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How have Anterior Cruciate Ligament reconstruction procedures evolved over the years?

Alexis E. Pokorski

College of Health and Human Sciences, Florida State University

ENC 2135: Research, Genre, and Context

Professor Ryan McHale

February 13th, 2024

Anterior cruciate ligament (ACL) injuries are injuries that affect the cruciate ligaments

which are located in the knee. ACL injuries are most common in sports, especially football.

When the cruciate ligaments of the knee are overstretched or pivoted due to a hard hit on the side

of the knee, like a football tackle or awkward placement of the foot on the ground, the ligaments

rupture. The discovery of the cruciate ligaments of the knee was first described in 170 AD (2nd

century) and have been studied since. Research on ACL reconstruction has been conducted by

many medical professionals, surgeons, and physicians, which are the main groups of people who

work with ACL injuries. The main findings to this research answers the question “How have

Anterior Cruciate ligament reconstruction procedures evolved over the years?”. Recent studies

focused on the history, evolution, and modern techniques of ACL reconstruction. Results of this

research have evolved throughout the years and resulted in improved ACL reconstruction

techniques. Although research has discussed ACL reconstruction throughout the years, there has

been little research done on the connection of past ACL reconstruction techniques to the

techniques that are used today. Focusing on the procedures that were developed in the early

years, and discovering how they have evolved into the modern day procedures would be very

beneficial for understanding how ACL reconstruction techniques evolved into what they are

today.

The discovery of the cruciate ligaments in the early years played a significant role in the

diagnosis of ACL injuries and the creation of reconstruction techniques. Smith Papyrus was the

first to describe the anatomy of the knee and Galen, a Greek physician, in the 2nd century dug

deeper and revealed the true anatomy of the knee. Galen described the cruciate ligaments as part

of the nervous system and as “a structure that supports the joint and prevents abnormal knee

motion” (Davarinos, O’Neill, Curtin, 2014, 1). The function of these ligaments were still
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unknown. The discovery and anatomy of these ligaments received little to no attention until the

19th century. German Scientists Wilhem and Edward Weber started to pay more attention to the

anatomy of the knee and described “the exact anatomic location of the cruciate ligaments but

also discovered that the anterior cruciate (ACL) was made-up of two distinct fiber bundles”

(Schindler, 2012, p. 163). The first diagnosis of an ACL injury was described in 1845 by French

Surgeon Amedeé Bonnet, when he provided three different clinical signs of an ACL rupture.

According to Bonnet, patients with an ACL injury suffered “a fracture, a snapping noise,

hemarthrosis, and loss of function” (Schindler, 2012, p. 164). The signs described by Bonnet are

similar to those that are currently used for the diagnosis of ACL injuries. During the early years,

the diagnosis of an ACL rupture was not obvious. Hemarthrosis, which is bleeding of the joint, is

invisible to the naked eye and cannot be seen right away, unlike a snapping noise or loss of

function. Many of the symptoms people had during an ACL injury were not symptoms that could

be seen with the naked eye, which explains the difficulties medical professionals had in the early

years when diagnosing ACL injuries. After Bonnet’s discovery of these symptoms, more people

shifted their attention to the diagnosis of ACL injuries and eventually different clinical tests were

created by medical professionals and physicians.

The diagnosis of ACL injuries primarily rely on different clinical tests and procedures used

to examine the patient and the injury. There are two main clinical tests that are used today that

contribute to the diagnosis of ACL injuries, which are the Pivot Shift Test and Lachman Test.

The turning point of the process of diagnosing an ACL injury was when these clinical tests were

developed. Around 1870, Greek surgeon Georgios C. Noulis described the Lachman technique

for the first time. He stated “fix the thigh with one hand, while with the other hand hold the

lower leg just below the knee with the thumb in front and the fingers behind. Then try to shift the
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tibia forward and backward” (Davarinos, O’Neill, Curtin, 2014, 2). The Lachman clinical test

technique that is used today is similar to how Noulis described it. The main goal of this clinical

test is to attempt to translate the tibia towards the front of the body. A positive test result shows

that there is damage to the ACL and a positive test is shown when the tibia has a soft, mushy

feel. Around the same time, the Pivot shift test was described by Galway and is known as the

ideal test to evaluate the status of the knee ligaments. The most common method of performing

the pivot shift test is “flexing the knee from 0° (full extension) to 90° of knee flexion while

applying an external rotation stress to the tibia and a valgus stress to the knee” (Vaudreuil,

