ARTICLE IN PRESS

Current Orthopaedics (2004) 18, 4957

www.elsevier.com/locate/cuor

KNEE

The anterior cruciate ligamentFII

S. Karmani1,*, T. Ember2

1
50 Hadyn Avenue Purley, Surrrey, CR8 4AE, UK
2
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK

Surgical principles Marshall et al.5 reported 70 patients with a mean

A number of approaches have been adopted over
time in dealing with the ACL deficient knee. These
can be considered under several headings.
ACL repair
Primary repair was the earliest approach to the ACL
problem, the first report in the literature being
Mayo Robson1 at Leeds General infirmary, England.
He treated a miner who presented with lameness
following a cave-in. Robson sutured the cruciate
ligaments to their normal femoral sites of attach-
ment; the result at 6 years was excellent. Palmer2
went on to describe anatomy, biomechanics and
techniques but not results. It was ODonoghue
et al.3 who first reported a follow-up of 25 patients
with acute ACL injuries over 618 months. All 25
were functionally stable and 22/25 objectively
stable but this term was not clearly defined. He
advocated surgical repair of acute ACL ruptures
within 2 weeks; for chronic injuries he adopted the
approach of reconstruction.
Feagin and Curl4 presented a 5-year follow-up of
a technique using a chromic catgut or mersilene
figure of eight suture in the ACL that was passed
through drill holes in the lateral femoral condyle.
Of the reported 32 cases, 94% had instability, 54%
reinjury, 71% pain and stiffness and 66% complained
of swelling. They concluded that primary repair
alone was not sufficient to treat the ACL deficient
knee and recommended the use of augmentation.
*Corresponding author.
E-mail address: karmani1@hotmail.com (S. Karmani).
follow-up of 29 months who had primary repair with
the Marshall multiple suture technique. This in-
volved passing multiple looped sutures through the
ligament stumps at various levels to give an even
pull of tension and then passing the proximal
sutures through drill holes in the tibial insertion
of the ACL. The sutures from the distal stump are
then passed through drill holes in the lateral
femoral condyle made from out to in meeting the
original site of the ACL; 93% returned to sports (69%
without restriction), none complained of giving way
or demonstrated subsequent meniscal injury; 36%
complained of pain and 5% of swelling.
Kaplan6 published long-term follow-up data on
the Marshall technique (50 patients with a mean
follow-up of 82 months), 17% cases failed clinically,
42% failed with KT-1000 measurements. Sherman7
looked at 50 patients with Marshall repairs, 46%
were successful (17% excellent on objective and
subjective assessment) 29% failure and 25% inter-
mediate successes.
The conclusion from studies on primary repair
suggest that alone it is unsatisfactory in treating
the ACL deficient knee; both Kaplan and Sherman
recommended intra-articular augmentation
Autogenous augmentation
Various techniques have been described involving
the iliotibial band, fascia lata, patellar or ham-
string tendon. Gillquist8 described a procedure
which involved placing sutures in the tibial portion
of the ACL remnant and then passing them over the
top and through the lateral femoral condyle at the
site of the attachment of the ACL and then tied
over the lateral femoral condyle. Augmentation

