Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-015-3615-7
HISTORICAL PAPER
Knee multi‑ligament reconstruction: a historical note on the fundamental landmarks B. Di Matteo1 · V. Tarabella1 · G. Filardo1 · Patrizia Tomba2 · Anna Viganò2 · M. Marcacci1 · S. Zaffagnini1
Received: 6 January 2015 / Accepted: 16 April 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Several eminent surgeons made breakthroughs in knee surgery throughout the nineteenth and twentieth centuries. Before that, knee injuries were only treated conservatively and it was thanks to the progress made in the field of biomechanics and biology that new surgical treatments were proposed. The history of medicine recalls some illustrious surgeons such as Thomas Annandale and Mayo Robson who were the first to perform and describe their revolutionary experience regarding meniscal and anterior cruciate ligament surgery. Less famous are the forefathers of multi-ligament reconstructive surgery: the purpose of this paper was to shed some light on the pioneers of this particular field of orthopaedic practice, which is gaining increasing interest in current clinical practice. Level of evidence V. Keywords History of surgery · Multi-ligament reconstruction · ACL · PLC · Collateral ligaments
* B. Di Matteo [email protected] 1
II Orthopaedic Clinic and Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano n. 1/10, 40136 Bologna, Italy
2
Donazione Putti, Biblioteche Scientifiche Istituto Ortopedico Rizzoli, Rizzoli Orthopaedic Institute, Via Pupilli n. 1, 40136 Bologna, Italy
Introduction: revolutions in knee surgery over the nineteenth and twentieth centuries Knee injuries to cartilage, menisci and ligaments have always been a key topic in orthopaedics: they have been intensively researched and have heralded new technical advancements, as demonstrated by the speed and scale of the progress made in the treatment of such pathologies. This historical note aims to shed a light on the pioneers of knee ligament reconstruction, by underlining those who, understanding the complexity of the knee anatomy, performed the first multi-ligament reconstructions, which are today common procedures in sport traumatology practice. It is important to remember the main breakthroughs that have been made in the field of knee surgery in the nineteenth and twentieth centuries in order to understand the “natural evolution” of treatments that are the foundation of modern knee surgery (Fig. 1). In the beginning, there was knee axial correction: a little over a century ago, John Rhea Barton [6] developed and performed the first corrective osteotomy of an ankylosed knee on his colleague Dr. Seaman Deas who, since childhood, had been afflicted by a severe postural deformity caused by “the tibia, the femur and patella having become united to each other in the form of a true anchylosis” [3]. It was a swift procedure, crude by our modern standards, but still the beginning of a new way to treat this kind of condition, a way to make “artificial joints” to restore the loss of function, and the seed of the idea that would give rise to arthroplasty. Following this path, in 1883, it was time for the first meniscus surgery. Scottish surgeon Thomas Annandale [7] marked a new breakthrough by performing the first meniscus repair in medical history. He achieved this milestone when treating a young miner injured while working
13
Knee Surg Sports Traumatol Arthrosc
MILESTONES IN KNEE SURGERY
1835 John Rhea Barton Tibial Osteotomy
1962 Masaki Watanabe Arthroscopic surgery 1895 Arthur W. Mayo-Robson ACL + PCL Repair
1883 Thomas Annandale Meniscus Repair
(meniscectomy)
1917 Ernest W. Hey Groves ACL + PCL Reconstruction
Fig. 1 A chronological presentation of some milestones in knee surgery: people and procedures who changed the approach to knee pathology
in a kneeling position, which caused the detachment of the anterior horn of the medial meniscus [1]. A few years later, Annandale was also the first to perform a meniscectomy, thus showing his ability to understand when to use techniques aimed at restoration and when instead to accept an irrecoverable situation to be treated in a different way. After the establishment of novel procedures to correct knee axial deformity and meniscal lesions, it was possible to find the first medical reports on ligament surgery. English surgeon Arthur Mayo-Robson is credited with the first cruciate ligament repair in 1895 [19]. It is truly remarkable that, although the anatomy of ACL was clearly described by Egyptians and anterior instability was well recognized by Greek and Roman physicians [5], the first surgical repair is dated at the end of the nineteenth century. This clearly shows that the timing of medical progress is quite unpredictable and innovations come at the end of a long process, which is not only necessary to collect enough data about anatomy, physiology and biomechanics, but also to allow technology to improve so that the proper equipment and tools can be developed to perform innovative procedures. A typical example of this is the invention of the arthroscope, an instrument that radically changed orthopaedic practice and brought our discipline into a new era. It was Kenji Takagi who took the first ‘peek’ inside a knee thanks to the cystoscope in 1918, but the real invention was made in 1962 by his pupil Watanabe who developed the “Type 21 arthroscope” used to perform the first
13
arthroscopic meniscectomy [17]. In summary, the evolution of knee surgery consisted of bone procedures first, followed by meniscus and ligament repairs. Looking at ligament surgery, there is plenty of literature regarding the evolution of anterior cruciate ligament reconstruction, whereas the history concerning multi-ligament injuries, i.e. those lesions involving multiple capsulo-ligamentous structures and resulting in a more severe joint instability, is a lot less clear. This is probably due to the fact that evolution in anatomical and biomechanical knowledge in the twentieth century led to a gradual understanding of the complexity of knee function, and multi-ligament reconstructive approaches could not be planned without this fundamental background. The purpose of the present paper was to describe the outstanding surgeons who introduced the concept of multi-ligament reconstruction in clinical practice, and their achievements, in order to trace the roots of this particular area of traumatology.
