Historical and Current Perspectives in the Treatment of Anterior Cruciate Ligament Insufficiency

  • R. P. Jakob
  • J. P. Warner


The treatment of anterior cruciate ligament (ACL) insufficiency continues to be a significant problem in orthopedic practice. Although the current problems are well known and have been identified, many questions remain unanswered. Major procedural differences and the contradictory results of many workers attest to the fact that there is still no general consensus regarding the natural history, management, and biomechanics of the knee with anterior instability. To appreciate the complexity of these problems, we must first understand the historical foundations laid by our predecessors. Otherwise we risk repeating previous mistakes or making “new” discoveries that actually are rediscoveries of previously known facts. A grasp of history is essential if we are to explore new areas in ACL surgery. A chronologic summary of historical milestones relating to the ACL and its injuries is presented in Table 1. Galen of Pergamum and Rome is credited with first describing the anatomy and nature of the ACL. Before Galen it was thought that the cruciate ligaments were part of the nervous system and had contractile properties. Galen developed the concept of these ligaments as static stabilizing structures that limit abnormal motion in diarthrotic joints. During the next 1600 years, scant attention was given to the knee ligaments except in descriptions of dislocations and severe sprains.


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Pivot Shift Tear Anterior Cruciate Ligament Anterior Cruciate Ligament Surgery 
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  1. AIm A, Ekström H, GilIquist J (1974) The anterior cruciate ligament. A clinical and experimental study on tensile strength, morphology, and replacement by patellar ligament. Acta Chir Scand [Suppl 445]Google Scholar
  2. Alwyn Smith S (1918) The diagnosis and treatment of injuries to the crucial ligaments. Br J Surg 6: 176–189CrossRefGoogle Scholar
  3. Andrish JT, Wood CD (1984) Dacron augmentation in anterior cruciate ligament reconstruction in dogs. Clin Orthop 183:298–302PubMedGoogle Scholar
  4. Amoczky SP, Warren RF, Minei JP (1985) Replacement of the anterior cruciate ligament using a synthetic prosthesis. An evaluation of graft biology in the dog. Am J Sports Med 14: 1–6CrossRefGoogle Scholar
  5. Arnoczky SP, Torzilli PA, Warren RF, Allen AA (1988) Biologic fixation of ligament prosthesis and augmentation. Am J Sports Med 16/2: 106–112PubMedCrossRefGoogle Scholar
  6. Arnold JA, Coker TP, Heaton LM et al. (1979) Natural history of anterior cruciate ligament tears. Am 1 Sports Med 7: 305–313CrossRefGoogle Scholar
  7. Augustine RW (1956) The unstable knee. Am J Surg 92:380–388PubMedCrossRefGoogle Scholar
  8. Bach BR, Warren RF, Wickiewicz TL (1988) The pivot shift phenomenon: results and description of a modified clinical test for anterior cruciate ligament insufficiency. Am J Sports Med 16/6: 571–576PubMedCrossRefGoogle Scholar
  9. Battle WH (1900) A case after open section of the knee joint for irreducible traumatic dislocation. Clin Soc Lond Trans 33: 232–233Google Scholar
  10. Bircher E (1921) Die Arthroendoskopie. Zentralbl Chir 48: 1460–1461Google Scholar
  11. Bircher E (1922) Beitrag zur Pathologie und Diagnose der Meniscus-Verletzungen. Bruns Beitr Klin Chir 127: 239–250Google Scholar
  12. Bosworth DM, Bosworth BM (1936) Use of fascia lata to stabilize the knee in cases of ruptured crucial ligaments. J Bone Joint Surg [Am] 18: 178–179Google Scholar
  13. Brantigan OC, Voshell AF (1941) The mechanics of the ligaments and menisci of the knee joint. J Bone Joint Surg 23: 44Google Scholar
