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The Bone

Journal
Volume

of Surgery

and Joint
American

VOLUME

56-A,

No.

MARCH

1974

The

Anatomy Anterior

and Cruciate

Function Ligament

of the

As DETERMINED
BY JOHN C. KENNEDY, ANDREW From the Division ofOrthopaedic

BY CLINICAL
M.D., S. WILSON, Surgery F.R.C.S.(C)t, M.D., and

AND MORPHOLOGICAL
HOWARD LONDON, W.

STUDIES
M.D.t, AND

WEINBERG, CANADA University

ONTARIO, ofAnatomv.

the Department
Ontario

of Western

Ontario,

London,

ABSTRACT:

In a biomechanical study of fifty function ofthe were varies during are adequate

and patients ligament, analyzed.

morphological

study

of cadaver

knees

and

clinical end-result the structure and various cruciate fiexion; forms ligament that there

with tears of the anterior the mechanism ofinjury, It was concluded that

cruciate ligament, and the results of of the anterior

of therapy

tension

knee motion, intraligamentous

being least at from 40 to 50 degrees of blood vessels and nerves for healing

to occur; that isolated tears of the anterior cruciate ligament do occur (probably as the result of internal-rotation displacement of the tibia with respect to the femur); that such tears are frequently associated with meniscal tears; and that early results of operative although
There

or non-operative late instability


are many aspects

treatment may occur.


of the

of the anterior

cruciate

ligament

are acceptable

anatomy

and

function

of the

anterior

cruciate

ligament

that

are not understood the operating

and room

need when

further a torn

study. anterior

An atmosphere cruciate ligament

of uncertainty is unexpectedly
it

invariably discov-

pervades

ered at arthrotomy. Among isolated tear of the anterior

authorities on the knee there is disagreement cruciate ligament can occur at all, and if There
and

as to whether an does, whether such way


anterior

a tear will affect knee function significantly 12.l4 tears located in the middle portion of the ligament.
We have been studying the pathomechanics

is also
morphology

no effective
of the

to repair
cruciate

ligament
provide

for a number following


precise more

of years injury
guidelines

and, to this
for

more ligament.
the

recently, The

have basic

been purpose

investigating

the behavior

of the knee terior them:


*

management

of patients

of these studies was to with an injury to the anquestions, among

cruciate
Read in part

ligament.

We

also

hoped

to find

answers

to numerous

at the 5, 1973.

Annual

Meeting

of The

American

Academy

of Orthopaedic

Surgeons,

Las

Vegas,

Nevada, February t Suite 312,

111 Waterloo Street, London 72, Ontario, Canada. 1920 Weston Road, Weston, Ontario, Canada. Department of Anatomy, University of Western Ontario, London,

Ontario,

Canada. 223

224 1
cruciate

.
.

J. C.

KENNEDY,

H.

W.

WEINBERG,

AND

A.

S.

WILSON

How

does
are

tension the

in the anterior various mechanisms

cruciate

ligament that

vary during cause

motion

ofthe of the

knee? anterior

2. What 3 4. most ment? The morphological (2) by analysis answers

of injury occur and,

rupture

ligament? Can an isolated At what levels

tear of this ligament in the anterior cruciate blood were knees who

if so, what do tears supply ways:

are the late sequelae? and what levels are ligaand and as demsigns

ligament and nerve

occur

advantageous for repair? 5 . What is the intraligamentous to these studies of fifty questions

of the anterior

cruciate

sought

in two at autopsy

( 1 ) by biomechanical six hours of death, cruciate ligament of injury,

of cadaver patients

obtained

within

had damage attention was

to the anterior given

onstrated by arthrotomy. In the clinical study, and symptoms, operative machine and strength-testing ten years after The fifty treatment. patients were

particular findings, table, selected

to the mechanism

the results of tests made with our clinical stress and the functional result found from seven months to at random, the only requirements for inclusion in the

study being the presence of an anterior cruciate ligament tear accurately throtomy, and an adequate clinical follow-up in terms of duration and

observed at arthe specificity of

evaluation. Three of the patients had been followed for less than one year, but their resuits were established (two, excellent and one, poor) at the time of the study. Of the fifty patients selected, twenty-four had isolated tears of the anterior cruciate ligament (ten with and fourteen tenor cruciate thirteen without without associated tears of a meniscus) ligament along with damage to other associated tears of a meniscus). Biomechanical Studies and twenty-six capsular ligaments had tears (thirteen of the anwith and

Dissections of one of the knees of ten adult cadavera (males and females included) obtained at autopsy revealed little individual variation in the length of the anterior cruciate ligament, the lengths ranging between 3.7 and 4. 1 centimeters (average, 3.9). In the same knees a central oblong block of bone was removed from the anterior aspect of the femur to
permit ten joints visualization in different of the entire positions

anterior
revealed

cruciate that the

ligament
anterior

(Fig.
cruciate

1). Observations
ligament is taut

in these
when the

knee is in full extension and in 5 and 20 degrees of flexion, becomes most relaxed between 40 and 50 degrees of flexion, and then becomes increasingly taut as flexion is increased to from 70 to 90 degrees. These estimates of tension were made by inspection and palpation of the anterior cruciate ligament using a septal elevator and a small curved hook (Figs. 2-A through 2-E). In 1907 Pringle observed that tightening and slackening of the cruciate ligaments occurred in adult human knees as they were flexed results were recorded, however, and he simply relaxation of the ligaments was approximately tension of the knee joint. Little additional information relative and extended at autopsy. No quantitative estimated that the position of maximum halfway between full flexion and full exfunction of the intact cruciate anterior cruciate was