Rothrauff, Darren de SA, Mushal, 2019). Similar to the Lachman test, a positive test shows that

there is a rupture of the ACL ligament and a positive test during the Pivot Shift test occurs when

“a rapid anterior subluxation of the tibia at 20–30° of flexion as it reduces under the femoral

condyles” (Vaudreuil, Rothrauff, Darren de SA, Mushal, 2019). This means that when the test

was performed there was at least a 20 to 30 degree dislocation of the ligaments. These tests play

a big role in the diagnosis of ACL injuries today because the main goal of these tests is to create

a sensation that is similar to the feeling the patient had when the ligaments of the knee ruptured.

One of the main procedures that is being used today to reconstruct the ACL is a Patellar

Tendon Autograft. The first technique to addressing ACL tears was one that was very similar to

this modern-day technique. The technique was discovered by Mitchell Langworthy around 1929,

however his method was never made public (Schindler, 2012, 169). Four years later, medical

professional Max Zur Verth, performed a technique where a strip of the patellar tendon was

attached to the tibial tubercle (Schindler, 2012, 169). After Verth published his procedure

technique, more surgeons began to research and look into how to improve this technique and

better the effects this surgery will have on the patient. Surgeons Kenneth Jones and William
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Clancy worked together on a procedure where they used “the central third of the tendon, which

he passed ‘beneath the fat pad’ into the femoral tunnel. As the graft was generally shorter than a

normal ACL, the tunnel had to be brought forward, away from the anatomical foot-print of the

ligament” (Schindler, 2012, 169). This technique had negative long term results mostly due to

the fact they were not using the correct graft length. Helmut Brückner realized the graft length

issue of this technique and eventually created a procedure where he “routed the patellar tendon

through a tibial tunnel, thereby gaining enough distance to position the femoral tunnel at the

anatomic foot-print” (Schindler, 2012, 169). As more medical professionals tested different

techniques, this slowly improved how the procedures were done. The creation of the Patellar

Tendon autograft developed from the need to improve ACL grafting techniques. This eventually

led to its widespread acceptance as the primary choice and eventually became “increasingly

popular…becoming the “gold standard” for ACL grafts” (Chambat, Guier, Sonnery-Cottet,

Fayard, Thaunat, 2013). This autograft procedure is a very complicated one and one little

mistake can cause the surgery to fail. The complexity of this procedure emphasizes the critical

nature of precision. The patient must be put under anesthesia and laid down in a supine position,

meaning they are laying on their back. The femoral plug that is used must be the correct length,

which is about 20-22 millimeters, for the surgery to succeed. At the start of the surgery, a small

incision is made “from the inferior pole of the patella to approximately 2 cm distal to the tibial

tubercle while” the knee is flexed at a 90 degree angle (Frank et al. 2017). This allows the

patellar tendon to be exposed. “Next, starting either medially or laterally, a scalpel is used to

incise the tendon longitudinally from proximal to distal, keeping the knife blade moving

smoothly in line with the fibers of the tendon until the tibia is reached” (Frank et al. 2017). Once

the second incision is properly made, it is time to harvest the tibial plug. The surgeons have to
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make sure that the incisions they are making are not too wide so that the tibial plug can be freed

up and harvested easily. The next focus is the patellar plug, and a saw blade is inserted near each

side of the patellar plug. Similar to the tibial plug, the incisions allow the patellar plug to be freed

up easily. When the plugs are being “freed up”, it means they are being exposed enough to be

available for use. Once both plugs are freed up, 2 small holes are drilled into the tibial bone. “In

the femoral plug, only 1 hole is drilled (followed by suture shuttling) to allow the graft to be

pulled through the tunnel during graft passing” (Frank et al. 2017). The final steps consist of

graft passing and fixation and then the closure process begins. During the procedures, bone is

saved from the bone tunnel incisions, and is “used to graft the patellar and tibia bone plug

harvest sites, emphasizing the patellar site” (Frank et al. 2017). To close up the patient, the

surgeons make many sutures to secure the incisions.

