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THE EVOLUTION OF ACL RECONSTRUCTION OVER THE LAST 50 YEARS
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presentation in Lyon for the first meeting of the
International Society of Knee in 1978, which
revisited his 1976 publication [25]. The novelty
consisted of harvesting the middle third of the
patellar tendon and uses it as a free graft, hence
affording a perfect anatomical position. This
option had previously been proposed by
Brückner [22] in 1966 to reconstruct the ACL
when the ipsilateral patellar tendon was
injured. Brückner then recommended the use
of the contralateral tendon.
This operation became increasingly popular,
the patellar tendon becoming the “gold
standard” for ACL grafts. Some authors
proposed maintaining some continuity between
the patellar tendon and Hoffa’s ligament in
order to improve its vascularization. Others
proposed associating this intra-articular plasty
with a lateral tenodesis [26, 27] to protect the
graft during the process of “ligamentization”,
with an effort to better control internal rotation
stresses to the neo-ligament. During this
period, the femoral tunnel was drilled from
outside to inside. Fixation of the graft was
initially done with wires and extra-articular
screws and subsequently greatly improved by
the use of interference screws. The original
idea goes to Lambert [28] who proposed AO
screws, Kurosaka [29] then developing a more
specific screw design.
As these techniques improved and gained in
reliability, the indication for antero lateral
tenodesis became progressively less necessary.
They increased the surgical burden to the knee
and rendered rehabilitation more difficult
without a proven functional benefit. The
indication for lateral tenodesis persists for
some surgeons in cases of significant laxity or
a proven antero lateral ligament injury.
The introduction of the arthroscope in the late
70’s for meniscal lesions began playing a role
in ACL surgery in the 80’s. Dandy [30] was the
first to use it to reconstruct the ACL using a
synthetic ligament. Since the mid 1980’s we
used the arthroscope to assist, at first only to
drill the tibial tunnel under anterior portal
visualization, the femoral tunnel being drilled
through a postero lateral arthrotomy using a
“rear entry guide”. With the development of
specific femoral guides, we were then able to
create the femoral tunnel from outside to inside
[31] under arthroscopic control. The goal was
to reproduce the anterior portion of the ACL,
namely the antero medial bundle. Its femoral
insertional position is located on the axial wall
of the lateral femoral condyle behind the
“pseudo” femoral isometric point of the ACL.
This gives the neo-ligament a “favorable non
isometry” (relaxed in flexion, taught in
extension), and addressed the parameters in
which the ACL deficient knee seemed to cause
the greatest sense of instability.
The problems posed by the passage of PT bone
blocks into the femoral tunnel drilled from
“outside-in” brought some medical companies
to propose new guides that facilitated drilling
the femoral tunnel “inside-out”. This option
facilitated the passage of the transplant. This
also
introduced
new
concepts
and
understandings of the insertional anatomy of
the ACL as it relates to arthroscopy. The
“inside-out” techniques remain in use today
but, in our opinion, do not offer an ideal
anatomic position with a real bone (and not a
mixed fibrous and bone) tunnel.
Hamstrings grafts
The use of the PT graft posed problems not
only encountered during passage of the bone
block portions of the graft. In addition, risks of
patellar fracture and secondary problems of
patellar tendinitis, residual flexion contracture
and anterior knee pain were discovered.
The use of the hamstring was thought to be a
solution to all these problems. Before becoming
a now widely used technique, many surgeons
had previously used this graft. The first
descriptions are attributable to [32, 33, 34], all
using the semitendinosus or gracilis tendon,
freed proximally to reconstruct the ACL. J.C.
Puddu [35] used the same technique with the
semitendinosus but the tibial tunnel had an
extra articular orifice positioned quite medially,
in a manner to preserve the internal rotational
action of the semitendinosus.