The pioneers of knee multi‑ligament reconstruction From cruciate ligaments repair to cruciate ligaments reconstruction As stated before, Mayo Robson (Fig. 2) was the first surgeon credited to have performed an ACL reconstruction in
Knee Surg Sports Traumatol Arthrosc
Fig. 3 A portrait of Ernest William Hey Groves Fig. 2 A picture of Sir Arthur William Mayo-Robson
1895 [20]. Actually, he did not perform a “reconstruction” according to modern understanding, but a simpler repair. Nonetheless, what has not been properly stressed is that, in this index operation (which he published some years later), he actually repaired not only the ACL, but the posterior cruciate ligament (PCL) as well. The patient was a 41-yearold miner who suffered a serious accident (resulting in a fracture to his left leg and three ribs) about 9 months before coming to the attention of Dr. Mayo Robson. His right knee was completely unstable, and it was immediately clear that there was no other treatment option besides surgery. This historical operation was performed on the 21st of November, and this is the original recollection made by Mayo-Robson to describe his achievement: “[…] both cruciate ligaments were found completely ruptured, being torn from their upper attachments, the ends being in a somewhat shreddy condition. They were stitched in position by means of catgut ligatures, the anterior being stitched to the synovial membrane and tissues of the inner side of the external condyle, and the posterior, which was too short and was split in order to lengthen it, was fixed by sutures to the synovial membrane and cartilage on the outer side of the inner condyle”. This repair allowed the patient a full return to his previous work activity; 6 years later, the knee was reported to be still “perfectly strong” [19] and the patient was even able to run without experiencing pain. It was a milestone, albeit outdated by today’s standards, an advancement in multiligamentous repair history that served as groundwork for the evolution of surgical technique. Mayo Robson’s historical achievement contributed deeply to the growing interest in surgical treatment of ligament injuries and kick-started the development of new techniques aimed at reconstructing torn ligaments. It became clear that suturing could not
provide a satisfactory outcome since cruciate ligament ruptures are often near their insertion, and therefore, research moved on to find new solutions to this issue. In 1906, Lange was the first to test “artificial ligaments” made of silk [4], whereas in 1913, the Italian surgeon Nicoletti was the first to perform an ACL reconstruction on a dog model using free and pedunculated flaps of fascia, periosteum and tendon. One year later, a brief report by Hesse described a case of ACL and PCL reconstruction with an innovative technique consisting of employing free grafts of fascia lata pulled through femoral tunnels [18]: all these contributions marked the beginning of the “autograft” approach, which survives up to the present date. Following these steps forward, roughly 20 years after the Mayo-Robson paper, the first full report clearly describing a reconstructive technique for both cruciate ligaments was published. The author of this paper is one of the most eminent orthopaedic surgeons of his era, E. W. Hey Groves (Fig. 3), founder of the British Journal of Surgery and teacher to many leading orthopaedic surgeons of the twentieth century. In his article [10], he provided a description of an innovative technique aimed at “forming a new anterior cruciate ligament from the iliotibial band and a new posterior ligament from the tendon of the semi-tendinosus” (Fig. 4). The ACL reconstruction was performed following this procedure: “the lower end of the fascia lata is exposed […] for about an inch below the tubercle of the tibia. At this point it is cut across and dissected upwards free from the underlying structures. With a 1-inch twist drill a canal is bored from within the joints upwards and outwards through the external condyle of the femur and another downwards and inwards through the internal tuberosity of the tibia. A probe is tied to the free end of the iliotibial band and by its means this piece of fascia, rolled up as a cord, is threaded through the femur and the tibia and drawn tight. When it emerges below the knee the fascial ligament is turned upwards and sewn to the deep fascia and periosteum of the tibia” (Fig. 4).
