History of ACL Reconstruction

Robert John Bartlett

Victoria, Australia

Study of the history of ACL injury is long and fascinating and can be traced back to Galen in about 170AD when he was treating the Gladiators. In 1845 Bonnet described the history of injury and in 1875 Noulis described diagnostic examination findings. In 1879 Segond described the small avulsion fracture on the lateral side of the tibia and this was some 16 years before the discovery of x-rays. The first ACL repair was by Robson in 1895 with a good outcome.
The early 20th Century saw the need for reconstructive surgery with the first synthetic graft inserted by Lange in 1903 and then the first autogenous graft Hey-Groves in 1917. Campbell in 1936 and Palmer 1938 reported on patellar tendon grafts and then Macey described the first hamstring graft in 1939. Great names such as Trillat, O'Donoghue, and Hughston contributed to the understanding of anatomy and mechanism of injury. Jones in 1963 renewed interest with his procedure using a patellar tendon graft.
Results were variable and many independent Surgeons were studying the importance of lateral capsular structures with MacIntosh describing the lateral pivot shift in 1972 and Surgeons such as Lemaire and Losee reporting results of their lateral extra articular reconstruction procedures. Feagin in 1976 suggested that repair procedures had a high failure rate. Much more understanding of biomechanics came from the publications of Muller in 1977 and further information on load to failure of the ACL and various grafts came from Noyes and Woo. The biological fate of the graft was clarified by the work of Clancy in 1981 and Oakes with electron microscopy work confirmed graft changes at a collagen fibre level. There have been great advances in graft fixation and rehabilitation and recent work from Surgeons such as Fu, Yasuda and Siebold among many others has led to much greater understanding of the anatomy, function and mechanisms of failure of the ACL. There is continued work in finding the perfect operative technique and finding the perfect graft be it autograft, allograft or synthetic. Utilisation of new technologies such as tissue engineering will lead to further advances.