REVIEW ARTICLE
Anterior Cruciate Ligament Reconstruction
John C. Richmond, MD
Abstract: The past 3+ decades have been a period of intense interest
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in the anterior cruciate ligament. Graft choices, techniques, and
fixation devices have all evolved. Our understanding of the anatomy
has improved. Our follow-up and criteria for success have also
expanded. Over the next several years advanced repair techniques,
extra-articular augmentation, and addressing elevated tibial slope
will all have to have their indications defined.
Key Words: anterior cruciate ligament, ACL injury, ACL recon-
struction, ACL repair
(Sports Med Arthrosc Rev 2018;26:165–167)
T he initial issue of Sports Medicine Arthroscopy Review
(SMAR) in April 1993 had 7 articles on allograft anterior
cruciate ligament (ACL) reconstruction. Since that time
Sports Medical Arthroscopy Review has been a leading review
journal in the fields of arthroscopic surgery and sports med-
icine. At the time of that first issue the choice of those articles
on allograft ACL represented a topic that was really felt to be
hot and current. This paper will review how ACL surgery had
evolved over the 15 years before 1993. That was a timeframe
that ACL surgery began to rapidly increase as the pioneers in
ACL reconstruction at that time developed the techniques
that would set the foundation for where we are today. In
addition, I will examine the developments of the 25 years
since that initial issue to put context on where we are today
and what might develop in the near future.
HISTORY BEFORE 1993
Although ACL repair and reconstruction go back to the
late 1800s, they did not become widespread until the 1970s. In
the 1970s repair of the ACL had a time, but the carefully
reported results of Feagen and Curl in 19761 showed that the
durability of ACL repair was clearly suspect. That led to the
expansion of reconstructive techniques with patellar tendon
autograft being the most popular intra-articular technique.
Extra-articular techniques by themselves or combined with
intra-articular reconstruction were being performed. These
were open techniques, which required relatively large incisions.
Because of the fear that early motion would compromise fix-
ation of the grafts, patients were often immobilized for many
weeks postsurgery. The combination of an open surgery and
immobilization often resulted in stiffness and articular surface
ulceration of either the patella or trochlea (Fig. 1). During the
1980s this problem with stiffness and potential postoperative
pain and the feeling of the necessity of immobilization with
autografts led to the pursuit of several synthetics (Gore-Tex,
From the Tufts University School of Medicine, New England Baptist
Hospital, Outpatient Care Center, Dedham, MA.
Disclosure: The author declares no conflict of interest.
Reprints: John C. Richmond, MD, Orthopedic Surgery, Tufts University
School of Medicine, New England Baptist Hospital, Outpatient Care
Center, 40 Allied Drive, Dedham, MA 02026.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Sports Med Arthrosc Rev  Volume 26, Number 4, December 2018
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Dacron, LAD among others). There was a brief spurt of
enthusiasm for these, but they quickly went by the wayside as
they failed to hold up long term, likely due to the fatigue failure
of the synthetic material and the inability of the graft to
stimulate biological replacement of the synthetic material.2,3
Dr Shelbourne, one of the thought leaders in ACL
reconstruction of the past 3+ decades, had the pioneering spirit
to dramatically advance the state of ACL reconstruction by
developing aggressive mobilization and rehabilitation pro-
grams, which are the basis for most current rehabilitation
protocols following ACL reconstructive surgery.4
Other changes were coming as well. The completely
open reconstructive techniques of the 1970s and early 1980s
evolved into 2 incision arthroscopically assisted techniques,
whereby the capsule of the knee was not violated, and the
surgery was much less painful. It needed the development of
acorn type reamers in the 1980s and the creativity of
Dr Rosenberg and colleagues to develop a single incision or
“endoscopic” ACL reconstructive techniques.5 Harner et al6
established that endoscopic techniques worked as well (at
least in a small series) as the classic 2 incision arthroscopic
procedures in restoring stability and function.
THE PAST 25 YEARS
By the time of first edition of Sports Medicine Arthro-
scopy Review in 1993, allograft use was beginning to
increase. Allografts were felt to be a reasonable alternative
for autograft, avoiding the pain of the harvest and the
potential downside of quadriceps weakness from harvesting
the patellar tendon or hamstring weakness from harvesting
the hamstring tendons.6,7 During the decade of the 1990s
endoscopic transtibial ACL reconstruction became popular.
