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

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

was then provided by a distally based 1.5 cm wide * Autogenous quadriceps tendon graft.
strip of iliotibial band which was passed through * Allograft.
the hole in the lateral femoral condyle and then
through a hole in the tibia immediately anterior to Autogenous bone-patellar tendon-bone graft
the ACL remnant. First described by Jones,14 it has become the most
Andesson et al.9 compared the results of con- popular graft option. A 10 mm wide graft has an
servative treatment, primary repair and repair with ultimate tensile strength of 2977 N, making it 170%
augmentation. Sixty-three per cent of the augmen- stronger than the native ACL; it is also 150%15
ted group returned to competitive sport, while only stiffer. The bony ends of the graft allow for bone to
32% of the primary repair group and 27% of the bone healing in the tibial and femoral tunnels.
conservative treatment group had such outcomes. The drawback of the bone-patellar tendon-bone
The conclusion was that patients with higher graft is donor site morbidity. The complications
functional demands should be treated with primary reported include patellofemoral pain 1756%,16,17
repair and augmentation. pain when kneeling 42%,18 quadriceps weakness
with flexion contracture and patellar irritability
Extra-articular tenodesis 65%,19 degeneration of the patellofemoral joint
57%,20 patellar fracture,21 patellar tendon rup-
Bennett in 192610 first described an extra-articular ture22 and patellar tendonitis.19
procedure for the anterior cruciate ligament The bone-patellar tendon-bone graft is not
deficient knee. He proposed that the knee could recommended in patients with patello-femoral
be stable without an ACL as long as other ligaments pain, patello-femoral arthritis, small patellar ten-
particularly the medial collateral, were intact. He dons and patellar malalignment.
used a free strip of fascia, woven longitudinally Clinical studies of the bone-patellar tendon-bone
along the medial joint line and then reefed the graft are encouraging, with absent pivot shift in
medial extensor retinaculum; excellent results 8090% and good to excellent results in 7090%.
were claimed in a series of six patients. Objective instrumented knee laxity measurements
Cotton et al.11 believed that by reconstructing have shown 3 mm or less laxity when compared with
the medial collateral ligament an unstable anterior the contralateral normal knee in 7093%.16,17,23,24
cruciate ligament could be rendered stable. He
used free strips of iliotibial band in a figure of eight Autogenous hamstring graft
technique through drill holes in the medial tibia Macy in 193925 described using the semitendinosus
and femur. Accurate placement of the graft was tendon based distally through the femur and tibia
essential. for reconstructing the anterior cruciate ligament;
Helfelt12 described a procedure to move the tibial no results were detailed.
tubercle medially, attempting to increase external The hamstring graft has evolved from single,
rotation of the tibia. He placed semitendinosus in a double, triple to the modern four-stranded semi-
longitudinal groove in line with the medial collateral tendinosus/gracilis graft. This standard graft has an
ligament to internally rotate the femur with flexion. ultimate tensile strength of 41084213 N26 and
Good results were obtained if the patient learned to stiffness of 807954 N/mm27 making it stronger
contract his hamstrings with knee flexion. Passive and stiffer than the native ACL and a 10 mm bone-
instability remained unchanged. patellar tendon-bone graft. An 8 mm hamstring
A consensual conference of the American Society graft has a cross-sectional area of 50 mm2 this
of Sports Medicine13 developed a report on the greater area favouring enhanced ligamentisation.
value of extra-articular procedures for ACL defi- This is 1.5  the area of a patellar tendon graft and
ciency. It concluded that extra-articular procedures comparable to a normal ACL.26
provided no improvement to the results of intra- The great advantage of the hamstring graft is its
articular reconstructions of the ACL. lack of donor site morbidity. Postoperative ham-
string weakness has not been demonstrated clini-
ACL reconstruction cally.28 Its main disadvantage is in graft fixation.
Due to lack of bone, fixation has to be outside the
Reconstruction has evolved as the mainstay of tunnels; this has the effect of increasing graft
surgical correction of the ACL deficient knee. The length therefore increasing the chance of graft
reconstructive options are: creep with cyclical loading. Stiffness is proportional
to graft length therefore instability of the graft
* Autogenous bone-patellar tendon-bone graft. increases as fixation moves away from the
* Autogenous hamstring graft. tibial plateau. These fixation problems prevent
 ARTICLE IN PRESS
The anterior cruciate ligamentFII 51