0268-0890/$ - see front matter & 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0268-0890(03)00103-8
 ARTICLE IN PRESS
50
was then provided by a distally based 1.5 cm wide
strip of iliotibial band which was passed through
the hole in the lateral femoral condyle and then
through a hole in the tibia immediately anterior to
the ACL remnant.
Andesson et al.9 compared the results of con-
servative treatment, primary repair and repair with
augmentation. Sixty-three per cent of the augmen-
ted group returned to competitive sport, while only
32% of the primary repair group and 27% of the
conservative treatment group had such outcomes.
The conclusion was that patients with higher
functional demands should be treated with primary
repair and augmentation.
Extra-articular tenodesis
Bennett in 192610 first described an extra-articular
procedure for the anterior cruciate ligament
deficient knee. He proposed that the knee could
be stable without an ACL as long as other ligaments
particularly the medial collateral, were intact. He
used a free strip of fascia, woven longitudinally
along the medial joint line and then reefed the
medial extensor retinaculum; excellent results
were claimed in a series of six patients.
Cotton et al.11 believed that by reconstructing
the medial collateral ligament an unstable anterior
cruciate ligament could be rendered stable. He
used free strips of iliotibial band in a figure of eight
technique through drill holes in the medial tibia
and femur. Accurate placement of the graft was
essential.
Helfelt12 described a procedure to move the tibial
tubercle medially, attempting to increase external
rotation of the tibia. He placed semitendinosus in a
longitudinal groove in line with the medial collateral
ligament to internally rotate the femur with flexion.
Good results were obtained if the patient learned to
contract his hamstrings with knee flexion. Passive
instability remained unchanged.
A consensual conference of the American Society
of Sports Medicine13 developed a report on the
value of extra-articular procedures for ACL defi-
ciency. It concluded that extra-articular procedures
provided no improvement to the results of intra-
articular reconstructions of the ACL.
ACL reconstruction
Reconstruction has evolved as the mainstay of
surgical correction of the ACL deficient knee. The
reconstructive options are:
* Autogenous bone-patellar tendon-bone graft.
* Autogenous hamstring graft.
S. Karmani, T. Ember
* Autogenous quadriceps tendon graft.
* Allograft.
Autogenous bone-patellar tendon-bone graft
First described by Jones,14 it has become the most
popular graft option. A 10 mm wide graft has an
ultimate tensile strength of 2977 N, making it 170%
stronger than the native ACL; it is also 150%15
stiffer. The bony ends of the graft allow for bone to
bone healing in the tibial and femoral tunnels.
The drawback of the bone-patellar tendon-bone
graft is donor site morbidity. The complications
reported include patellofemoral pain 1756%,16,17
pain when kneeling 42%,18 quadriceps weakness
with flexion contracture and patellar irritability
65%,19 degeneration of the patellofemoral joint
57%,20 patellar fracture,21 patellar tendon rup-
ture22 and patellar tendonitis.19
The bone-patellar tendon-bone graft is not
recommended in patients with patello-femoral
pain, patello-femoral arthritis, small patellar ten-
dons and patellar malalignment.
Clinical studies of the bone-patellar tendon-bone
graft are encouraging, with absent pivot shift in
8090% and good to excellent results in 7090%.
Objective instrumented knee laxity measurements
have shown 3 mm or less laxity when compared with
the contralateral normal knee in 7093%.16,17,23,24
Autogenous hamstring graft
Macy in 193925 described using the semitendinosus
tendon based distally through the femur and tibia
for reconstructing the anterior cruciate ligament;
no results were detailed.
The hamstring graft has evolved from single,
double, triple to the modern four-stranded semi-
tendinosus/gracilis graft. This standard graft has an
ultimate tensile strength of 41084213 N26 and
stiffness of 807954 N/mm27 making it stronger
and stiffer than the native ACL and a 10 mm bone-
patellar tendon-bone graft. An 8 mm hamstring
graft has a cross-sectional area of 50 mm2 this
greater area favouring enhanced ligamentisation.
This is 1.5  the area of a patellar tendon graft and
comparable to a normal ACL.26
The great advantage of the hamstring graft is its
lack of donor site morbidity. Postoperative ham-
string weakness has not been demonstrated clini-
cally.28 Its main disadvantage is in graft fixation.
Due to lack of bone, fixation has to be outside the
tunnels; this has the effect of increasing graft
length therefore increasing the chance of graft
creep with cyclical loading. Stiffness is proportional
to graft length therefore instability of the graft
increases as fixation moves away from the
tibial plateau. These fixation problems prevent
 ARTICLE IN PRESS
The anterior cruciate ligamentFII
accelerated rehabilitation.29 Femoral cross pin
fixation is the strongest and stiffest fixation in
ACL reconstruction, with fixation strengths of
10021600 N and stiffness of 224 N/mm.30 Other
successful fixation devices have included the
Washerloc (Arthrotek, Warsaw, IN) and soft tissue
interference screws.
The results of the four-stranded hamstring graft
have shown absent pivot shift in 90% patients31,32
and with objective instrument laxity measurements
there is 3 mm or less laxity compared with the
contralateral knee in 90%.14,17 In comparative
studies with patellar tendon grafts most have failed
to demonstrate a significant difference between
the two,33,34 a few have shown increased laxity in
female patients reconstructed with hamstring
grafts34 and there has been a higher incidence of
patello-femoral pain and quadriceps weakness in
those reconstructed with patellar tendon grafts.
This experience has raised some concern in
reconstructing female patients and those with
increased ligamentous laxity with hamstring grafts.
Autogenous bone quadriceps tendon graft
This was first described by Blauth.35 A standard
10 mm graft has a cross-sectional area of 52
65 mm36 greater than other grafts and the normal
ACL, with an ultimate tensile strength of 4048 N.37
The bone block allows for fixation with interference
screws onto the femur with several soft tissue
fixation options for the tibia.
Donor site morbidity has not been shown to be a
problem with excellent results, high patient satis-
faction and low morbidity. Comparative studies
with the patellar tendon graft have not demon-
strated any difference in outcome.38
Allograft
A number of allograft options are available for
reconstruction including; bone-patellar tendon-
bone, Achilles tendon, fascia lata, tibialis anterior,
grouped toe-flexor tendons and semitendinosus.
The main advantages of allografts are the lack of
donor site morbidity and the ability to perform
reconstructions through minimally invasive techni-
ques. The greatest disadvantage is the potential for
disease transmission. Sterilisation can alter the
properties of the graft and Gamma irradiation can
decrease graft strength by 20% after 3 Mrad and 26%
with 4 Mrad,39 2.5 Mrad is needed to eliminate HIV
virus. Irradiation remains the least damaging mode
of graft sterilisation.40
The results of allografts are comparable to
autografts with good to excellent results in 70
90% and objective instrument laxity measurements