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Knee Surg Sports Traumatol Arthrosc
Fig. 4 Original pictures describing Hey Groves’ technique for ACL and PCL reconstruction, as published in 1917
And this was the procedure for the PCL reconstruction: “the semitendinous is cut from its lower attachment 1.5 inches below the joint. New canals are then formed by drilling from within the joint upwards, inwards and backwards through the internal condyle of the femur, and then downwards and outwards through the external tuberosity of the tibia. Through these canals the semi-tendinosus tendon is threaded and fixed to the periosteum of the tibia” (Fig. 4). Collateral ligaments repair Collateral ligament lesions are among the most common injuries in the sport-active population and are encountered in everyday clinical practice. At the beginning of twentieth century, sport practice was just episodic and therefore not the main cause for collateral ligament injuries, which instead occurred mainly in a work setting, affecting people involved in physically demanding jobs. However, in the majority of cases, this kind of lesion was unrecognized or just conservatively treated. Therefore, it is not strange that, to find the first report about collateral ligament surgery, we have to consider a very complex case, which has little to do with the trauma sport patient commonly treated today. The first report was by the Swedish surgeon K. H. Giertz who, in 1912, treated a 13-year-old girl suffering from both medial and lateral collateral ligaments injuries, caused by septic arthritis which developed when she was 1 year old. Besides a complete varus–valgus instability, the young patient presented an extension lag of about 45° [9]. The surgical approach was quite complex and consisted of two steps: first of all, a corrective tibial osteotomy
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was performed, by removing a triangular bony wedge with anterior basis to regain the full extension of the knee; 2 weeks later, a second operation on the soft tissues was performed. A fascia lata autograft was harvested from the lateral side of the thigh. The graft was 7 cm long by 5 cm wide and was split into two halves that would later be used to reconstruct both collateral ligaments. The knee joint was then exposed, and a capsular remplissage was performed on both the medial and lateral compartments. Then, the two strips of fascia lata were carefully sutured upwards to the periosteum of the epicondyles and downwards to the tibial tubercle and to the fibular head in order to reconstruct the collateral ligaments. The tension of the neo-ligaments was also provided by suturing them to the joint capsule with catgut stitches. One year after this complex procedure, the patient regained satisfactory knee function; the joint was much more stable on the coronal plane and the extension was almost complete, so that the patient was able to walk for up to 5 km. The achievement of K. H. Giertz deserves particular attention since it can be regarded as an attempt of joint reconstruction similar to that performed and described by J. R. Barton a few decades earlier. Giertz performed a combined approach both on the bone and soft tissues, understanding that knee function can be properly restored only by addressing all the comorbidities. In the following years, new techniques for the reconstruction of collateral ligaments were proposed and applied, such as those of Edwards and Mauck in the 20’s and 30’s consisting, respectively, of using hamstrings and biceps femuris tendons as autografts for reconstruction or
Knee Surg Sports Traumatol Arthrosc
retensioning the collateral ligaments by changing their distal insertions [8, 15]. Even in this case, it was fundamental to perfect the knowledge about collateral ligament anatomy and biomechanics and to develop novel reconstructive techniques aimed not only at restoring the integrity of these structures, but also at re-establishing their functional properties. The postero‑lateral corner A much more difficult topic is the postero-lateral corner (PLC). While collateral ligament anatomy and biomechanics have been investigated since the end of the nineteenth century, the studies focusing on the PLC are relatively recent. The first biomechanical essays investigating what is currently known as PLC date back to the 50s, thanks to the efforts made by Sneaths and Kaplan [12, 21]. It required some decades (and some surgical failures) to fully recognize the anatomy and the functional role played by PLC, and therefore, the development of reconstructive techniques was affected by the long time required for basic science and biomechanical studies. However, in a historical perspective, the very first attempt to reconstruct the PLC was performed in 1930 by the American surgeon Leo Mayer in a patient affected by genu recurvatum with a paralytic limb [16]. The operation consisted of stripping the ilio-tibial tract and the biceps tendon to reinforce the postero-lateral knee capsule. However, this procedure on soft tissues was just a part of a much more complex operation consisting also of a corrective osteotomy of the knee, so the historical value of this PLC reconstruction should be critically evaluated. More than 50 years after Leo Mayer, in 1982, Hughson and Jacobson were the first to propose the arcuate complex advancement, and a few years later (1986), Bousquet introduced the technique of popliteus tendon recession [14]. These procedures, and further biomechanical studies performed in the meantime, opened the path to more “complex” reconstructive techniques that were developed during the last decade of the twentieth century and aimed at recreating the whole functional complexity of PLC [13]. The surgery for PLC reconstruction is still evolving [2]: biomechanics and anatomical studies are still ongoing, with the help of novel technologies, to better understand the peculiar features of this anatomical complex [22, 23], and despite the increasing number of trials available, it remains one of the most challenging research fields in sports medicine.
Discussion Looking back at the history of knee multi-ligament reconstruction, the first consideration regards the particular kind of patients that were treated for these injuries: as stated,