accelerated rehabilitation.29 Femoral cross pin contralateral knee in 71%. Failure rates of 33%
fixation is the strongest and stiffest fixation in have been reported. Comparative studies have
ACL reconstruction, with fixation strengths of shown no difference in functional outcome com-
10021600 N and stiffness of 224 N/mm.30 Other pared to autografts.
successful fixation devices have included the
Graft placement
Washerloc (Arthrotek, Warsaw, IN) and soft tissue
The isometric point is that part of the ACL insertion
interference screws.
about which there is no change in length of the
The results of the four-stranded hamstring graft
ligament during the full range of flexion and
have shown absent pivot shift in 90% patients31,32
extension and isometric graft placement has been
and with objective instrument laxity measurements
favoured by many authors.41 Current thinking
there is 3 mm or less laxity compared with the
regarding the complex fibre arrangement of the
contralateral knee in 90%.14,17 In comparative
ACL suggests that the concept of isometry is no
studies with patellar tendon grafts most have failed
longer valid.42,43
to demonstrate a significant difference between
Sakane et al.44 studied the in situ forces on the
the two,33,34 a few have shown increased laxity in
ACL during anterior tibial displacement. They
female patients reconstructed with hamstring
noted that the forces in the intact ACL were
grafts34 and there has been a higher incidence of
greatest at 301 of flexion decreasing with increasing
patello-femoral pain and quadriceps weakness in
flexion. This profile of tension was most closely
those reconstructed with patellar tendon grafts.
mirrored by the posterolateral band of the ACL.
This experience has raised some concern in
The anteromedial bundle showed a more constant
reconstructing female patients and those with
tension from full extension to flexion. Many authors
increased ligamentous laxity with hamstring grafts.
suggest graft placement near the posterolateral
band position. This may not only allow better
Autogenous bone quadriceps tendon graft
reproduction of ACL function but reduces the
This was first described by Blauth.35 A standard
chances of graft impingement during exten-
10 mm graft has a cross-sectional area of 52
sion.45,46
65 mm36 greater than other grafts and the normal
The ideal position for ACL graft placement is still
ACL, with an ultimate tensile strength of 4048 N.37
unknown.
The bone block allows for fixation with interference
screws onto the femur with several soft tissue Graft tension
fixation options for the tibia. The ACL acts in tension to restrain anterior tibial
Donor site morbidity has not been shown to be a translation. In order for grafts to reproduce this
problem with excellent results, high patient satis- effect they need to be inserted under tension, but
faction and low morbidity. Comparative studies what is the correct tension? Many investigators
with the patellar tendon graft have not demon- have empirically suggested 44 N or 10 lb.
strated any difference in outcome.38 Yoshiya et al.47 in a canine study of graft tension
in ACL reconstruction, assessed the effect of
Allograft various tensions from 1 to 39 N on patellar tendon
A number of allograft options are available for autografts. At 3 months no difference was found in
reconstruction including; bone-patellar tendon- the anteroposterior laxity and tensile properties of
bone, Achilles tendon, fascia lata, tibialis anterior, the differently tensioned grafts; however, the 39 N
grouped toe-flexor tendons and semitendinosus. tensioned grafts demonstrated increased histologic
The main advantages of allografts are the lack of evidence of cartilage degeneration.
donor site morbidity and the ability to perform Yasuda et al.48 in a prospective randomised trial
reconstructions through minimally invasive techni- studied the effect of three different initial graft
ques. The greatest disadvantage is the potential for tensions; 20, 40 and 80 N respectively on anterior
disease transmission. Sterilisation can alter the tibial laxity at 2 years. They found that the 80 N
properties of the graft and Gamma irradiation can group had significantly less anterior tibial laxity
decrease graft strength by 20% after 3 Mrad and 26% compared with the 20 N group; clinically however
with 4 Mrad,39 2.5 Mrad is needed to eliminate HIV all three groups were equivalent.
virus. Irradiation remains the least damaging mode The knee position at the time of tensioning and
of graft sterilisation.40 fixation is also significant. In a cadaveric study, it
The results of allografts are comparable to was demonstrated that graft fixation at 301 knee
autografts with good to excellent results in 70 flexion resulted in significantly less anterior tibial
90% and objective instrument laxity measurements translation than when grafts were fixed with the
of 3 mm or less compared with the normal knee extended.49
 ARTICLE IN PRESS
52 S. Karmani, T. Ember