of 3 mm or less compared with the normal
51
contralateral knee in 71%. Failure rates of 33%
have been reported. Comparative studies have
shown no difference in functional outcome com-
pared to autografts.
Graft placement
The isometric point is that part of the ACL insertion
about which there is no change in length of the
ligament during the full range of flexion and
extension and isometric graft placement has been
favoured by many authors.41 Current thinking
regarding the complex fibre arrangement of the
ACL suggests that the concept of isometry is no
longer valid.42,43
Sakane et al.44 studied the in situ forces on the
ACL during anterior tibial displacement. They
noted that the forces in the intact ACL were
greatest at 301 of flexion decreasing with increasing
flexion. This profile of tension was most closely
mirrored by the posterolateral band of the ACL.
The anteromedial bundle showed a more constant
tension from full extension to flexion. Many authors
suggest graft placement near the posterolateral
band position. This may not only allow better
reproduction of ACL function but reduces the
chances of graft impingement during exten-
sion.45,46
The ideal position for ACL graft placement is still
unknown.
Graft tension
The ACL acts in tension to restrain anterior tibial
translation. In order for grafts to reproduce this
effect they need to be inserted under tension, but
what is the correct tension? Many investigators
have empirically suggested 44 N or 10 lb.
Yoshiya et al.47 in a canine study of graft tension
in ACL reconstruction, assessed the effect of
various tensions from 1 to 39 N on patellar tendon
autografts. At 3 months no difference was found in
the anteroposterior laxity and tensile properties of
the differently tensioned grafts; however, the 39 N
tensioned grafts demonstrated increased histologic
evidence of cartilage degeneration.
Yasuda et al.48 in a prospective randomised trial
studied the effect of three different initial graft
tensions; 20, 40 and 80 N respectively on anterior
tibial laxity at 2 years. They found that the 80 N
group had significantly less anterior tibial laxity
compared with the 20 N group; clinically however
all three groups were equivalent.
The knee position at the time of tensioning and
fixation is also significant. In a cadaveric study, it
was demonstrated that graft fixation at 301 knee
flexion resulted in significantly less anterior tibial
translation than when grafts were fixed with the
knee extended.49
 ARTICLE IN PRESS
52
The initial tension applied to all ACL grafts will
reduce (stress relax) with time. The ligament will
also lengthen (creep) so one must consider the
percentage of the initial tension that remains in the
graft to stabilise the knee joint. Cyclical loading
causes cyclical elongation thus the peak load
decreases with an increased number of cycles
(cyclical stress relaxation), initial loss of graft
tension is followed by a relatively constant residual
tension. The factors determining the residual
tension still need to be elucidated. Primate studies
have shown that, stress in the patellar tendon can
reduce by 70% of its initial stress within 30 min.50
Graft fixation
ACL grafts eventually incorporate into their bony
tunnels; initial fixation however is provided by
mechanical devices and it is the graft fixation
construct that provides initial knee stability allow-
ing patient mobilisation. With trends towards
accelerated rehabilitation, considerable demands
are made upon the fixation. Fixation methods can
be divided into direct devices (interference screws,
staple, washers and cross pins) and indirect devices
(polyester tape, titanium buttons and suture
posts). Many studies into the ultimate tensile
strength and stiffness of different fixation techni-
ques have been performed (Table 1).
The most popular fixation method for bone-
patellar tendon-bone grafts has been interference
screw fixation. Various size screws exist but
no significant difference in ultimate load to failure
has been demonstrated for the different sized
screws.63 More critical has been screw placement.
Screws placed parallel to bone blocks have higher
ultimate tensile loads to failure than diverging
screws; screw divergence of greater than 151
lowers ultimate tensile load by 50%.64
The healing of grafts
A firm attachment of ACL graft to bone is essential
for the restoration of normal function in the ACL
deficient knee. The normal ACL has a zonal
fibrocartilaginous insertion into bone. ACL grafts
incorporate into their bony tunnels by different
mechanisms initially. The healing of bone block
grafts such as the bone-patellar tendon-bone or
bone quadriceps tendon grafts differs from ham-
string tendon grafts.
Schiavone et al.65 in a rabbit study showed that
the bone blocks of the bone-patellar tendon-bone
graft incorporated directly into the bone tunnels by
16 weeks, with the establishment of a normal four-
zone fibrocartilaginous attachment by 69 months.
The process was felt to be more complex than
direct bone-to-bone healing as it took longer than
normal fracture healing.
S. Karmani, T. Ember
The tendon component of the graft undergoes
necrosis followed by vascularisation, and then
cellular replacement and eventually ligamentisa-
tion,66 with remodelling of its collagenous struc-
ture. A synovial layer forms around the graft
providing a blood supply.67 Revascularisation
from the proximal insertion is also noted within
20 days, a process that continues for up to 18
months.68
Animal studies reveal the graft has 5080% of its
initial strength at 12 months.69 In human subjects,
however, the patellar tendon autograft is viable by
3 weeks after surgery and may never undergo
complete necrosis.70 Thus in humans the patellar
tendon may maintain a strength equal to or greater
than the native ACL. This may have implications
with regards to rehabilitation, suggesting that
bone-patellar tendon-bone graft may be rehabili-
tated more aggressively.
The healing of hamstring grafts within a bone
tunnel initially produces a sleeve of fibrous tissue
attachment around the graft, with the fibres
aligned along the load axis. By 6 weeks collagen
fibres start to pass from the graft through the
fibrous tissue into bone, anchoring the graft
directly to cancellous bone, this process attains
significant strength by 12 weeks.71 Further animal
work has shown that in dogs the initial fibrous tissue
envelope that anchors hamstring grafts is even-
tually transformed into a direct fibrocartilaginous
attachment as in the native ACL by 30 52 weeks.72
Hamstring grafts may benefit from protection
during the first 12 weeks postop.
It can be seen that in both bone block and free
tendon grafts, there is an initial unstructured
fibrous tissue attachment that matures to a
structured zonal fibrocartilaginous enthesis over
6 12 months.
Rehabilitation
Rehabilitation is an integral part of the chain that
takes a patient from injury through surgery to full
recovery. ACL rehabilitation has evolved through
many phases as attitudes and understanding of the
biology and mechanics of the ACL injury and ACL
reconstruction has changed.
Rehabilitation after ACL reconstruction plays a
major role in the functional outcome of a patient.
There are a number of elements that any
rehabilitation program must address:
* Range of knee motion.
* Weight bearing.
* Quadriceps and hamstrings strength.
 ARTICLE IN PRESS
The anterior cruciate ligamentFII 53