  14. Burman MS, Finkelstein H, Mayer L (1934) Arthroscopy of the knee-joint. J Bone Joint Surg 16: 255–268Google Scholar
  15. Campbell WC (1936) Repair of the ligaments of the knee joint. Surg Gynecol Obstet 62: 964–968Google Scholar
  16. Campbell WC (1939) Reconstruction of the ligaments of the knee. Am J Surg 43: 473–480CrossRefGoogle Scholar
  17. Cerabona F, Sherman MF, Bonamo JR, Sklar J (1988) Patterns of meniscal injury with acute anterior cruciate ligament tears. Am J Sports Med 16/6: 603–609PubMedCrossRefGoogle Scholar
  18. Chick RR, Jackson A W (1979) Tears of the anterior cruciate ligament in young athletes. J Bone Joint Surg [Am] 60: 970Google Scholar
  19. Clancy WG, Nelson DA, Reider B et al. (1982) Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extraarticular tendon transfers. J Bone Joint Surg [Am] 67: 352–359Google Scholar
  20. Cubbins WR, Callahan JJ, Scuderi CS (1937) Cruciate ligament injuries. Surg Gynecol Obstet 64: 218–225Google Scholar
  21. Daniel D, Biden EN (1987) The language of knee motion. In: Jackson DW, Drez D (eds) The anterior cruciate deficient knee. Mosby, St Louis, pp 1–16Google Scholar
  22. DeHaven KE (1980) Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med 8: 9–14PubMedCrossRefGoogle Scholar
  23. Dye SF (1988) An evolutionary perspective. In: Feagin JA (ed) The crucial ligaments. Diagnosis and treatment of ligamentous injuries about the knee. Churchill Livingstone, New York, pp 161–172Google Scholar
  24. Eriksson E (1983) Ivar Palmer. A great name in the history of cruciate ligament surgery. Clin Orthop 172: 4–13Google Scholar
  25. Feagin JA (1979) The syndrome of the torn anterior cruciate ligament. Orthop Clin North Am 10/1: 81–91PubMedGoogle Scholar
  26. Feagin JA, Curl WW (1976) Isolated tear of the anterior cruciate ligament: 5-year follow up study. Am J Sports Med 4:95–100PubMedCrossRefGoogle Scholar
  27. Feagin JA, Abbott HG, Rokus JR (1972) The isolated tear of the anterior cruciate ligament. J Bone Joint Surg [Am] 54: 1370Google Scholar
  28. Felsenreich F (1937) Klinik der Kreuzbandverletzungen. Arch Klin Chir 179: 375–408Google Scholar
  29. Fetto JF, Marshall JL (1980) The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 147:29PubMedGoogle Scholar
  30. Freiberger RH, Kaye JJ, Spiller J (1979) Arthrography. Appleton- Century-Crofts, New YorkGoogle Scholar
  31. Galen C (1968) On the usefulness of parts of the body. May MT (trans). Cornell University Press, Ithaca/NYGoogle Scholar
  32. Galway HR, Beaupre A, MacIntosh DL (1972) Pivot shift. A clinical sign of anterior cruciate ligament instability. J Bone Joint Surg [Br] 54: 763Google Scholar
  33. Garrick JG (1988) Epidemiology of the ACL. In: Feagin JA (ed) The crucial ligaments. Diagnosis and treatment of ligamentous injuries about the knee. Churchill Livingstone, New York, pp 173–176Google Scholar
  34. Gillquist J, Hagberg G, Oretorp N (1977) Arthroscopy in acute injuries of the knee joint. Acta Orthop Scand 48: 190–196PubMedCrossRefGoogle Scholar
  35. Girgis FG, Marshall JC, Monajem AL (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimenta analysis. Clin Orthop 106: 216–231PubMedCrossRefGoogle Scholar
  36. Goetjes H (1913) Über Verletzungen der Ligamenta cruciata des Kniegelenks. Dtsch Z Chir 123: 221–289CrossRefGoogle Scholar
  37. Goodfellow J, O’Connor J (1978) The mechanics of the knee and prosthetic design. J Bone Joint Surg [Br] 60: 358–369Google Scholar
  38. Grona WA, Muse G (1988) The effect of exercise on laxity in the anterior cruciate deficient knee. Am J Sports Med 16/6:586–588CrossRefGoogle Scholar
  39. Harter RA, Osternig LR, Singer KM, James SL, Larson RC, James DC (1988) Long-term evaluation of knee stability and function following surgical reconstruction for anterior cruciate ligament insufficiency. Am J Sports Med 16/8: 434–443PubMedCrossRefGoogle Scholar
