The field of orthopedic surgery has seen remarkable progress in the management of knee injuries, particularly in the realm of anterior cruciate ligament (ACL) reconstruction. This comprehensive review traces the historical journey of ACL surgery from its inception to modern-day techniques, offering valuable insights into the advancements that have shaped current clinical practice. Understanding this evolution is crucial for appreciating why today’s surgical approaches prioritize restoring native knee anatomy to achieve superior, long-lasting outcomes.
From Non-Anatomic to Anatomically-Focused Techniques
Early attempts at ACL reconstruction in the 20th century were often performed using non-anatomic methods, both intra-articular and extra-articular. These techniques focused on stabilizing the knee joint through mechanical means without precisely replicating the original ligament’s function or insertion points. While they provided some level of stability, they often failed to restore the complex kinematics of the knee, leading to residual rotational laxity and a greater risk of long-term complications, such as osteoarthritis.
Over time, a significant paradigm shift occurred. The focus moved away from simply preventing anterior tibial translation to meticulously restoring the native knee anatomy and kinematics. This modern approach, known as anatomic reconstruction, aims to place the new graft in the same location and orientation as the original ACL. By doing so, surgeons can better replicate the biomechanical functions of the natural ligament, leading to more predictable and stable results. This change in philosophy has become a cornerstone of contemporary ACL surgery, directly influencing surgical planning and graft selection to improve knee stability and patient satisfaction.
Renewed Interest in ACL Repair and Lateral Procedures
In addition to the evolution of the primary reconstruction technique, recent years have seen a renewed interest in methods that were once considered outdated. This review highlights the re-evaluation of ACL repair and lateral procedures with a modern perspective. Previously abandoned due to high failure rates, ACL repair is now being revisited in select patients with specific tear patterns, thanks to improved understanding of ligament biology and advanced surgical techniques.
Similarly, lateral procedures, such as anterolateral ligament (ALL) reconstruction, are regaining prominence. These techniques, which address the knee’s anterolateral structures, are now being combined with standard ACL reconstruction to tackle persistent rotational instability, especially in high-risk individuals like young athletes. This dual-ligament approach reflects a deeper appreciation for the interconnectedness of knee structures and a commitment to providing comprehensive, long-term solutions for patients. The review provides an excellent overview of the rationale behind these revived and refined methods, underscoring the dynamic nature of orthopaedic medicine.
This research highlights key milestones, offering a clear overview of the concepts that guide today’s surgical decisions. It shows that the goal of ACL reconstruction is no longer just to replace a torn ligament, but to restore the knee’s full functional capacity through an evidence-based and anatomically sound approach.
Professor Wilson’s Comments
“This is a well-written review paper highlighting several important innovations in ACL surgery. It explores our efforts to make ACL reconstruction more anatomic through a mid-bundle approach — a concept that made sense in the lab but ultimately proved suboptimal in clinical practice. Biomechanical studies showed that as the knee moved from full extension to flexion, this mid-bundle positioning subjected the graft to increased strain, leading to a higher failure rate. As a result, we reverted to placing the femoral tunnel in a deeper, more posterior position within the intercondylar notch — the natural attachment site of the ACL on the femur — which restored appropriate graft isometry and reduced failure rates.
The paper also discusses extra-articular procedures, referencing the excellent work of Dr. Steven Claes and my good friend Professor Johan Bellemans, who performed groundbreaking anatomical and biomechanical studies of the anterolateral ligament (ALL). Their research led to the development of anatomic ALL reconstruction surgery. I am proud to note that I was the first to perform an anatomic ALL reconstruction, a technique inspired by my earlier adoption of the all-inside ACL reconstruction method.
The all-inside ACL technique requires only the semitendinosus tendon, leaving the gracilis intact — unlike traditional techniques that harvest both. Recognising this, I repurposed the intact gracilis as a free graft for an extra-articular reconstruction, pioneering a combined approach that enhanced rotational stability.
Overall, this review paper provides surgeons with an up-to-date overview of the evolution of ACL surgery, covering the rationale, successes, and lessons learned from various innovations. I believe it remains a valuable contribution to the literature and a reflection of how our understanding of ACL biomechanics continues to evolve.”
To delve into the complete findings, methodology, and analysis, the full research paper is available for your review:
Anterior Cruciate Ligament Reconstruction – Evolution and Current Concepts
Sources used in report overview:
- https://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327(14)00165-1/abstract