Table 1 Fixation option for ACL grafts (adapted from Mologne et al.).51
Ultimate strength Stiffness Slippage under cyclical Extension at
(N) (N/mm) control failure (mm)
Fixation method
Metal interference screw 41664052 515852 12.653
with bone patellar tendon
Knitted loop of Mersilene 49354
tape
Knitted loop of #5 Ethibond 30254

Femoral devices
Endobutton 35270353 89853 155 N 250 000 cycles53 23.653
Continuos loop Single, 103055 Single 1.8 mm at
Endobutton Double, 132455 1000 cycles of
150 N55
Double 1.6 mm at
1000 cycles of
150 N55
Mitek anchor 31256 2656
RCI screw 33644557 6.8 mm after 1100
cycles of 150 N57
Arthrex metal soft screw 22658
Bone mulch screw (Athrotek) 112656 22556
Deputy cross pin 35 mm pin
1003 N57
70 mm pin
1604 N57
Bioabsorbable screw 32741056
Arthrex Transfix 100255 1.7 mm after 1000
cycles of 150 N55
LinxHT (Innovative) 63971155 1.4 mm after 1000
cycles of 150 N55
Bioscrew (Linvatec) 31055 4 of 5 failed prior to 1000
cycles of 150 N55
FastLoc 11 mm with STG 556659 1.1 mm after 1.5 7.49.459
(Neoligaments) 600 N59 14959 mil cycles of 200500 N59 4.959
11 mm with
Leeds/Keio Lig
1258 N59
8 mm with
Leeds/Keio Lig 1.4 mm after 1.5
1027 N59 mil cycles of 200500 N59
6 mm with #2
Ethibond
483510 N59
6 mm with #5
Ethibond 735 N59
Clawed washer with 6 mm 50257 6.7 mm after 300 cycles
screw of 150 N57