  40. Henche HR, Holder J (1985) Arthroskopie des Kniegelenks, 2. Aufl. Springer, Berlin Heidelberg New YorkGoogle Scholar
  41. Hey Groves EW (1920) The crucial ligaments of the knee joint. Their function, rupture, and the operative treatment of the same. Br J Surg 7: 505–515CrossRefGoogle Scholar
  42. Hobson D, Torfason L (1974) Optimization of the four-bar knee mechanism - a computerized approach. J Biomech 7:371–376PubMedCrossRefGoogle Scholar
  43. Hughston JC, Andrews JR, Gross MJ et al. (1976) Classification of knee ligament instability. Parts I and II. J Bone Joint Surg [Am] 58: 159–179Google Scholar
  44. Jakob RP (1987) Pathomechanical and clinical concepts of the pivot shift sign. Semin Orthop 2/1: 9–17Google Scholar
  45. Jakob RP, Stäubli H-U, Deland JT (1987) Grading the pivot shift. Objective tests with implications for treatment. J Bone Joint Surg [Br] 69: 294–299Google Scholar
  46. Jones R, Smith A (1913) On rupture of the crucial ligaments of the knee and on fractures of the spine of the tibia. Br J Surg 1: 70–89CrossRefGoogle Scholar
  47. Kain CC, McCarthy JA, Arms S, Pope MA, Steadman RJ, Manske PRo Shively RA (1988) An in vivo analysis of the effect of transcutaneous electrical stimulation of the quadriceps and hamstrings on anterior cruciate ligament deformation. Am J Sports Med 16/2: 147–152PubMedCrossRefGoogle Scholar
  48. Kannus P, Jarvinen M (1987) Conservatively treated tear of the anterior cruciate ligament. J Bone Joint Surg [Am] 69: 1007–1011Google Scholar
  49. Kennedy JC, Weinberg HW, Wilson AS (1976) The anatomy and function of the anterior cruciate ligament as determined by clinical and morphological studies. J Bone Joint Surg [Am] 56: 223–235.Google Scholar
  50. Kornblatt I, Warren RF, Wickiewicz TL (1988) Long-term follow up of anterior cruciate ligament reconstruction using the quadriceps tendon substitute for chronic anterior cruciate ligament insufficiency. Am J Sports Med 16/5:444–448PubMedCrossRefGoogle Scholar
  51. Kreuscher PH (1925) Semilunar cartilage disease. A plea for early recognition by means of the arthroscope and early treatment of this condition. Int Med J 47: 290–292Google Scholar
  52. Lemaire M (1967) Ruptures anciennes du ligament croise antérieur du genou. J Chir (Paris) 93: 311–320Google Scholar
  53. Lynch MA, Henning CE, Glick KR Jr (1983) Knee joint sur face changes: long-term follow up of meniscus-tear treatments in stable anterior cruciate ligament reconstructions. Clin Orthop 172: 148–153PubMedGoogle Scholar
  54. Mayo Robson A W (1903) Ruptured crucial ligaments and their repair by operation. Ann Surg 37: 716–718Google Scholar
  55. McDaniel WJ Jr, Dameron JB Jr (1980) Untreated rupture of the anterior cruciate ligament. A follow up study. J Bone Joint Surg [Am] 62: 696Google Scholar
  56. McPherson GK, Mendenhall HV, Gibbons OF et al. (1985) Experimental mechanical and histological evaluation of the Kennedy ligament augmentation. Clin Orthop 196: 186–195PubMedGoogle Scholar
  57. Noyes FR, Grood ES (1976) The strength of the anterior cruciate ligament in humans and rhesus monkeys. Age-related and species-related changes. J Bone Joint Surg [Am] 58: 1074–1082Google Scholar
  58. Noyes FR, McGinnes GH (1985) Controversy about treatment of the knee with anterior cruciate laxity. Clin Orthop 198: 61–76PubMedGoogle Scholar
  59. Noyes FR, Bassett RW, Grood ES et al. (1980a) Arthroscopy in acute traumatic hemarthrosis of the knee: incidence of anterior cruciate tear and other injuries. J Bone Joint Surg [Am] 6: 687–695Google Scholar
  60. Noyes FR, Grood ES, Butler DL, Malick M (1980b) Clinical laxity tests and functional stability of the knee. Biomechanical concepts. Clin Orthop 196: 84–89Google Scholar