at the beginning of twentieth century, sport participation was rare and mainly limited to the elite classes, and therefore, the principal cause for knee ligamentous injuries was the working activity, in a population mainly involved in very demanding and physically intense job [19]. However, despite being performed on non-sport-active patients, the request for high functional outcome was still impelling, since the impossibility of coming back to work was correlated with severe impairment, which could literally lead to poverty and social exclusion. The necessity of providing the best care for their patients stimulated surgeons to find new ways for repairing torn ligaments and restore the joint integrity, thus leading to a natural evolution in techniques, directly linked to the advancement in medical technology and surgical tools. Paradigmatic is the case regarding the ACL and PCL reconstruction [5, 20]: it took almost two decades to shift from repair to reconstruction, and this reflects the time required for a better understanding of the biomechanics of cruciate ligaments to develop the proper techniques, find the most suitable graft and then test the procedure on the animal model, before reaching clinical application. The approach is not different from current practice, thus showing that the inner principles of surgery are still the same and nothing can be done without the support of basic science and pre-clinical models. Another aspect worth of attention is the complexity of the cases surgeons had to manage: isolated lesions of the cruciate or collateral ligaments were more likely misrecognized or just treated conservatively whereas, in the majority of the cases, multi-ligament reconstructive procedures were performed in knees affected by other concurrent pathologies, such as the sequelae of septic arthritis, tubercular infection or even neuro-muscular diseases [9, 16]. A century ago, these conditions were much more common and much more severe in their clinical presentation, and therefore, surgeons managing them had to consider all the comorbidities before planning a surgical treatment: this is the reason why the first multi-ligament reconstructions were just part of more complex procedures, where often also a bone corrective osteotomy was performed [9, 16]. This approach was aimed at obtaining the best clinical result possible in terms of functional recovery, and it is still the main purpose of any orthopaedic treatment. In the light of this, history clearly reveals that the pioneers of multi-ligament reconstruction were not the typical “sport medicine surgeons” [18] as we understand them today, and also, the patients treated were different from those “typically” found in the current operating theatres: it took several decades to have the establishment of this new figure, the “sport medicine” surgeon, and this was due to the huge spreading of sport practice all over the world especially in the second half of the twentieth century. The increasing number of people involved in sport activities at different levels, ranging
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from amateurs to professional athletes, and the wide range of pathologies linked to sport practice led finally to have a specialist dedicated to sport-related injuries. This is another relevant lesson coming from history: socio-economic factors are almost as important in medical evolution as other “technical factors”, such as the knowledge of anatomy, biology and biomechanics. Medical progress faces the requests coming from the patients, and when new needs emerge, this is a constant stimulus to improve the existing practice and the standards of care. Even in the field of multi-ligament reconstruction, it is possible to observe such a trend: at the beginning, patients and methods were rather different from the present time. However, what is currently done in clinical practice is the direct consequence of the studies performed by the forefathers mentioned in the present manuscript. Even if the features of the patient have changed and the techniques have been perfected, the basis for these achievements has been set across the nineteenth and twentieth century.
Conclusion: work still in progress… It is easy to think of surgical progress as the outcome of inventive genius alone, as history tends to simplify and isolate exceptional experiences, to highlight particular individuals and set exemplary milestones, and, of course, it is not the purpose of the present paper to systematically report the history of multi-ligament reconstruction nor to report the clinical results of every single different technique over time. What should be clear is that new perspectives were opened between the nineteenth and twentieth centuries, and knee surgery underwent a massive evolution thanks to the work of the whole medical community, including the contribution of both basic scientists and surgeons. The present paper describes surgeons that can be considered as pioneers in the field of multi-ligament knee reconstruction before the advent of arthroscopy. Much has been done since those years, and much will be achieved in the near future thanks to the introduction of biotechnologies and biomaterials, such as in the case of biological augmentation for ligament reconstruction and regeneration [11]. New solutions and surgical innovations are yet to come, but the conclusive finding is always the same: evolution in surgery comes after a process of acquiring basic knowledge, improving techniques and available technologies. Sometimes, this happens very quickly, and sometimes, it takes a long time. Lessons from the past are always useful to understand the brilliant intuitions, but also the mistakes, which represented the groundwork leading to the achievements of modern surgery. Acknowledgments The authors would like to thank Liliana Draghetti (Donazione Putti, Biblioteche Scientifiche, Rizzoli Orthopaedic
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Knee Surg Sports Traumatol Arthrosc Institute), Keith Smith, Davide Puppini, Linda Accorsi and Chiara Casalboni for their help. The present paper was supported by the following funds granted to Rizzoli Orthopaedic Institute: “5 ‰ (5 per mille), anno 2011”. Conflict of interest The authors declare that they have no conflict of interest with respect to the contents of the present manuscript.