The steadily increasing population of orthopedic surgeons
who were trained in arthroscopic techniques and the wide-
spread sports reports of injured collegiate and professional
athletes returning to play after ACL reconstruction led to a
steady growth in ACL surgery. Hamstring use became more
widespread as fixation techniques for soft tissue grafts
improved. In some geographic locations the use of allograft
for ACL reconstruction became more widespread.
The 21st century has led to a steady evolution in ACL
reconstructive technique, ACL graft choice and an improved
understanding of the causes for failure of ACL reconstructive
surgery. Focusing on the reproduction of ACL anatomy dur-
ing reconstruction, Fu and a myriad of co-workers demon-
strated that the transtibial endoscopic ACL reconstruction
made it difficult to reproduce the anatomy of the ACL, and
were pioneers in trying to reproduce the anatomy with double
bundle constructs.8 This has led to an extensive volume of
literature on the development of double bundle ACL recon-
struction. While the double bundle technique has not devel-
oped widespread use, it has led to a growing number of ACL
reconstructions being done via a myriad of different techniques
which allow independent drilling of the tibial tunnel and the
femoral socket.
www.sportsmedarthro.com | 165
Richmond
FIGURE 1. Ulceration of the articular cartilage in the femoral
trochlea noted 5 years following an open anterior cruciate liga-
ment reconstruction. The patient had been immobilized for 4
weeks in a cast at 30 degrees of flexion after the surgery.
Several major changes in the research techniques
applied to ACL surgery have made significant impact on
ACL reconstruction over the last decade and a half. Most
importantly among these is the use of large prospective
multicenter randomized control trials, most notably pio-
neered the MOON Group.9 The development and applica-
tion of meta-analysis techniques and systematic reviews
have likewise improved our ability to identify differences in
ACL reconstructive techniques and graft materials. Finally,
most recently the establishment of large registries including
those from Kaiser in the United States and the Scandinavian
registries have improved our ability to identify subtle dif-
ferences in the results with different grafts and/or
techniques.10 While this registry data may not carry the
power of a level 1 randomized multicenter control trial, the
fact that they reflect the success or failure of the techniques
employed by a very large number of surgeons over a wide
geographic area helps us to understand the outcomes
obtained by a large number of diverse sports medicine/
arthroscopic surgeon. The early meta-analyses and system-
atic reviews of various graft sources for ACL reconstruction
identified bone-tendon-bone autograft as being the best
choice to restore stability and function to the joint in young
active athletes.11 Hamstring grafts had a lower percentage of
young patients resuming their high risk cutting sports and
allografts trailed even behind that. The MOON Group data
confirmed that and careful analysis of the MOON Group
data identified that smaller diameter hamstring grafts had a
higher failure rate. Allografts did not fare as well as either
patellar tendon or hamstring grafts until patients reach their
40s. Among the most powerful data from the MOON
Group is that failure rate of hamstring grafts drops off
precipitously as the grafts are > 8 mm in diameter.12 Tech-
niques that increase the diameter of hamstring grafts, such
as shorter constructs that are 4 strands of semitendinosus or
4 strands of semitendinosus plus 2 strands of gracilis, uni-
formly result in grafts that are > 8 mm in diameter. In
addition, the use of allograft to augment 4 strand hamstring
grafts results in a greater diameter and seems to demonstrate
improved results. Both data from the Scandinavian registry
and the Kaiser registry here in the States show an increased
percentage of revision for hamstring grafts over patellar
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Sports Med Arthrosc Rev  Volume 26, Number 4, December 2018
tendon grafts.10 One could theorize that modification of the
graft preparation technique to bring the diameter of the
construct to > 8 mm may improve the revision rate for
hamstring autografts.
In putting all of the data for various graft choices
together has fostered my development of a personal algo-
rithm for graft selection. For the young high school and
college athlete who has no contraindication (eg, very thin
patellar tendon, significant patellar tendinosis), to using the
patellar tendon, that is my graft choice for that population
and professional athletes. For less demanding younger
athletes and those recreational athletes from ages 22 to late
30s, I recommend a hamstring autograft. It is my preference
to use a 4 strand semitendinosus graft prepared to use with
adjustable flip buttons. This graft can be an overall length of
7.5 to 8.0 cm and should be carefully sized. If that graft is
not at least 8.5 mm in diameter, I will supplement it with an
additional double gracilis tendon to increase the size of the
construct. I reserve the use of allograft for patients over 40
(or those in their late 30s who are relatively inactive) and the
special consideration of multiligament injuries.
