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The story of anterior cruciate ligament reconstruction - part 2.

ACL reconstruction with non-autologous and synthetic tissue

The desire to replace human tissue with artificial materials, that are ubiquitous and readily available off the shelf, has intrigued surgeons for centuries, and the ACL posed no exception. The first recorded use of synthetic material to replace the ACL is credited to Fritz Lange of Munich (1864-1952) who, in 1903, placed silk sutures across the joint to stabilise what he described as 'wobbly knees' (Lange 1903) (Figure 1). Lange recognised the fibrogenic potential of silk when placed in direct proximity to collagen rich tissue and became fascinated by its 'wonderful ability to produce fibrous tissue under functional stress'. He later modified his technique by routing the silk through a femoral tunnel after attaching it to the tibial remains of the ACL. Lange's grandson Max achieved clinical success by utilising silk augmented with ilio-tibial band (ITB) when reconstructing the ACL (Lange 1933).


In 1914, London surgeon Edred Corner (1873-1950) replaced a torn ACL with two interlaced loops of silver wire, but despite initial success the wire loop broke when the patient started to ambulate without his prescribed knee brace (Corner 1914) (Figure 2). Karl Ludloff in 1927 combined silk and living tissue (ITB) to perform the first recorded augmentation procedure (Ludloff 1927). In 1949 ROther of Germany used Supramid[R], a polyamide derivative, with disappointing results (ROther 1949). In the late 1950s US surgeon Olav Rostrup started the off-label use of synthetic grafts made of Teflon[R] and Dacron[R] as augmentation devices to support fascia or tendon in humans (Rostrup 1964). The first synthetic graft materials to receive approval by the Food and Drug Administration (FDA) was Proplast[R], a porous Teflon graft, in 1973. Its clinical performance however was disappointing (Woods et al 1979). The 1970s and 1980s saw a plethora of synthetic ligament graft materials appear, which included Gore-Tex[R], carbon fibre, ABC[R], PRO-LAD[R], and Polyfex[R] (Kennedy & Willis 1976, Jenkins 1978, James et al 1979, Rushton et al 1983). Although their performance in the laboratory was promising, in vivo many of these ligaments led to foreign body reactions, chronic synovitis, and osteolysis and eventually succumbed to fatigue failure (Plitz & Huber 1983, Woods et al 1991). When long-term studies became available the results were usually devastating. Richard Wilk and John Richmond reported a 37.5% failure rate of the Stryker Dacron[R] ligament device at 5 years whilst the group of Richard Steadman encountered a 29% failure rate with the Gore-Tex[R] ligament over the same study period (Sledge et al 1992, Wilk & Richmond 1993). Both devices, like many others, were subsequently removed from the market, a trend the Swedish surgeon Einar Eriksson already anticipated in 1976 when, he compared synthetic grafts with 'shoestrings, which if used continually, eventually break' (Eriksson 1976).


Others like Swiss surgeon Eugen Bircher and the ltalien Michele successfully experimented with Kangaroo tendon in the 1930s, but xenografts generally remained an unpopular choice (Bircher 1929). In contrast human allograft attracted wider attention mainly through Konsei Shino's experimental studies in the early 1980s. Shino, who initially compared properties of allografts and autografts in a dog model with equal result, was able to reproduce his findings in 31 patients following ACL reconstruction with anterior tibial or calcaneal tendon allografts (Shino et al 1986). Emerging knowledge of the risks of viral disease transmission (HIV, Hepatitis C) and the detrimental effects of sterilisation methods on collagen structure and mechanical properties signalled the decline of allografts in the 1990s, a trend which only very recently has been reversed through improved and more 'graft-friendly' sterilisation techniques (Smith et al 1996, Rihn et al 2006). However, allograft remains relatively expensive and is henceforth often reserved for complex primary or revision cases where autologous tissue is unavailable.

Alternative surgical procedures

Since open reconstructions of the ACL was complex and associated with significant morbidity, surgeons started to experiment with extra-articular procedures. In 1913 Swedish surgeon Knut Giertz (1876-1950) successfully stabilised the knee of a young girl who had lost her ACL due to sepsis, by augmenting both collateral ligaments with strips of ITB (Giertz 1913). In the following period a plethora of similar procedures were designed, namely those by Matti of Switzerland, and Bosworth and Milch in the US, but opinion remained divided upon the merits of extra-articular compared to intra-articular reconstruction (Matti 1918, Bosworth & Bosworth 1936, Milch 1941) (Figure 3).


The 1960s saw the creation of the concept of rotatory instability based on the work of Slocum and Larson (Slocum & Larson 1968) As a consequence extra-articular procedures became fashionable and enjoyed a period of popularity until the late 1990s. The principles behind surgery to the outside envelope of the joint were elegantly summarised by the American Arthur Ellison (1926-2010) (Ellisson 1980). He compared the ACL with a hub of a wheel, which is located at the centre axis of the knee, hence in an ideal position to guide rotation but unable to restrict it. As such he believed that 'it is easier to control rotation of a wheel at its rim than at its hub', hence making a case for stabilising the knee on the outside rather than to reconstruct the ACL on the inside.