References 1. Annandale T (1885) An operation for displaced semilunar cartilage. Br Med J 1(1268):779 2. Apsingi S, Nguyen T, Bull AM, Unwin A, Deehan DJ, Amis AA (2009) A comparison of modified Larson and ‘anatomic’ posterolateral corner reconstructions in knees with combined PCL and posterolateral corner deficiency. Knee Surg Sports Traumatol Arthrosc 17(3):305–312 3. Barton JR (1827) On the treatment of anchylosis by the formation of artificial joints. North Am Med Surg J 3:279–292 4. Burnett QM, Fowler PJ (1985) Reconstruction of the anterior cruciate ligament: historical overview. Orthop Clin North Am 16(1):143–157 5. Davarinos N, O’Neill BJ, Curtin W (2014) A brief history of anterior cruciate ligament reconstruction. Adv Orthop Surg. doi:10.1155/2014/706042 6. Di Matteo B, Tarabella V, Filardo G, Viganò A, Tomba P, Marcacci M (2013) John Rhea Barton: the birth of osteotomy. Knee Surg Sports Traumatol Arthrosc 21(9):1957–1962 7. Di Matteo B, Tarabella V, Filardo G, Viganò A, Tomba P, Marcacci M (2013) Thomas Annandale: the first meniscus repair. Knee Surg Sports Traumatol Arthrosc 21(9):1963–1966 8. Edwards AH (1920) Operative procedure suggested for the repair of collateral ligaments of the knee-joint. Br J Surg 8:266–271 9. Giertz KH (1913) Über freie Transplantation der Fascia lata als Ersatz für Sehnen und Bänder. Dtsch Z Chir 125(5):480–496 10. Hey Groves EW (1917) Operation for repair of the crucial ligaments. Lancet 190:674–675 11. Hutchinson ID, Rodeo SA, Perrone GS, Murray MM (2015) Can platelet-rich plasma enhance anterior cruciate ligament and meniscal repair? J Knee Surg. 28(1):19–28 12. Kaplan EB (1958) The iliotibial tract: clinical and morphological significance. J Bone Joint Surg Am 40:817–832 13. Laprade RF, Griffith CJ, Coobs BR, Geeslin AG, Johansen S, Engebretsen L (2014) Improving outcomes for posterolateral knee injuries. J Orthop Res 32(4):485–491 14. Malek M, Fanelli G, Johnson D, Jonhson D, Noyes FR (2001) Knee surgery: complications, pitfalls and salvage. Springer, New York, pp 129–135 15. Mauck HP (1936) A new operative procedure for instability of the knee. J Bone Joint Surg Am 18(4):984–990 16. Mayer L (1930) An operation for the cure of paralytic genu recurvatum. J Bone Joint Surg 12(4):845–852 17. Mostofi SB (2004) Masaki Watanabe. Who’s who in orthopedics. Springer, London, pp 347–348 18. Pässler HH (1993) The history of the cruciate ligaments: some forgotten (or unknown) facts from Europe. Knee Surg Sports Traumatol Arthrosc 1(1):13–16 19. Robson AWM (1903) Ruptured crucial ligaments and their repair by operation. Ann Surg 37:716–718 20. Schindler OS (2012) Surgery for anterior cruciate ligament deficiency: a historical perspective. Knee Surg Sports Traumatol Arthrosc 20(1):5–47 21. Sneath RS (1955) The insertion of the biceps femoris. J Anat 89:550–553
Knee Surg Sports Traumatol Arthrosc 22. Takeda S, Tajima G, Fujino K, Yan J, Kamei Y, Maruyama M, Kikuchi S, Doita M (2014) Morphology of the femoral insertion of the lateral collateral ligament and popliteus tendon. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-3059-5
23. Tschauner S, Sorantin E, Singer G, Eberl R, Weinberg AM, Schmidt P, Kraus T (2014) The origin points of the knee collateral ligaments: an MRI study on paediatric patients during growth. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-2991-8
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HISTORICAL PAPER
Knee multi‑ligament reconstruction: a historical note on the fundamental landmarks B. Di Matteo1 · V. Tarabella1 · G. Filardo1 · Patrizia Tomba2 · Anna Viganò2 · M. Marcacci1 · S. Zaffagnini1
Received: 6 January 2015 / Accepted: 16 April 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Several eminent surgeons made breakthroughs in knee surgery throughout the nineteenth and twentieth centuries. Before that, knee injuries were only treated conservatively and it was thanks to the progress made in the field of biomechanics and biology that new surgical treatments were proposed. The history of medicine recalls some illustrious surgeons such as Thomas Annandale and Mayo Robson who were the first to perform and describe their revolutionary experience regarding meniscal and anterior cruciate ligament surgery. Less famous are the forefathers of multi-ligament reconstructive surgery: the purpose of this paper was to shed some light on the pioneers of this particular field of orthopaedic practice, which is gaining increasing interest in current clinical practice. Level of evidence V. Keywords History of surgery · Multi-ligament reconstruction · ACL · PLC · Collateral ligaments
* B. Di Matteo [email protected] 1
II Orthopaedic Clinic and Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano n. 1/10, 40136 Bologna, Italy
2
Donazione Putti, Biblioteche Scientifiche Istituto Ortopedico Rizzoli, Rizzoli Orthopaedic Institute, Via Pupilli n. 1, 40136 Bologna, Italy
Introduction: revolutions in knee surgery over the nineteenth and twentieth centuries Knee injuries to cartilage, menisci and ligaments have always been a key topic in orthopaedics: they have been intensively researched and have heralded new technical advancements, as demonstrated by the speed and scale of the progress made in the treatment of such pathologies. This historical note aims to shed a light on the pioneers of knee ligament reconstruction, by underlining those who, understanding the complexity of the knee anatomy, performed the first multi-ligament reconstructions, which are today common procedures in sport traumatology practice. It is important to remember the main breakthroughs that have been made in the field of knee surgery in the nineteenth and twentieth centuries in order to understand the “natural evolution” of treatments that are the foundation of modern knee surgery (Fig. 1). In the beginning, there was knee axial correction: a little over a century ago, John Rhea Barton [6] developed and performed the first corrective osteotomy of an ankylosed knee on his colleague Dr. Seaman Deas who, since childhood, had been afflicted by a severe postural deformity caused by “the tibia, the femur and patella having become united to each other in the form of a true anchylosis” [3]. It was a swift procedure, crude by our modern standards, but still the beginning of a new way to treat this kind of condition, a way to make “artificial joints” to restore the loss of function, and the seed of the idea that would give rise to arthroplasty. Following this path, in 1883, it was time for the first meniscus surgery. Scottish surgeon Thomas Annandale [7] marked a new breakthrough by performing the first meniscus repair in medical history. He achieved this milestone when treating a young miner injured while working
13
Knee Surg Sports Traumatol Arthrosc
MILESTONES IN KNEE SURGERY
1835 John Rhea Barton Tibial Osteotomy
1962 Masaki Watanabe Arthroscopic surgery 1895 Arthur W. Mayo-Robson ACL + PCL Repair
1883 Thomas Annandale Meniscus Repair
(meniscectomy)
1917 Ernest W. Hey Groves ACL + PCL Reconstruction
Fig. 1 A chronological presentation of some milestones in knee surgery: people and procedures who changed the approach to knee pathology