RECENT, CURRENT, AND FUTURE
DEVELOPMENTS
While primary repair of the ACL had been discarded
40 years ago, it began to creep back in to the literature as a
possible technique as potential enhancements to healing
have been developed. These included advanced suturing
techniques with an internal stent and the use of a biological
scaffold seeded with blood to protect the repair site from the
deleterious effects on healing of the synovial fluid.13,14
In another back to the future movement in ACL
understanding and reconstructive techniques, Claes et al15
discovered the anterolateral ligament (ALL) of the knee
only 5 years ago. They had reidentified the mid third lateral
capsule as a structure that is important for controlling
anterior translation and pivot shift in an ACL deficient
knee. A myriad of extra-articular lateral reconstructions had
existed back in the 1970s and 1980s. They were rejected as
being unnecessary as they did not result in improved stability of
the joint when combined with an intra-articular ACL recon-
struction, and led to increased pain.16 The careful attention that
has been paid to the somewhat variable anatomy of the ALL,
as well as trying to define accurately the indications and tech-
niques for reconstructing the ALL in an ACL injured knee is an
interesting and though-provoking focus for ACL surgeons as
we approach 2020.
A number of thoughtful and creative ACL surgeons from
around the world have focused attention on tibial slope as being
a problem which may contribute to ACL injury and failure of
ACL reconstruction. Webb et al from Australia and DeJour
et al from France have both contributed to our understanding
of this problem.17,18 A tibial slope that is 12 degrees or greater
not only increases the risk of ACL injury, it significantly
increases the risk of failure of ACL reconstruction. Our veteri-
nary colleagues have abandoned the use of ACL reconstruction
in the canine species, and switched to a surgical procedure (tibial
plateau level osteotomy) to replace ligament reconstructive
techniques for the ACL injured canine. This has a much more
reproducible result and actually more rapid recovery as both
does heal faster than soft tissue grafts incorporate. DeJour
et al18 has recommended considering a tibial plateau leveling
osteotomy for those patients with an elevated tibial slope who
have failed previous reconstructions.
Sports Med Arthrosc Rev  Volume 26, Number 4, December 2018
SUMMARY
ACL injury remains a frequent problem for athletes
and others involved in cutting, twisting or pivoting activities.
An untreated ACL tear typically leads to recurrent episodes
of instability and progressive damage to the knee joint with
decreased function over time. ACL reconstruction, while far
from perfect, can restore function to the ACL injured knee and
allow the athlete to return to sports or the worker to return to
strenuous work activities. ACL repair, which went by the
wayside in the 1970s/early 1980s, is now returning as a possible
alternative for acute injuries with the development of advanced
suturing techniques, internal stents and biological scaffolds.
While it is too early to recommend any of these techniques, they
offer potential exciting alternatives to our standard recon-
structive techniques, if future studies warrant adoption and can
identify appropriate indications. The placement of ACL grafts,
particularly in the femur, has gone through an evolution from
tibial independent femoral sockets/tunnels to transtibial endo-
scopic placement, and now back to independent placement of
the femoral and tibial tunnels.
The current best information for graft selection indicates
that bone-patellar tendon-bone autograft remains the graft
of choice for high performance athletes desiring to return to
that level. New techniques with hamstring grafts, with either
shortening the graft to increase diameter or adding allograft to
increase diameter to reach 8.5 mm or greater, support con-
tinued use of hamstring grafts in the less demanding athletic
population. Allografts may remain a viable alternative for less
demanding athletes, particularly those over 40.
In addition, the rediscovery of the mid third lateral
capsule (anterolateral ligament or ALL) has refocused
attention on that structure as a restraint to anterior trans-
lation and the pivot shift phenomenon. It remains unclear
where the addition of ALL reconstruction fits in the grand
scheme of ACL reconstruction.
Finally, tibial slope has now been identified as a major
player in the risk of both ACL injury and failure of ACL grafts.
It should be carefully thought of by any ACL surgeon facing an
ACL injured patient. A high tibial slope ( ≥ 12 degrees) warrants
very careful counseling of the patient and their family as to their
risk for further injury, be it on the injured side of the contra-
lateral side. Tibial slope leveling osteotomy will find a place in
the armamentarium of the ACL surgeon.
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