Anterior cruciate ligament (ACL) surgery - past, present and future

Abstract

Anterior cruciate ligament (ACL) injury is a common reported injury in an athlete. Historically, with the first description of the structure of ACL in 150 AD, the surgical repair and reconstruction techniques have evolved. Over the years the ACL surgery was done as direct repair, reconstruction, anatomical repair, intra-articular repair and extra-articular repair. This narrative review will discuss the different modes and techniques used for surgery chronologically, the challenges and outcomes with regard to the surgery, and the latest techniques used to improve patient outcome. 1 Senior Consultant Orthopedic Surgeon, Former Director General, Institute of Sports Medicine, Ministry of Sports, Sri Lanka. Introduction Ligamentous injury in the athlete is a major cause of morbidity and time away from sport [1]. The ligamentous sporting injuries in the knee are the leading cause of sport-related surgery [2] and can have devastating consequences on the sporting career of athletes. Anterior cruciate ligament (ACL) injuries account for anywhere between 25 and 50% of ligamentous knee injuries and are more common and gradually increasing in numbers [3]. It has been estimated with a prevalence of 1 in 3000 in the United States (greater than 120 000 cases annually) [4]. ACL injury is important because of increasing number and also the sequelae of the injury. Complete rupture of the ACL has a very poor potential to heal on its own [5]. ACL deficient knee will lead to meniscal damage and articular cartilage damage leading to premature onset of degeneration of the knee joint. Unfortunately, ACL repair or reconstruction cannot prevent premature degeneration, but can only achieve a stable joint in the short term and postpone the onset of arthritis [6] by about 10 years. Diagnosis of ACL injury ACL injury is diagnosed by history, clinical examination and radiological imaging. Correspondence: UB, e-mail: First identification and description of ACL ligament is attributed to Claudius Galen (150 AD), a Greek physician in the Roman Empire [7]. In 1845, Amedee Bonnet of Lyon described a patient who developed a “Popp” sound, and swelling of the knee. It was attributed to a torn ACL. Thirty years later Georges Noulis from Greece demonstrated that anterior subluxation of knee could cause ACL rupture in a series of cadaver studies [8]. In 1879, Paul Segond attributed a small fracture of the tibial plateau associated with ACL injury [9]. Since it was noticed that untreated ACL injury causes premature joint degeneration, instability, and meniscus and cartilage damage; the surgical treatment emerged. Historical background of different techniques used for ACL surgery