  61. Noyes FR, Matthews OS, Movar PA (1983a) The symptomatic anterior cruciate deficient knee. Part II: The results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg [Am] 65: 163–174Google Scholar
  62. Noyes FR, Movar PA, Mathews DS, Butler DL (1983b) The symptomatic anterior cruciate-deficient knee. Part I: The long term functional disability in athletically active individuals. J Bone Joint Surg [Am] 65: 154–162Google Scholar
  63. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy M (1984) Biomechanical analysis of human ligament grafts used in knee-ligament repair and reconstruction. J Bone Joint Surg [Am] 66: 344–352Google Scholar
  64. Odensten M, Tegnér Y, Lysholm J, Gillquist J (1983) Knee function and muscle strength following distal iliotibial band transfer for anterolateral rotary instability. Acta Orthop Scand 54: 924PubMedCrossRefGoogle Scholar
  65. Odensten M, Hamberg P, Nordin M, Lysholm J, Gillquist J (1985) Surgical or conservative treatment of the acutely tom anterior cruciate ligament. Clin Orthop 198: 87–93PubMedGoogle Scholar
  66. O’Donoghue DH (1950) Surgical treatment of fresh injuries to the major ligaments of the knee. J Bone Joint Surg [Am] 32: 721–738Google Scholar
  67. O’Donoghue DH (1977) An analysis of end results of surgical treatment of major injuries to the ligaments of the knee. J Bone Joint Surg [Am] 37: 1–13Google Scholar
  68. O’Donoghue DH, Rockwood CA, Frank GR et al. (1966) Repair of the anterior cruciate ligament in dogs. II. J Bone Joint Surg [Am] 48: 503–519Google Scholar
  69. Palmer I (1938) On the injuries to the ligaments of the knee joint. A clinical study. Acta Chir Scand 81 [Suppl 53]: 2–282Google Scholar
  70. Paulos LE, France PE, Rosenberg TO, Jayaraman G, Abbott PJ, Jean J (1987) The biomechanics of lateral knee bracing. Parts I and II. Am J Sports Med 15: 419–439PubMedCrossRefGoogle Scholar
  71. Schutte MT, Dabazies EJ, Zimny ML, Happel LT (1987) Neural anatomy of the human anterior cruciate ligament. J Bone Joint Surg [Am] 69: 243–247Google Scholar
  72. Snook GA (1988) The ACL: a historical review. In: Feagin JA (ed) The crucial ligaments. Diagnosis and treatment of ligamentous injuries about the knee. Churchill Livingstone, New York, pp 157–161Google Scholar
  73. Solonen KA, Rokkanen P (1967) Operative treatment of tom ligaments in injuries to the knee joint. Acta Orthop Scand 38: 67PubMedCrossRefGoogle Scholar
  74. Sommer R (1937) Die Endoskopie des Kniegelenkes. Zentralbl Chir 64: 1692–1697Google Scholar
  75. Stark J (1850) Two cases of ruptured crucial ligaments of the knee-joint. Edinb Med Soc 74: 267–271Google Scholar
  76. Steadman JR (1983) Rehabilitation of acute injuries of the anterior cruciate ligament. Clin Orthop 172: 129–132PubMedGoogle Scholar
  77. Tim KE (1988) Postsurgical knee rehabilitation. A five year study of four methods and 5381 patients. Am J Sports Med 16/5:463–468CrossRefGoogle Scholar
  78. Turner NP, Turner IG, Jones CB (1987) Prosthetic anterior cruciate ligaments in the rabbit - a comparison of four types of replacement. J Bone Joint Surg [Br] 69: 312–316Google Scholar
  79. Warren RF, Levy IM (1983) Meniscal lesions associated with anterior cruciate ligament injury. Clin Orthop 172: 32–37PubMedGoogle Scholar
  80. Watanabe M, Takeda S, Ikeuchi H (1969) Atlas of arthroscopy, 2nd edn. Igako-Shoin, TokyoGoogle Scholar
  81. Wilke KH (1939) Endoskopie des Kniegelenkes an der Leiche. Bruns Beitr Klin Chir 169: 75–83Google Scholar
  82. Wood GW (1985) Synthetics in anterior cruciate ligament reconstruction: a review. Orthop Clin North Am 16: 227–235Google Scholar

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© Springer-Verlag Berlin Heidelberg 1992

Authors and Affiliations

  • R. P. Jakob
  • J. P. Warner

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