The initial tension applied to all ACL grafts will The tendon component of the graft undergoes
reduce (stress relax) with time. The ligament will necrosis followed by vascularisation, and then
also lengthen (creep) so one must consider the cellular replacement and eventually ligamentisa-
percentage of the initial tension that remains in the tion,66 with remodelling of its collagenous struc-
graft to stabilise the knee joint. Cyclical loading ture. A synovial layer forms around the graft
causes cyclical elongation thus the peak load providing a blood supply.67 Revascularisation
decreases with an increased number of cycles from the proximal insertion is also noted within
(cyclical stress relaxation), initial loss of graft 20 days, a process that continues for up to 18
tension is followed by a relatively constant residual months.68
tension. The factors determining the residual Animal studies reveal the graft has 5080% of its
tension still need to be elucidated. Primate studies initial strength at 12 months.69 In human subjects,
have shown that, stress in the patellar tendon can however, the patellar tendon autograft is viable by
reduce by 70% of its initial stress within 30 min.50 3 weeks after surgery and may never undergo
complete necrosis.70 Thus in humans the patellar
Graft fixation
tendon may maintain a strength equal to or greater
ACL grafts eventually incorporate into their bony
than the native ACL. This may have implications
tunnels; initial fixation however is provided by
with regards to rehabilitation, suggesting that
mechanical devices and it is the graft fixation
bone-patellar tendon-bone graft may be rehabili-
construct that provides initial knee stability allow-
tated more aggressively.
ing patient mobilisation. With trends towards
The healing of hamstring grafts within a bone
accelerated rehabilitation, considerable demands
tunnel initially produces a sleeve of fibrous tissue
are made upon the fixation. Fixation methods can
attachment around the graft, with the fibres
be divided into direct devices (interference screws,
aligned along the load axis. By 6 weeks collagen
staple, washers and cross pins) and indirect devices
fibres start to pass from the graft through the
(polyester tape, titanium buttons and suture
fibrous tissue into bone, anchoring the graft
posts). Many studies into the ultimate tensile
directly to cancellous bone, this process attains
strength and stiffness of different fixation techni-
significant strength by 12 weeks.71 Further animal
ques have been performed (Table 1).
work has shown that in dogs the initial fibrous tissue
The most popular fixation method for bone-
envelope that anchors hamstring grafts is even-
patellar tendon-bone grafts has been interference
tually transformed into a direct fibrocartilaginous
screw fixation. Various size screws exist but
attachment as in the native ACL by 30 52 weeks.72
no significant difference in ultimate load to failure
Hamstring grafts may benefit from protection
has been demonstrated for the different sized
during the first 12 weeks postop.
screws.63 More critical has been screw placement.
It can be seen that in both bone block and free
Screws placed parallel to bone blocks have higher
tendon grafts, there is an initial unstructured
ultimate tensile loads to failure than diverging
fibrous tissue attachment that matures to a
screws; screw divergence of greater than 151
structured zonal fibrocartilaginous enthesis over
lowers ultimate tensile load by 50%.64
6 12 months.
The healing of grafts
A firm attachment of ACL graft to bone is essential
for the restoration of normal function in the ACL Rehabilitation
deficient knee. The normal ACL has a zonal
fibrocartilaginous insertion into bone. ACL grafts Rehabilitation is an integral part of the chain that
incorporate into their bony tunnels by different takes a patient from injury through surgery to full
mechanisms initially. The healing of bone block recovery. ACL rehabilitation has evolved through
grafts such as the bone-patellar tendon-bone or many phases as attitudes and understanding of the
bone quadriceps tendon grafts differs from ham- biology and mechanics of the ACL injury and ACL
string tendon grafts. reconstruction has changed.
Schiavone et al.65 in a rabbit study showed that Rehabilitation after ACL reconstruction plays a
the bone blocks of the bone-patellar tendon-bone major role in the functional outcome of a patient.
graft incorporated directly into the bone tunnels by There are a number of elements that any
16 weeks, with the establishment of a normal four- rehabilitation program must address:
zone fibrocartilaginous attachment by 69 months.
The process was felt to be more complex than * Range of knee motion.
direct bone-to-bone healing as it took longer than * Weight bearing.
normal fracture healing. * 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 S. Karmani, T. Ember