2 (Two) 6 mm soft tissue 82160 2960 2658

washers
Sutures tied over 6.5 mm 57360 1860 2258
screw post
20 mm spiked washer with 24861
6.5 mm screw
 ARTICLE IN PRESS
54
Table 1 (continued)
Ultimate strength
(N)
Tibial fixation
Fixation method
Stirrup (Corfix) Bovine bone 89857
WasherLoc plate/screw 90562
(Arthrotek)
RCI screw 35062
Tandem AO washers/screws 115962
AO washer/screw & sutures 76862
around screw post
* Proprioceptive knee control.
* Functional return to activity.
These must be balanced against the ability of the
ACL graft fixation construct to withstand stresses
during the phase of graft incorporation and patient
tolerances.
The earliest rehabilitation programs involved a
period of initial postoperative cast immobilisation
followed by resisted unloaded knee extension
work. They were based on the principle of
protecting the graft while healing occurred before
considering any stress upon it. They were compli-
cated by muscle wasting and arthrofibrosis.73
As understanding of the biomechanics of the
knee improved so there was a trend away from
prolonged cast immobilisation towards limited
immobilisation using range of motion braces.
Braces were locked allowing a limited range of
motion, short of full extension protecting the graft
from anterior shear forces generated by the
quadriceps during the last 301 of extension.74
The next movement in rehabilitation was pow-
ered by the principles of isometric graft placement,
improvements in graft fixation and an understand-
ing of the need for early mobilisation. Patients
progressed through a process of regulated passive
range of motion exercises, stopping 101 short of full
extension; these movements were performed in
range of motion braces. Progression to full weight
bearing and 0 100 flexion was achieved by 6
weeks. Muscle strengthening exercises were of the
open kinetic chain variety.75
Shelbourne et al.76 in the late 1980s using the
bone-patellar tendon-bone graft noted the progress
of his patients, comparing those who complied well
with his traditional rehabilitation (Table 2) and
those who did not comply, progressing as they
desired, obtaining full extension earlier than
recommended. He found these non-compliant
patients returned to normal function without knee
S. Karmani, T. Ember
Stiffness Slippage under cyclical Extension at
(N/mm) control failure (mm)
2.1 mm after 1100 cycles
150 N57
27362 2 mm at 500 N62
248 3.7 mm at 500 N (4 of 7
failed at 500 N)62
25962 0.5 mm at 500 N62
18162 0.9 mm at 500 N62
instability sooner than his compliant group. In
response he developed an accelerated rehabilita-
tion program, patient driven with medical super-
vision guiding progression based on absence of knee
effusion, lack of pain and ability to gain muscle
control. Exercises were closed kinetic chain,
performed with the foot fixed on a surface, so that
the entire limb is loaded during the movement,
with compressive loading of all the joints.
Open kinetic chain exercises by contrast are
performed with the limb extremity free, in this
case there is no compressive loading of the joints of
the limb with resultant increased shear forces
across the joints. Closed kinetic exercises are
performed near full extension, knee joint shear
stresses and thus graft stresses are less, patello-
femoral joint forces are decreased and the knee
is loaded in a more functional manner with
greater loads being taken allowing more strenuous
exercising.
Shelbournes rehabilitation programme became
more patient-tailored according to the patients
tolerances, motivation and ultimate functional
goals. He reviewed 350 patients managed by his
traditional rehabilitation and 450 by his acceler-
ated programme. He found that the accelerated
programme was more effective in reducing limita-
tions of knee motion (particularly knee extension),
loss of strength, while maintaining stability and
preventing anterior knee pain. There was also
improved patient compliance and satisfaction.
Histological analysis of ACL grafts failed to show
any adverse effects on graft incorporation and
ligamentisation in patients undergoing accelerated
rehabilitation.
Accelerated rehabilitation has represented the
current position in the rehabilitation of patients
with bone-patellar tendon-bone ACL grafts, the
ideal rehabilitation of hamstring ACL grafts is still
undecided and is presently more along the more
protected line of older programmes.
 ARTICLE IN PRESS
The anterior cruciate ligamentFII 55

