An illustrated history of anterior cruciate ligament surgery

Baylor College of Medicine, Houston, TX, USA.
The journal of knee surgery (Impact Factor: 1.44). 05/2007; 20(2):95-104.
Source: PubMed


The past 30 years have brought remarkable change in the evolution of ACL surgery. Surgeons have recognized the important role of the ACL and developed techniques for its reconstruction. As these techniques evolved, certain themes echo throughout the historical literature. Dynamic, nonisometric operations have not worked well, nor have synthetic substitutes. Perhaps most importantly, the more anatomic the reconstruction, the better it was able to restore patient function and the more predictable the result. Technological advances allowed these techniques to be refined so that they are now routinely performed with less tissue trauma, faster recovery, and reproducibly excellent results. This article reviews the historical surgical progress that has evolved coupled with overlapping controversies and concepts, which have impacted surgical changes.

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    • "To address the problems associated with current ACL grafts, several alternative approaches have been attempted, including the use of synthetic grafts, as far back as the 1970s. Such synthetic grafts, composed of various polymers, have been employed as both standalone grafts and as tissue augments (McCulloch et al., 2007). Although initial results were often quite good, unfortunately using synthetic grafts reconstructions were found to be universal failures after intermediate and long-term follow-up (Ventura et al., 2009). "
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    ABSTRACT: Rupture of the anterior cruciate ligament (ACL) is the one of the most common sports-related injuries. With its poor healing capacity, surgical reconstruction using either autografts or allografts is currently required to restore function. However, serious complications are associated with graft reconstructions and the number of such reconstructions has steadily risen over the years, necessitating the search for an alternative approach to ACL repair. Such an approach may likely be tissue engineering. Recent engineering approaches using ligament-derived fibroblasts have been promising, but the slow growth rate of such fibroblasts in vitro may limit their practical application. More promising results are being achieved using bone marrow mesenchymal stem cells (MSCs). The adipose-derived stem cell (ASC) is often proposed as an alternative choice to the MSC and, as such, may be a suitable stem cell for ligament engineering. However, the use of ASCs in ligament engineering still remains relatively unexplored. Therefore, in this study, the potential use of human ASCs in ligament tissue engineering was initially explored by examining their ability to express several ligament markers under growth factor treatment. ASC populations treated for up to 4 weeks with TGFβ1 or IGF1 did not show any significant and consistent upregulation in the expression of collagen types 1 and 3, tenascin C and scleraxis. While treatment with EGF or bFGF resulted in increased tenascin C expression, increased expression of collagens 1 and 3 were never observed. Therefore, simple in vitro treatment of human ASC populations with growth factors may not stimulate their ligament differentiative potential. Copyright © 2011 John Wiley & Sons, Ltd.
    Full-text · Article · Oct 2012 · Journal of Tissue Engineering and Regenerative Medicine
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    • "The anterior cruciate ligament (ACL) is commonly injured and is the most frequently reconstructed ligament of the knee. Reconstructive techniques have evolved over time with variable results [1]. Modern intra-articular reconstructive techniques allow clinically stable ligament reconstruction in the majority of cases; however, failed reconstruction continues to be a problem. "
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    ABSTRACT: Between 5 and 20% of patients undergoing ACL reconstruction fail and require revision. Animal studies have demonstrated slower incorporation of allograft tissue, which may affect the mechanism of graft failure. The purpose of this study is to determine the location of traumatic graft failure following ACL reconstruction and investigate differences in failure patterns between autografts and allografts. The medical records of 34 consecutive patients at our center undergoing revision ACL reconstruction following a documented traumatic re-injury were reviewed. Graft utilized in the primary reconstruction, time from initial reconstruction to re-injury, activity at re-injury, time to revision reconstruction, and location of ACL graft tear were recorded. Median patient age at primary ACL reconstruction was 18.5 years (range, 13-39 years). The primary reconstructions included 20 autografts (13 hamstrings, 6 patellar tendons, 1 iliotibial band), 12 allografts (5 patellar tendon, 5 tibialis anterior tendons, 2 achilles tendons), and 2 unknown. The median time from primary reconstruction to re-injury was 1.2 years (range, 0.4 - 17.6 years). The median time from re-injury to revision reconstruction was 10.4 weeks (range, 1 to 241 weeks). Failure location could be determined in 30 patients. In the autograft group 14 of 19 grafts failed near their femoral attachment, while in the allograft group 2 of 11 grafts failed near their femoral attachment (p < 0.02). When ACL autografts fail traumatically, they frequently fail near their femoral origin, while allograft reconstructions that fail are more likely to fail in other locations or stretch. Level III - Retrospective cohort study.
    Full-text · Article · Jun 2012 · Sports Medicine Arthroscopy Rehabilitation Therapy & Technology
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    ABSTRACT: Conventional tunnel positions for single-bundle (SB) transtibial anterior cruciate ligament (ACL) reconstruction are located in the posterolateral (PL) tibial footprint and the anteromedial (AM) femoral footprint, resulting in an anatomic mismatch graft that is more vertical than native fibers. This vertical mismatch position may significantly influence the ability of an ACL graft to stabilize the knee. Anatomic ACL fibers undergo a greater change in length during anterior translation and internal rotation than a conventional SB reconstruction from the PL tibial footprint to the AM femoral footprint. Controlled laboratory study. The Praxim ACL Surgetics navigation system was used to acquire kinematic data during a flexion/extension cycle and to register all points within the ACL footprint from 5 fresh-frozen cadaveric knees. Virtual fibers were placed in the center of the AM and PL bundles as well as central and conventional SB positions. After transection of the ACL, the absolute length change and apparent strain of the fibers were computed for each knee during the Lachman and anterior drawer tests and internal rotation at 0 degrees and 30 degrees of flexion. Each of the anatomic fibers (AM, PL, and central) had more elongation and apparent strain than the conventional SB fiber during the Lachman maneuver. During the anterior drawer test, the AM and central (but not the PL) fibers lengthened significantly more and the AM had more apparent strain than the conventional SB fiber. During internal rotation at 0 degrees and 30 degrees of flexion, anatomic fibers elongated significantly more than the conventional fiber. Except for the AM fiber with the knee at full extension, apparent strain was greater in all anatomic fibers than in the conventional SB fiber during internal rotation maneuvers. In ACL-deficient cadaveric knees, anatomic fibers undergo greater elongation and apparent strain in response to anterior translation and internal rotation maneuvers than a conventional SB graft. Because of their optimal orientation, anatomic fibers may resist pathologic anterior translation and internal rotation more than the conventional SB position. Conventional placement of a single-bundle graft results in suboptimal changes in fiber length and strain, suggesting that alternatives such as anatomic placement of an SB graft or double-bundle reconstruction may result in greater control of translation and rotation.
    No preview · Article · Aug 2008 · The American Journal of Sports Medicine
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