History of ACL Surgery

The knee joint consists of three bones held together by ligaments. One of the most important ligaments---the anterior cruciate ligament, or ACL---creates joint stability by limiting forward and twisting motions. The ACL is frequently damaged in injuries to the knee, especially the types of twisting injuries sustained in sports. Depending on the severity of the injury, surgery is necessary to reconstruct a torn ACL.

Early History

• Early steps toward ACL surgery began in the 1800s when physicians first identified the role of the ACL and described ways to diagnose injuries. A Greek doctor named Georges Noulis was the first to describe a method for diagnosing damage to the ACL. The first surgical repair of the ACL was performed in 1895 by A.W. Robson, who stitched the torn ligament together. He did not report his surgery until 1903 so when W.H. Battle repaired a torn ACL in 1900 it was cited as the first ACL surgery ever completed.

Progress in Early 1900s

• In 1903, a German doctor named F. Lange attempted the first ACL replacement using braided silk to replace the ligament. His surgery was not successful. An ACL reconstruction was first accomplished by Ernest Hey Groves in 1917. This was complicated surgery in which grafted connective tissue was rerouted through the joint and connected to the upper leg bone. The procedure failed to stabilize the knee joint but he continued trying. After 14 surgeries, he reported success in four cases and some improvement in four others.

Reconstruction with Tendons

• The first ACL reconstruction using a tendon was reported by Willis Campbell in 1935. He grafted the portions of tendons, drilled tunnels in the upper and lower leg bones, routed the tendons through the joint and attached them into the tunnels. Dr. Campbell performed ACL reconstruction on 17 athletes. Nine of them returned to playing football.

Decades of Refinement

• Over the 1940s, 50s, and 60s diagnostic procedures were better defined and surgical techniques were refined. In the late 1950s, Dr. MacIntosh performed the first successful ACL reconstruction using an extra-articular technique. He successfully stabilized the joint by rerouting ligaments along the outside of the knee joint. Several physicians focused on ACL surgeries using the patellar tendon to replace the ACL. Until this point, ACL reconstruction used ligaments that were left anchored to one bone and attached to the other. In 1969 Kurt Franke pioneered the free bone-tendon-bone graft. He detached a piece of the patellar tendon with small pieces of bone at either end, replaced the torn ACL with the tendon, and used the bones to attach the tendon to tunnels in the upper and lower leg bones. During the 1980s physicians experimented with synthetic ligaments but with poor results. A high rate of infections and ruptures caused this technique to be abandoned. In the 1990s the free bone-tendon-bone graft was improved with the addition of screws to anchor the tendon replacement.

Arthroscopy

• The history of ACL surgery would not be complete without mentioning arthroscopy, which is one of the three most important advances in orthopedics. The inside of the knee was first viewed via a cytoscope by Kenji Takagi in 1918. He also refined the cytoscope into the arthroscope that became the model for present day instruments. In 1921 Dr. Eugene Bircher became the first physician to perform arthroscopy of the knee on a live patient. During the 1930s Michael Burman viewed and described anatomic structures using the arthroscope. Shortly after his work, interest in arthroscopy declined in North America but not in Japan where Masaki Watanabe was hard at work developing the arthroscope. Originally used only as a diagnostic tool, his success turned the arthroscope into a surgical instrument. Watanabe performed the first arthroscopic surgery of the knee in 1962. Today it is the preferred method for surgically treating knee injuries, including reconstruction of the anterior cruciate ligament.