Table 1 (continued)
Ultimate strength Stiffness Slippage under cyclical Extension at
(N) (N/mm) control failure (mm)
Tibial fixation
Fixation method
Stirrup (Corfix) Bovine bone 89857 2.1 mm after 1100 cycles
150 N57
WasherLoc plate/screw 90562 27362 2 mm at 500 N62
(Arthrotek)
RCI screw 35062 248 3.7 mm at 500 N (4 of 7
failed at 500 N)62
Tandem AO washers/screws 115962 25962 0.5 mm at 500 N62
AO washer/screw & sutures 76862 18162 0.9 mm at 500 N62
around screw post

* Proprioceptive knee control. instability sooner than his compliant group. In

* Functional return to activity. response he developed an accelerated rehabilita-
tion program, patient driven with medical super-
These must be balanced against the ability of the vision guiding progression based on absence of knee
ACL graft fixation construct to withstand stresses effusion, lack of pain and ability to gain muscle
during the phase of graft incorporation and patient control. Exercises were closed kinetic chain,
tolerances. performed with the foot fixed on a surface, so that
The earliest rehabilitation programs involved a the entire limb is loaded during the movement,
period of initial postoperative cast immobilisation with compressive loading of all the joints.
followed by resisted unloaded knee extension Open kinetic chain exercises by contrast are
work. They were based on the principle of performed with the limb extremity free, in this
protecting the graft while healing occurred before case there is no compressive loading of the joints of
considering any stress upon it. They were compli- the limb with resultant increased shear forces
cated by muscle wasting and arthrofibrosis.73 across the joints. Closed kinetic exercises are
As understanding of the biomechanics of the performed near full extension, knee joint shear
knee improved so there was a trend away from stresses and thus graft stresses are less, patello-
prolonged cast immobilisation towards limited femoral joint forces are decreased and the knee
immobilisation using range of motion braces. is loaded in a more functional manner with
Braces were locked allowing a limited range of greater loads being taken allowing more strenuous
motion, short of full extension protecting the graft exercising.
from anterior shear forces generated by the Shelbournes rehabilitation programme became
quadriceps during the last 301 of extension.74 more patient-tailored according to the patients
The next movement in rehabilitation was pow- tolerances, motivation and ultimate functional
ered by the principles of isometric graft placement, goals. He reviewed 350 patients managed by his
improvements in graft fixation and an understand- traditional rehabilitation and 450 by his acceler-
ing of the need for early mobilisation. Patients ated programme. He found that the accelerated
progressed through a process of regulated passive programme was more effective in reducing limita-
range of motion exercises, stopping 101 short of full tions of knee motion (particularly knee extension),
extension; these movements were performed in loss of strength, while maintaining stability and
range of motion braces. Progression to full weight preventing anterior knee pain. There was also
bearing and 0 100 flexion was achieved by 6 improved patient compliance and satisfaction.
weeks. Muscle strengthening exercises were of the Histological analysis of ACL grafts failed to show
open kinetic chain variety.75 any adverse effects on graft incorporation and
Shelbourne et al.76 in the late 1980s using the ligamentisation in patients undergoing accelerated
bone-patellar tendon-bone graft noted the progress rehabilitation.
of his patients, comparing those who complied well Accelerated rehabilitation has represented the
with his traditional rehabilitation (Table 2) and current position in the rehabilitation of patients
those who did not comply, progressing as they with bone-patellar tendon-bone ACL grafts, the
desired, obtaining full extension earlier than ideal rehabilitation of hamstring ACL grafts is still
recommended. He found these non-compliant undecided and is presently more along the more
patients returned to normal function without knee 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

major ligaments of the knee. J Bone Joint Surg 1950;32A:
72138.
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reports concern details of surgical technique and/ 4:95100.
or short-term results. A search on Pubmed produces 5. Marshall JL, Warren RF, Wickiewicz TL. The anterior cruciate
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ACL has improved. The pathological consequences treatment for anterior cruciate ligament ruptures. A long
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Defining a rational for augmentation. Am J Sport Med 1991;
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