in a kneeling position, which caused the detachment of the anterior horn of the medial meniscus [1]. A few years later, Annandale was also the first to perform a meniscectomy, thus showing his ability to understand when to use techniques aimed at restoration and when instead to accept an irrecoverable situation to be treated in a different way. After the establishment of novel procedures to correct knee axial deformity and meniscal lesions, it was possible to find the first medical reports on ligament surgery. English surgeon Arthur Mayo-Robson is credited with the first cruciate ligament repair in 1895 [19]. It is truly remarkable that, although the anatomy of ACL was clearly described by Egyptians and anterior instability was well recognized by Greek and Roman physicians [5], the first surgical repair is dated at the end of the nineteenth century. This clearly shows that the timing of medical progress is quite unpredictable and innovations come at the end of a long process, which is not only necessary to collect enough data about anatomy, physiology and biomechanics, but also to allow technology to improve so that the proper equipment and tools can be developed to perform innovative procedures. A typical example of this is the invention of the arthroscope, an instrument that radically changed orthopaedic practice and brought our discipline into a new era. It was Kenji Takagi who took the first ‘peek’ inside a knee thanks to the cystoscope in 1918, but the real invention was made in 1962 by his pupil Watanabe who developed the “Type 21 arthroscope” used to perform the first
13
arthroscopic meniscectomy [17]. In summary, the evolution of knee surgery consisted of bone procedures first, followed by meniscus and ligament repairs. Looking at ligament surgery, there is plenty of literature regarding the evolution of anterior cruciate ligament reconstruction, whereas the history concerning multi-ligament injuries, i.e. those lesions involving multiple capsulo-ligamentous structures and resulting in a more severe joint instability, is a lot less clear. This is probably due to the fact that evolution in anatomical and biomechanical knowledge in the twentieth century led to a gradual understanding of the complexity of knee function, and multi-ligament reconstructive approaches could not be planned without this fundamental background. The purpose of the present paper was to describe the outstanding surgeons who introduced the concept of multi-ligament reconstruction in clinical practice, and their achievements, in order to trace the roots of this particular area of traumatology.
The pioneers of knee multi‑ligament reconstruction From cruciate ligaments repair to cruciate ligaments reconstruction As stated before, Mayo Robson (Fig. 2) was the first surgeon credited to have performed an ACL reconstruction in
Knee Surg Sports Traumatol Arthrosc
Fig. 3 A portrait of Ernest William Hey Groves Fig. 2 A picture of Sir Arthur William Mayo-Robson
1895 [20]. Actually, he did not perform a “reconstruction” according to modern understanding, but a simpler repair. Nonetheless, what has not been properly stressed is that, in this index operation (which he published some years later), he actually repaired not only the ACL, but the posterior cruciate ligament (PCL) as well. The patient was a 41-yearold miner who suffered a serious accident (resulting in a fracture to his left leg and three ribs) about 9 months before coming to the attention of Dr. Mayo Robson. His right knee was completely unstable, and it was immediately clear that there was no other treatment option besides surgery. This historical operation was performed on the 21st of November, and this is the original recollection made by Mayo-Robson to describe his achievement: “[…] both cruciate ligaments were found completely ruptured, being torn from their upper attachments, the ends being in a somewhat shreddy condition. They were stitched in position by means of catgut ligatures, the anterior being stitched to the synovial membrane and tissues of the inner side of the external condyle, and the posterior, which was too short and was split in order to lengthen it, was fixed by sutures to the synovial membrane and cartilage on the outer side of the inner condyle”. This repair allowed the patient a full return to his previous work activity; 6 years later, the knee was reported to be still “perfectly strong” [19] and the patient was even able to run without experiencing pain. It was a milestone, albeit outdated by today’s standards, an advancement in multiligamentous repair history that served as groundwork for the evolution of surgical technique. Mayo Robson’s historical achievement contributed deeply to the growing interest in surgical treatment of ligament injuries and kick-started the development of new techniques aimed at reconstructing torn ligaments. It became clear that suturing could not
provide a satisfactory outcome since cruciate ligament ruptures are often near their insertion, and therefore, research moved on to find new solutions to this issue. In 1906, Lange was the first to test “artificial ligaments” made of silk [4], whereas in 1913, the Italian surgeon Nicoletti was the first to perform an ACL reconstruction on a dog model using free and pedunculated flaps of fascia, periosteum and tendon. One year later, a brief report by Hesse described a case of ACL and PCL reconstruction with an innovative technique consisting of employing free grafts of fascia lata pulled through femoral tunnels [18]: all these contributions marked the beginning of the “autograft” approach, which survives up to the present date. Following these steps forward, roughly 20 years after the Mayo-Robson paper, the first full report clearly describing a reconstructive technique for both cruciate ligaments was published. The author of this paper is one of the most eminent orthopaedic surgeons of his era, E. W. Hey Groves (Fig. 3), founder of the British Journal of Surgery and teacher to many leading orthopaedic surgeons of the twentieth century. In his article [10], he provided a description of an innovative technique aimed at “forming a new anterior cruciate ligament from the iliotibial band and a new posterior ligament from the tendon of the semi-tendinosus” (Fig. 4). The ACL reconstruction was performed following this procedure: “the lower end of the fascia lata is exposed […] for about an inch below the tubercle of the tibia. At this point it is cut across and dissected upwards free from the underlying structures. With a 1-inch twist drill a canal is bored from within the joints upwards and outwards through the external condyle of the femur and another downwards and inwards through the internal tuberosity of the tibia. A probe is tied to the free end of the iliotibial band and by its means this piece of fascia, rolled up as a cord, is threaded through the femur and the tibia and drawn tight. When it emerges below the knee the fascial ligament is turned upwards and sewn to the deep fascia and periosteum of the tibia” (Fig. 4).