In France Marcel Lemaire (1918-2006) became aware of the debilitating effect of antero-lateral subluxation elicited through the pivot-shift manoeuvre and designed a procedure to control this motion (Lemaire 1975) (Figure 4). A strip of distally based ITB was routed through a tunnel in the femoral metaphysis before being folded back on itself. By 1975 he had operated on 328 isolated ACL ruptures of which 87% were rated as 'Good'. The Canadian David Macintosh modified Lemaire's procedure, calling it the 'lateral substitution reconstruction' or otherwise known as the Macintosh tenodesis (Macintosh & Darby 1976). Although these procedures often allowed patients to resume some sporting activities they were unable to fully control knee laxity and were susceptible to stretching-out with time (Warren & Marshall 1978, Moyen et al 1992). Slowly the scientific community started to echo Russell Warren's view that 'as a general rule, extra-articular surgery without attention to the cruciate ligaments will often result in failure' (Warren et al 1978, O'Brien et al 1991, Anderson et al 2001). The inability to provide satisfactory knee stability in all cases following ACL reconstruction has more recently created renewed interest in combining intra-with extra-articular reconstruction. This has been highlighted by Maurilio Marcacci and Stefano Zaffagnini of Italy, who achieved excellent long-term results in terms of knee function and stability in over 90% of their patients when using a combined technique (Marcacci et al 1998, 2009).


Graft fixation methods

The importance of reliable graft fixation remained largely ignored for the best part of the 20th century, and anchorage of any tissue material used in replacing a torn ACL was reliant on sutures which secured the graft against periosteum or soft tissue near the tunnel exits. Although Austrian surgeon Arnold Wittek had already used intra-articular screws for the fixation of an ACL graft in 1927, such efforts remained an exception (Wittek 1927) In 1966 BrOckner, suggested using a slightly oversized triangular bone block attached to the inferior part of a free patellar tendon graft which he press-fitted into the tibial tunnel thereby creating the first suture free fixation (BrOckner 1966, Pietsch et al 1969).

In 1970 Kenneth Jones secured the femoral bone block of his patellar tendon graft with 2.4 mm Kirschner wire 'drilled across the femoral tunnel and into the opposite femoral condyle' (Jones 1970). His idea was later utilised by Wolf and Grafton in the development of the Transfix[R] suspension device, introduced in the late 1990s (Clark et al 1998). The concept of aperture fixation with interference screws was first introduced in 1983 by Kenneth Lambert (Lambert 1983). In his technique he utilised standard AO-screws, which were passed alongside the graft into the bony tunnel. The Japanese surgeon Kurosaka, being aware that the 'mechanically weak link of the reconstructed graft is located at the fixation site', compared various fixation methods and found specifically designed interference screws to provide the strongest fixation (Kurosaka et al 1987). In the 1990s the Australian Leo Pinzcewski developed the round-headed, RCI[R] interference screw, which, due to its 'soft' thread was also suitable for fixation of both patellar and soft tissue grafts (Pinzcewski et al 1997). Although metal and later biodegradable interference screws became the standard mode of graft fixation, by the end of the 20th century a plethora of alternative fixation devices had become available (Martin et al 2002) (Figure 5).


In 1994 Joseph Sklar and Tom Rosenberg introduced the Endobutton[R], a ligament suspension device that anchors itself against the cortex of the femoral condyle (Rosenberg 1994, Chen et al 2003) (Figures 6 & 7). Over the past few years the Endobutton[R] has become one of the most popular fixation methods in ligament surgery due to its versatility and ability to accommodate both hamstring or patellar tendon graft. Despite some theoretical biomechanical disadvantages of suspensory fixation, namely windscreen-wiper and bungee effect, clinical results between the various fixation methods have broadly been similar without any claiming superiority (Hoher et al 1999).