There have been a variety of reconstruction techniques that have been used to repair the

anterior cruciate ligaments of the knee. In the early years, ACL injuries were treated by

immobilizing the knee with a cast without a surgical procedure (Chambat, Guier, Sonnery-Cottet,

Fayard, Thaunat, 2013). The technique used by Marcel Lamaire and others included “a

posteromedial imbrication followed by cast immobilization” (Chambat, Guier, Sonnery-Cottet,

Fayard, Thaunat, 2013). Posteromedial imbrication is a technique used to tighten and reinforce

the structures of the inner part of the knee. The realization that the current surgical method of

ACL reconstruction did not contribute to the long term stability of the knee was soon discovered.

Frequently, the wrong tendons were moved or the graft was incorrectly positioned. This

motivated medical professionals and surgeons to conduct more research of different ACL

reconstruction methods. There were many exploratory techniques that other medical

professionals used to develop different models. The most popular technique in the 1970s was the
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Marshall MacIntosh technique, which was created by Insall, MacIntosh, and McCulloch. This

technique was similar to the popular autograft technique that is used today, more specifically the

Patellar Tendon autograft. This technique involved “a continuous strip of PT, prepatellar fascia

throughout its pre-patellar surface and a tabularized strip of quadriceps tendon. The proximal

portion was passed through a tibial tunnel, ‘over the top’ and then fixed to the femur” (Chambat,

Guier, Sonnery-Cottet, Fayard, Thaunat, 2013). Surgeons began to enhance and improve this

technique. The variety of techniques that were being tested and researched, eventually helped

allografts and autografts evolve.

Currently, the two techniques used most frequently for ACL reconstruction are autografts

and allografts. There are a variety of different autografts, including the hamstring tendon

autograft, patellar tendon autograft, and the quadriceps tendon autograft. Both techniques are

beneficial to the patient, but there are some differences between the two procedures. The main

difference between the two is that during an autograft, the tissue that is being used comes from

the patient's own body, while during an allograft, the tissue comes from a donor. There are many

advantages and disadvantages to both procedures. Allografts are beneficial due to “ no donor site

morbidity, a shorter operation and less painful initial recovery” (Mistry et al. 2018, 1,2). But,

allografts have a “slower graft incorporation and concern about higher rupture rates in some

young highly active groups, concern about disease transmission and increased cost”(Mistry et al.

2018, 1,2). During an allograft procedure, one of the main issues is disease transmission. Since

the tissue that is being used for the procedure is not from the patient's own body, like an

autograft, diseases have a higher chance of entering the body. When disease enters the body

during a graft procedure, it can cause the graft not to successfully work and the failure rate of

soft tissue increases. The benefits of autograft procedures include “healthy living tissue, stronger
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than tissue that has been sterilized and less possibility of disease transmission” (Cluett, 2023).

Although there are many benefits to the autograft procedure, the graft must “be obtained from a

healthy part of the body, involves a larger surgical procedure and more discomfort, and there is

potential damage” that can occur in the healthy parts of the patient's body (Cluett, 2023). Using

your own tissue for a graft procedure is a lot more beneficial because the surgeons would be

transferring living, healthy tissue cells to the damaged area. Using tissue that has been given

from a donor, is expected to decrease structural damage to the damaged tissue, but it is weaker

than tissue taken from the patient's own body. Although, during an autograft, you are transferring

healthy tissue, there is a higher risk that the area that the tissue is being removed from could be

damaged. Allograft procedures are a lot more expensive than autografts. A study was done by

the UK National Health Service and Personal Social Service that compared the costs of these two

procedures. Some factors that were studied that contributed to the total costs of the procedures

were pre surgery consultations, medications and physiotherapy sessions. The total cost for an

allograft was about 5,523 pounds while the autograft's total cost came out to around 1,706

pounds (Mistry et. al, 2019, 3). Allografts and autografts are the two most popular procedures

that are used today when the ACL is being reconstructed. Despite the differences, both

procedures have high success rates and will continue to be used and improved during the future.

Anterior cruciate ligament injuries are one of the most popular and recurring injuries.

ACL injuries and the reconstruction procedures of the ACL have been increasingly drawing the

attention of medical professionals and surgeons. Multiple research studies have been conducted

focusing on the history and evolution of ACL reconstruction techniques since the first discovery

of the cruciate ligaments during the early years. The discovery of the cruciate ligaments and the

first techniques used to reconstruct the ACL caused medical professionals and surgeons to shift
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their attention to the anatomy of the ligaments and how to reconstruct them when ruptured.