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Fig. 4 Original pictures describing Hey Groves’ technique for ACL and PCL reconstruction, as published in 1917
And this was the procedure for the PCL reconstruction: “the semitendinous is cut from its lower attachment 1.5 inches below the joint. New canals are then formed by drilling from within the joint upwards, inwards and backwards through the internal condyle of the femur, and then downwards and outwards through the external tuberosity of the tibia. Through these canals the semi-tendinosus tendon is threaded and fixed to the periosteum of the tibia” (Fig. 4). Collateral ligaments repair Collateral ligament lesions are among the most common injuries in the sport-active population and are encountered in everyday clinical practice. At the beginning of twentieth century, sport practice was just episodic and therefore not the main cause for collateral ligament injuries, which instead occurred mainly in a work setting, affecting people involved in physically demanding jobs. However, in the majority of cases, this kind of lesion was unrecognized or just conservatively treated. Therefore, it is not strange that, to find the first report about collateral ligament surgery, we have to consider a very complex case, which has little to do with the trauma sport patient commonly treated today. The first report was by the Swedish surgeon K. H. Giertz who, in 1912, treated a 13-year-old girl suffering from both medial and lateral collateral ligaments injuries, caused by septic arthritis which developed when she was 1 year old. Besides a complete varus–valgus instability, the young patient presented an extension lag of about 45° [9]. The surgical approach was quite complex and consisted of two steps: first of all, a corrective tibial osteotomy
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was performed, by removing a triangular bony wedge with anterior basis to regain the full extension of the knee; 2 weeks later, a second operation on the soft tissues was performed. A fascia lata autograft was harvested from the lateral side of the thigh. The graft was 7 cm long by 5 cm wide and was split into two halves that would later be used to reconstruct both collateral ligaments. The knee joint was then exposed, and a capsular remplissage was performed on both the medial and lateral compartments. Then, the two strips of fascia lata were carefully sutured upwards to the periosteum of the epicondyles and downwards to the tibial tubercle and to the fibular head in order to reconstruct the collateral ligaments. The tension of the neo-ligaments was also provided by suturing them to the joint capsule with catgut stitches. One year after this complex procedure, the patient regained satisfactory knee function; the joint was much more stable on the coronal plane and the extension was almost complete, so that the patient was able to walk for up to 5 km. The achievement of K. H. Giertz deserves particular attention since it can be regarded as an attempt of joint reconstruction similar to that performed and described by J. R. Barton a few decades earlier. Giertz performed a combined approach both on the bone and soft tissues, understanding that knee function can be properly restored only by addressing all the comorbidities. In the following years, new techniques for the reconstruction of collateral ligaments were proposed and applied, such as those of Edwards and Mauck in the 20’s and 30’s consisting, respectively, of using hamstrings and biceps femuris tendons as autografts for reconstruction or
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retensioning the collateral ligaments by changing their distal insertions [8, 15]. Even in this case, it was fundamental to perfect the knowledge about collateral ligament anatomy and biomechanics and to develop novel reconstructive techniques aimed not only at restoring the integrity of these structures, but also at re-establishing their functional properties. The postero‑lateral corner A much more difficult topic is the postero-lateral corner (PLC). While collateral ligament anatomy and biomechanics have been investigated since the end of the nineteenth century, the studies focusing on the PLC are relatively recent. The first biomechanical essays investigating what is currently known as PLC date back to the 50s, thanks to the efforts made by Sneaths and Kaplan [12, 21]. It required some decades (and some surgical failures) to fully recognize the anatomy and the functional role played by PLC, and therefore, the development of reconstructive techniques was affected by the long time required for basic science and biomechanical studies. However, in a historical perspective, the very first attempt to reconstruct the PLC was performed in 1930 by the American surgeon Leo Mayer in a patient affected by genu recurvatum with a paralytic limb [16]. The operation consisted of stripping the ilio-tibial tract and the biceps tendon to reinforce the postero-lateral knee capsule. However, this procedure on soft tissues was just a part of a much more complex operation consisting also of a corrective osteotomy of the knee, so the historical value of this PLC reconstruction should be critically evaluated. More than 50 years after Leo Mayer, in 1982, Hughson and Jacobson were the first to propose the arcuate complex advancement, and a few years later (1986), Bousquet introduced the technique of popliteus tendon recession [14]. These procedures, and further biomechanical studies performed in the meantime, opened the path to more “complex” reconstructive techniques that were developed during the last decade of the twentieth century and aimed at recreating the whole functional complexity of PLC [13]. The surgery for PLC reconstruction is still evolving [2]: biomechanics and anatomical studies are still ongoing, with the help of novel technologies, to better understand the peculiar features of this anatomical complex [22, 23], and despite the increasing number of trials available, it remains one of the most challenging research fields in sports medicine.