Table 2 The accelerated rehabilitation program of Shelbourne.76

Time after Rehabilitation programme
reconstruction
Day1 Continuous passive motion (CPM), rigid knee immobiliser in full extension for
walking, weight bearing as tolerated without crutches
23 days CPM, passive range of motion (ROM) 0901 (emphasis on full extension) weight
bearing without crutches as tolerated
24 days Discharge from hospital (prerequisite for discharge pain controlled, full extension
equal to non-operated side, able to straight leg raise for leg control, full weight
bearing with or without crutches), CPM at home
710 days ROM terminal extension, prone hangs (2 pounds) if patient has not achieved full
extension, towel extensions, wall slides, heel slides, active assisted flexion,
strengthening knee bends, step ups, calf raises weight bearing, partial to full weight
bearing; gradual elimination of required use of knee immobiliser
2-3 weeks ROM (01101), unilateral knee bends, step ups, calf raises, StairMaster 4000, weight
room activities, leg press, quarter squats and calf raises in the squat rack, stationary
bicycling, swimming, custom-made functional knee braces with no preset limits (to
be used at all times out of the home for the next 4 weeks)
56 weeks ROM (01301), isokinetic evaluation with 201 block at 180 and 2401/s. When strength
is 70% or greater than the opposite unoperated knee, the patient can begin lateral
shuffles, cariocas, light jogging, jumping rope, agility drills, weight room activities,
stationary bicycling and swimming. Note: Functional brace discontinued (except for
sport activities) when muscle tone and strength are sufficient
10 weeks Full ROM; isokinetic evaluation at 60, 180 and 2401/s, KT-1000, increased agility
workouts, sports specific activities
16 weeks Isokinetic evaluation, KT-1000, increased agility workouts
46 months Return to full sports participation (if patient has not met criteria of full ROM, no
effusion, good knee stability, and has completed the running programme)

Conclusion 3. ODonoghue DH. Surgical treatment of fresh injuries to the

The orthopaedic literature is replete with the
management of the ACL deficient knee; most
reports concern details of surgical technique and/
or short-term results. A search on Pubmed produces
5233 hits and Medline 5195. Our understanding of
the anatomy, biochemistry and biomechanics of the
ACL has improved. The pathological consequences
of ACL deficiency are also clearer. When it comes to
treatment, however, the lack of well-designed
long-term studies means the way forward is not
well established. When dealing with the ACL
deficient knee, both patient and surgeon need to
be clear about the ultimate goals of treatment and
to achieve these the literature has provided some
important principles to which they can both adhere
for good results, however they may be defined.
References
Key references are indicated by an asterisk
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