospect of return to sports activities than [did] muscle and fascia transplants.” Several variants of the technique (Lemaire II, III, IV) were developed, each with a different way of routing the graft in relation to the lateral collateral ligament. Lemaire himself reported on 453 knees that he had operated on and followed up for 12 months, with particular attention to the patients’ return to sports activities. In patients with isolated ACL tears, the rate of good results was 91 per cent. In his conclusions, Lemaire drew attention to the fact that any associated meniscal lesions tended to have an adverse effect on the outcome.

In 1976, the contribution of John Lachman (1956-1989), of Philadelphia, became known through one his students, Joseph S. Torg46, who described the test at the 1976 Annual Meeting of the LAOS at New Orleans, and called it the Lachman test, in honour of his teacher. However, the principle of the test had been described earlier, by Ritchey in 1960, Trillat in 1948, and, above all, by Noulis in 1875. Sadly, their contribution to the diagnosis of ACL tears went unrecognized.

In 1979, D. L. MacIntosh and J. L. Marshall30 changed the nature of the graft material used, and decided to harvest the central one-third of the entire extensor mechanism, with a wider portion taken from the prepatellar aponeurotic tissue, which was tubed to give greater strength to what would otherwise have been a relatively thin area of the graft. The graft was routed “over the top” of the lateral femoral condyle, and attached with sutures or a staple. The final portion was taken back to be attached to Gerdy’s tubercle. This procedure (the MacIntosh 3/Marshall-Macintosh) still involved a tibially based graft, which meant that the strongest part of the graft would be in the tibial tunnel.

The Eighties
Synthetic Ligaments

and Arthroscopy

The techniques in use in the late 70s were aggressive to the soft tissues and did not produce consistently good results. This is why the new generation of surgeons went back to earlier ideas of ACL reconstruction. As far back as 1903, Lange, in Munich, had used silk to augment the semitendinosus, albeit without success. Corner, in 1914, had used silver wire. In 1975, Rubin, Marshall, and Wang41 had developed an experimental model of a prosthetic ACL made of Dacron. In the early 80s, there was a first wave of carbon fibre-reinforced prostheses, using a material that was in vogue at the time.

In 1981, D. J. Dandy (Cambridge) was the first to implant a carbon fibre-reinforced ligament substitute, using an arthroscopic procedure. The results were rather poor10,11. Unfortunately, carbon deposits were found in the synovial membrane and the liver, which put a stop to the further use of the technique.

As carbon fibre went out, Dacron and Gore-Tex came in, and the “arthroscopy generation” of surgeons seized on these synthetic materials, as a means of performing ACL reconstructions quickly, with minimal trauma, and effectively. However, towards the end of the 80s, there was an unacceptably high rate of synovitis and subsequent rupture of the neoligaments. This rate was seen to be rising with the passage of time. As a result, this line of ACL reconstruction had to be abandoned as well.

During those years, some surgeons had remained faithful to the concept of autografts, the only difference being that they were now increasingly performing these procedures arthroscopically. However, the autografting community was riven by two rival philosophies. On the one hand, there were the adherents of the principle of

OUTSIDE-IN, routing the ligament into the joint through a femoral tunnel:

1980: Clancy7

1983: Noyes33

1884: H. Dejour (Lyon)12.

On the other hand, there were the advocates of

INSIDE-OUT, routing the ligament from inside the joint into a femoral socket:

1984: Rosenberg (Salt Lake City)40

1983: Gillquist (Sweden)163

These arguments notwithstanding, the 80s were a time when arthroscopy flourished, and surgeons obtained a better understanding of the ligament attachment sites. These facts appear to have played a major role in the good results obtained over that period.

The Nineties
The Jones Procedure as the “Gold Standard”?

One technique appeared to establish itself as the superior procedure, because of its simplicity and consistently good results: the free bone-tendon-bone graft of the central one-third of the patellar tendon - the so-called Jones procedure - came to be very widely used. At the same time, metal interference screws were introduced into orthopaedic surgery. In 1987, M. Kurosaka24 (Kobe, Japan) showed that the mechanically weak link of the reconstructed graft was its fixation. The research had been done in young human cadavers, and showed clearly that 9-mm diameter cancellous screws were much superior to other fixation systems. Within a few years, such screws came to be made of resorbable materials such as PLA (polylactic acid - France, 1992) or PGA (polyglycolic acid - US, 1990).

In the early 90s, the Jones procedure was backed up with a lateral reinforcement; towards the mid-90s, the procedure was used without this feature, with equally good results. There were, obviously, several reasons for the increased rate of success, chief among them the earlier diagnosis and treatment of ACL injuries, which prevented the occurrence of associated lesions whose adverse effect on the eventual outcome was well recognized.

Fig. 3  A. B. Lipscomb’s technique

The Jones procedure did, however, have its weak points. It could leave the patient with some stiffness, and, above all, extensor mechanism (patellar and patellar tendon) problems. This is why, in 1982A. B. Lipscomb28 (Nashville, US) started using pes anserinus (semitendinosus and gracilis) tendons pedicled on the tibia, for ACL reconstruction (Fig. 3). A similar procedure, using only the semitendinosus tendon, had been proposed previously, in 1975, by K. O. Cho6.

In 1988, M. J. Friedman14 pioneered the use of an arthroscopically assisted four-stranded hamstring autograft technique. He was followed, in 1993 (after the 1992 AAOS Annual Meeting in Boston), by R. L. Larson, S. M. Howell19, Tom Rosenberg40 (US), and Leo Pinczewski35-38 (Sydney), who used the pes tendons (semitendinosus and gracilis) in three or four strands, with graft placement in a femoral socket. Pinczewski used an “all-inside” technique, with a special large (8 mm) round-headed interference screw, known as the RCI screw. Other leading-edge groups started using hamstring tendons, with different means of fixation. Tom Rosenberg devised fixation with the so-called Endo-Button that locked itself against the lateral aspect of the femoral condyle. L. Paulos34 used a polyethylene anchor; G. Barrett, a bone graft; S. Howell and E. Wolf, cross-pinning; A. Staehelin45, biodegradable interference screws; L. Johnson21, a staple; and others, screws and washers. There was no shortage of ideas - but only time will tell which of these designs were sound.

Looking Forward to

the 21st Century

There is every prospect of further progress being made. As suggested by J. C. Imbert20, it is likely that ligament replacements will take the form of “bioimplants” produced with the aid of cell and tissue culture techniques. Perhaps, fresh lesions will be made to heal with gene therapy. Research along these lines is currently being conducted at Pittsburgh, US (F. Fu). One thing is certain: the last word has not yet been said in the fascinating story of ACL surgery, and for those of us who have dedicated themselves to this branch of orthopaedics, there are great things still to come.


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