Procedures done in the early years, like the technique created by Marshall MacIntosh, eventually

allowed the Patellar Tendon Autograft to evolve. Results of the research studies done allowed

people to create connections between the techniques used in the early years to modern day

procedures. The two main procedures used today are allografts and autografts, and these modern

day techniques would not be as effective and successful if surgeons and medical professionals

did not research, study and improve the techniques from the earlier years. Results also showed

the differences between the different procedures and allowed people to get a better understanding

of which technique could be the most beneficial. The evolution of ACL reconstruction

techniques has been studied for many years and will continue to improve in the future. New

surgical developments including the Bridge-enhanced ACL repair (BEAR) method and improved

autograft procedures are serving the baseline for future reconstruction techniques.
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References

ACL Reconstruction Surgery: Procedure and Recovery | HSS. (n.d.). Hospital for Special

Surgery. https://www.hss.edu/condition-list_acl-surgery.asp

Biau, D. J., Katsahian, S., Kartus, J., Harilainen, A., Feller, J. A., Sajovic, M., Ejerhed,

L., Zaffagnini, S., Röpke, M., & Nizard, R. (2009). Patellar Tendon Versus

Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament.

The American Journal of Sports Medicine, 37(12), 2470–2478.

https://doi.org/10.1177/0363546509333006

Chambat, P., Guier, C., Sonnery-Cottet, B., Fayard, J.-M., & Thaunat, M. (2013). The

evolution of ACL reconstruction over the last fifty years. International

Orthopaedics, 37(2), 181–186. https://doi.org/10.1007/s00264-012-1759-3

Davarinos, N., O’Neill, B. J., & Curtin, W. (2014). A Brief History of Anterior Cruciate

Ligament Reconstruction. Advances in Orthopedic Surgery, 2014, 1–6.

https://doi.org/10.1155/2014/706042

Frank, R. M., Higgins, J., Bernardoni, E., Cvetanovich, G., Bush-Joseph, C. A., Verma,
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N. N., & Bach, B. R. (2017). Anterior Cruciate Ligament Reconstruction Basics:

Bone–Patellar Tendon–Bone Autograft Harvest. Arthroscopy Techniques, 6(4),

e1189–e1194. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5621981/

Hewett, T. E., Myer, G. D., Ford, K. R., Paterno, M. V., & Quatman, C. E. (2016).

Mechanisms, prediction, and prevention of ACL injuries: Cut risk with three

sharpened and validated tools. Journal of Orthopaedic Research, 34(11),

1843–1855. https://doi.org/10.1002/jor.23414

McMellen, C. J., Ina, J. G., Calcei, J. G., Goodfellow, D. G., & Voos, J. E. (2022). The

Evolution of Femoral Tunnel Drilling in ACL Reconstruction: History, Current

Practices, and Future Applications. SN Comprehensive Clinical Medicine, 4(1).

https://doi.org/10.1007/s42399-022-01278-y

Schindler, O. S. (2012). The Story of Anterior Cruciate Ligament

Reconstruction - Part 1. Journal of Perioperative Practice, 22(5), 163–171.

https://doi.org/10.1177/175045891202200505

‌Vaudreuil, N. J., Rothrauff, B. B., de SA, D., & Musahl, V. (2019). The Pivot Shift: Current

Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture
and Associated Injury. Current Reviews in Musculoskeletal Medicine, 12(1), 41–49.
https://doi.org/10.1007/s12178-019-09529-7

Mistry, H., Metcalfe, A., Colquitt, J., Loveman, E., Smith, N. A., Royle, P., & Waugh, N.

(2019). Autograft or allograft for reconstruction of anterior cruciate ligament: a

health economics perspective. Knee Surgery, Sports Traumatology, Arthroscopy, 27(6),

1782–1790. https://doi.org/10.1007/s00167-019-05436-z

Cluett, J. (2023, July 21). Allograft vs. Autograft in Orthopedic Surgery Using Your Own
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Tissue vs. Using Donor Tissue [Review of Allograft vs. Autograft in Orthopedic

Surgery Using Your Own Tissue vs. Using Donor Tissue]. Verywell Health.

https://www.verywellhealth.com/allograft-vs-autograft-in-orthopedic-surgery-458

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