Arthroscopic ACL reconstruction

In 1933 the British surgeon Timbrell Fisher appealed for prudence when considering ACL reconstruction as 'we must bear in mind that an operation, which may appear easy, when performed by a master of technical methods, may present extreme difficulty to the average surgeon' (Fisher 1933). Fisher's view remains true even today despite significant improvements in surgical equipment and the advent of arthroscopy, as a sound understanding of the anatomy, biomechanics and kinematics of the ACL are essential in order to achieve reproducible results. One of the greatest advances in ACL surgery was achieved through the change from open to arthroscopically assisted reconstruction, although some surgeons had already experimented with closed trans-articular reconstructions using anatomical land-marks or radiographic control in the 1940s and 50s (Tees 1940, Konig 1955).Arthroscopy was originally developed by Bircher in Switzerland in 1921 but remained a purely diagnostic tool until the 1970s. On the 24th April 1980 David Dandy performed the first arthroscopically assisted ACL reconstruction at Newmarket General Hospital (Dandy et al 1982) (Figures 8 & 9).Dandy used a carbon fibre ligament and augmented the repair with a Macintosh tenodesis, which was popular at the time (Dandy 2011). Arthroscopic ACL reconstruction in those days was highly complex and challenging, as neither sophisticated instrumentation nor audio-visual aids (e.g. camera and monitor) were available. In addition the close proximity between the surgeon's eye and the lens system created a constant danger of desterilisation. However developments in arthroscopic instrumentation (e.g. drilling jigs and off-set guides) and the arrival of electronic cameras provided for improved surgical accuracy, making ACL reconstruction a more reliable procedure (Hewson 1983, Flandry et al 1992). Studies comparing open versus arthroscopic ACL reconstructions soon confirmed the benefits associated with key-hole techniques, namely the speed of recovery and the increase in range of motion (Bray & Dandy 1987). By the end of the 1990s most surgeons had embraced the all-inside technique of arthroscopic ACL reconstruction which has remained the surgical gold standard since (Hardin et al 1992, O'Neil 1996).



Anatomic single and double bundle reconstruction

Surgeons have always strived to find better ways to recreate physiological ACL biomechanics in the hope that this may reduce the risk of degenerative changes developing following ACL reconstruction. In 1911 the anatomist Rudolf Fick of Leipzig (1866-1939) describe in detail the tension pattern of the two ACL bundles and recognised that parts of the ACL were tensioned at all times (Fick 1911). Based on Fick's observations, Ludloff recognised that 'reconstitution of relatively normal function would require the new cruciate ligament to consist of two separate bundles' (Ludloff 1927). In 1938 Ivar Palmer of Sweden (1897-1985) introduced the first femoral drill guide and advocated separate suture repair of each bundle in the management of acute ACL tears but his efforts remained unrecognised (Palmer 1938).

The first double bundle reconstruction was performed by Viernstein and Keyl in Munich in the early 1970s (Viernstein & Keyl 1973) (Figure 10). As graft material they utilised 0 distally based gracilis and semtendinosus hamstring tendons which they passed through a single tibial tunnel into two separate femoral tunnels (Figure 10). Werner Muller of Bale in Switzerland introduced his 'anatometric' double bundle technique in 1982 attempting to combine anatomic reconstruction principles with the concept of graft isometry (Muller 1983) (Figure 11). US surgeon William Mott followed in 1983 with his STAR technique (semitendinosus anatomic reconstruction), for which he created double tunnels in both tibia and femur (Mott 1983). The first arthroscopically assisted double-bundle reconstruction was performed by Tom Rosenberg of Salt Lake City in 1994 (Rosenberg 1994). Over the past decade the group of Freddie Fu of Pittsburgh has been at the forefront in promoting the benefits of anatomic reconstruction with promising short to medium term results (Zelle et al 2006, Fu & Karlsson 2010) (Figures 12 & 13). Biomechanical studies have shown that anatomic double bundle reconstruction creates more normal knee joint kinematics, which are hoped to positively influence the prevalence of osteoarthritis long-term (Yagi et al 2002). Despite enthusiasm for this new technology however, concerns have been raised in some quarters that increased surgical complexity associated with double bundle reconstruction might outweigh those proposed benefits (Gobbi et al 2011).






Through the centuries scientific minds have been concerned with the function of the anterior cruciate ligament, the consequences of its loss and the various surgical means to re-establish functional knee stability. Many brilliant propositions and discoveries were dismissed and forgotten, only to be re-discovered many years later and often without adequate credit being given to their original inventors. The history of ACL surgery however, also exposes misguided ideas and failures as well as the influence of surgical fashion and personal whim which on occasions distracted our view away from scientific objectivity. Anyone interested in the management of ACL injuries should not only possess an understanding of modern ways of treatment but be aware of the ingenuities and achievements of our surgical ancestors.


The author would like to convey his gratitude for the inspirational support provided by David Dandy of Cambridge, Werner Muller of Bale, Thomas Drobny of ZOrich, Wolfgang Plitz of Munich and Freddie Fu of Pittsburgh. Special appreciation is conferred to Leslie, Madeleine, Beverly and Jackie at the library of the Learning & Development Centre at Southmead Hospital in Bristol and to Chris Wiles of the JPP for her understanding and patience during the editing process.


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Correspondence address: Oliver Schindler, Bristol Arthritis & Sports Injury Clinic, St Mary's Hospital, Bristol, BS8 1/U. Email:

About the author

Oliver S Schindler


Consultant Orthopaedic Surgeon & Knee Specialist, Bristol Arthritis & Sports Injury Clinic St Mary's Hospital, Bristol

No competing interests declared
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Author:Schindler, Oliver S.
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:4EUUK
Date:Jul 1, 2012
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