The evolution of anatomic anterior cruciate ligament reconstruction

Abstract

Anterior cruciate ligament reconstruction has evolved significantly since the early 1900's, back when an emphasis was placed on repair and not reconstruction. Over the past century, the technique has evolved from intra-articular non anatomic reconstruction, to extra articular reconstruction, back to intra articular (performed arthroscopically), to now, the advent of anatomic insertion site restoration. This review will aim to illustrate the changes that have occurred, describing the rational for this process, based upon anatomical, radiological, biomechanical and clinical studies, all of which have aimed to improve patient function following ACL injury.

Keywords: Anterior cruciate ligament; evolution.; reconstruction; repair; surgical technique.

Fig. (1)

An anterior view of the intercondylar notch in a cadaver with a clock face superimposed. The native ACL can be seen to attach to the femur between the 1 and 3 o’clock positions.

Fig. (2)

a) A cadaveric dissection demonstrating the two bundles of the ACL; the anteromedial (AM) and posterolateral (PL) bundles, and b) the fan-like insertion on the femoral condyle, viewed from the medial side. Courtesy of Dr. Charles Brown.

Fig. (3)

An intra-operative fluoroscopic lateral image of the knee with the Bernard and Hertel grid laid over the lateral wall of the intercondylar notch. The microfracture awl is placed in the mid bundle position of the femoral insertion footprint.

Fig. (4)

Arthroscopic view of the lateral wall of the intercondylar notch from the anteromedial portal. a) the lateral intercondylar ridge (‘residents ridge) (A) and the lateral bifurcate ridge (B) are shown. b) the mid bundle position being marked with a microfracture awl, placed on the lateral bifurcate ridge.

Fig. (5)

The arthroscopic description of tunnel position on the femur.

Fig. (6)

Arthroscopic view of two ACL reconstructions: a) Pre anatomic position, with the graft placed higher in the notch resulting in more vertical collagen fibre orientation, and b) anatomic ACL reconstruction with a low placed graft resulting in a more oblique graft position. Courtesy of Dr. Charles Brown.