Discussion Looking back at the history of knee multi-ligament reconstruction, the first consideration regards the particular kind of patients that were treated for these injuries: as stated,
at the beginning of twentieth century, sport participation was rare and mainly limited to the elite classes, and therefore, the principal cause for knee ligamentous injuries was the working activity, in a population mainly involved in very demanding and physically intense job [19]. However, despite being performed on non-sport-active patients, the request for high functional outcome was still impelling, since the impossibility of coming back to work was correlated with severe impairment, which could literally lead to poverty and social exclusion. The necessity of providing the best care for their patients stimulated surgeons to find new ways for repairing torn ligaments and restore the joint integrity, thus leading to a natural evolution in techniques, directly linked to the advancement in medical technology and surgical tools. Paradigmatic is the case regarding the ACL and PCL reconstruction [5, 20]: it took almost two decades to shift from repair to reconstruction, and this reflects the time required for a better understanding of the biomechanics of cruciate ligaments to develop the proper techniques, find the most suitable graft and then test the procedure on the animal model, before reaching clinical application. The approach is not different from current practice, thus showing that the inner principles of surgery are still the same and nothing can be done without the support of basic science and pre-clinical models. Another aspect worth of attention is the complexity of the cases surgeons had to manage: isolated lesions of the cruciate or collateral ligaments were more likely misrecognized or just treated conservatively whereas, in the majority of the cases, multi-ligament reconstructive procedures were performed in knees affected by other concurrent pathologies, such as the sequelae of septic arthritis, tubercular infection or even neuro-muscular diseases [9, 16]. A century ago, these conditions were much more common and much more severe in their clinical presentation, and therefore, surgeons managing them had to consider all the comorbidities before planning a surgical treatment: this is the reason why the first multi-ligament reconstructions were just part of more complex procedures, where often also a bone corrective osteotomy was performed [9, 16]. This approach was aimed at obtaining the best clinical result possible in terms of functional recovery, and it is still the main purpose of any orthopaedic treatment. In the light of this, history clearly reveals that the pioneers of multi-ligament reconstruction were not the typical “sport medicine surgeons” [18] as we understand them today, and also, the patients treated were different from those “typically” found in the current operating theatres: it took several decades to have the establishment of this new figure, the “sport medicine” surgeon, and this was due to the huge spreading of sport practice all over the world especially in the second half of the twentieth century. The increasing number of people involved in sport activities at different levels, ranging
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from amateurs to professional athletes, and the wide range of pathologies linked to sport practice led finally to have a specialist dedicated to sport-related injuries. This is another relevant lesson coming from history: socio-economic factors are almost as important in medical evolution as other “technical factors”, such as the knowledge of anatomy, biology and biomechanics. Medical progress faces the requests coming from the patients, and when new needs emerge, this is a constant stimulus to improve the existing practice and the standards of care. Even in the field of multi-ligament reconstruction, it is possible to observe such a trend: at the beginning, patients and methods were rather different from the present time. However, what is currently done in clinical practice is the direct consequence of the studies performed by the forefathers mentioned in the present manuscript. Even if the features of the patient have changed and the techniques have been perfected, the basis for these achievements has been set across the nineteenth and twentieth century.
Conclusion: work still in progress… It is easy to think of surgical progress as the outcome of inventive genius alone, as history tends to simplify and isolate exceptional experiences, to highlight particular individuals and set exemplary milestones, and, of course, it is not the purpose of the present paper to systematically report the history of multi-ligament reconstruction nor to report the clinical results of every single different technique over time. What should be clear is that new perspectives were opened between the nineteenth and twentieth centuries, and knee surgery underwent a massive evolution thanks to the work of the whole medical community, including the contribution of both basic scientists and surgeons. The present paper describes surgeons that can be considered as pioneers in the field of multi-ligament knee reconstruction before the advent of arthroscopy. Much has been done since those years, and much will be achieved in the near future thanks to the introduction of biotechnologies and biomaterials, such as in the case of biological augmentation for ligament reconstruction and regeneration [11]. New solutions and surgical innovations are yet to come, but the conclusive finding is always the same: evolution in surgery comes after a process of acquiring basic knowledge, improving techniques and available technologies. Sometimes, this happens very quickly, and sometimes, it takes a long time. Lessons from the past are always useful to understand the brilliant intuitions, but also the mistakes, which represented the groundwork leading to the achievements of modern surgery. Acknowledgments The authors would like to thank Liliana Draghetti (Donazione Putti, Biblioteche Scientifiche, Rizzoli Orthopaedic
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Knee Surg Sports Traumatol Arthrosc Institute), Keith Smith, Davide Puppini, Linda Accorsi and Chiara Casalboni for their help. The present paper was supported by the following funds granted to Rizzoli Orthopaedic Institute: “5 ‰ (5 per mille), anno 2011”. Conflict of interest The authors declare that they have no conflict of interest with respect to the contents of the present manuscript.
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