to the

ligament has been published The effect of rotation

since that time. of the tibia on the tension

of the anterior

ligament

also investigaged in our study. Internal rotation in all positions of flexion consistently increased tension, even with the knee flexed 40 degrees, the position in which the anterior cruciate ligament was most lax during flexion from full extension to 90 degrees (Figs. 3-A and 3-B). The effect of external rotation on the tension of the anterior cruciate ligament was not studied with the knee in different degrees of flexion. Our
ThE

previous
JOURNAL

studies
OF BONE

had showed
AND JOINT

that

SURGERY

ANATOMY

AND

FUNCTION

OF

THE

ANTERIOR

CRUCIATE

LIGAMENT

225

FIG.

Dissection to expose the entire anterior cruciate four centimeters of the ligament can be visualized.

ligament.

With

a large

central

notch

cut in the femur

the

full

FIG.

2-A

FIG.

2-B

Figs. 2-A through 2-D: Photographs showing tautness of the anterior cruciate ligament with the knee in different positions from S to 90 degrees of flexion. Each pair of photographs shows the knee before (above) and after (below) a notch was cut in the femur to permit more accurate assessment of tension in the cruciate ligament.
In each position placed under the the same ligament. upward and anterior Note that the tautness force (judged subjectively) is less at 40 to 50 degrees. was being applied to the instrument

VOL.

56-A,

NO.

2. MARCH

1974

226

J.

C.

KENNEDY,

H.

W.

WEINBERG,

AND

A.

S.

WILSON

9O#{176}F]

FIG.

2-C

FIG.

2-D

tension

increased

as abduction

and

external-rotation

forces

were

applied

indicating

that

this ligament
Mechanisms

is the last line of defense


of Injury Causing Tears

against

these

forces.
Cruciate Ligament

of the Anterior

Our

previous

cadaver

studies

showed

that

a tear

of the anterior

cruciate

ligament

and

FIG.

3-A

FIG.

3-B of flexion and of the anterior the tibia cruciate

Dissection showing effect of internal rotation of the tibia. With the knee in 40 degrees internally rotated on the femur to its fullest degree (Fig. 3-B), the increased tautness ligament (compare with Fig. 3-A) is readily visualized.
THE JOURNAL OF BONE

AND

JOINT

SURGERY

ANATOMY

AND

FUNCTION

OF

THE

ANTERIOR

CRUCIATE

LIGAMENT

227 and
8,10,

other duction sion,

capsular forces

and

ligamentous directed

structures by complete force

could applied

be produced dislocation to the posterior

by external-rotation produced aspect of the tibia

#{228}bas

in combination,

anterior

by hyperexten-

and by an anteriorly rotation

follows: External nal rotation lar ligament same knee Finally,


rupted.

and abduction:

With a torque producing

40 to 50 degrees

of exter-

of the tibia while the knee was held in 90 degrees was first stretched and then torn. If an abduction in addition to the rotation, tearing of the tibial forces studies were increased it was evident

of flexion, the medial capsuforce was then applied to the collateral ligament occurred. was disbe tensed

if both In these

further, the anterior cruciate ligament that the anterior cruciate ligament could

over the medial border external-rotation forces tenor cruciate ligament sufficiently taut to rupture Complete dislocation duced by hyperextension initially and then ruptured hyperextension, ment. After

of the lateral femoral condyle only when both abduction and were applied simultaneously. With external rotation alone, the anneither came in contact with the femoral condyle, nor became while other structures remained intact. of the knee joint: When complete anterior dislocation forces applied to cadaver knees 8, the posterior capsule at approximately 30 degrees of hyperextension. and then inspection the anterior of the joint With cruciate revealed of first the posterior had partially torn,
was

pro-

stretched further ligathat

there was tearing the posterior capsue

the posterior cruciate ligament was still intact, but accurate assessment of the integrity of the anterior cruciate ligament was not possible. With further hyperextension, rupture of both cruciate ligaments occurred, as well as an anterior dislocation of the knee. Direct posterior violence: In unpublished studies of cadaver limbs, an anteriorly directed force was applied to the posterior surface of the tibia, displacing it forward, while the knee was held in 90 degrees of flexion (a mechanism identical to that produced by clipping anterior damage that there structures. producing
Mechanism

in North American football). In fifteen consecutive cadaver limbs, tears of the cruciate ligament were produced, eight of them in the middle of the ligament. The seemed to be limited to the anterior cruciate ligament, but we could not be certain was neither an isolated
of Injury

damage

to the

posterior cruciate
Tears

capsule direct ligament.

nor

stretching violence

of other

important

For this reason

we have

not classified

posterior

as a mechanism

tear of the anterior


Causing Isolated

of the Anterior

Cruciate

Ligament

Authorities

disagree

as to whether
12.14

there

is such

a clinical

entity

as an isolated

tear

of two as-

the anterior cruciate (abduction-external

ligament rotation

and

Of the three mechanisms anterior dislocation)

just described, unquestionably

the first produced

sociated capsular and ligament injuries along with the tear of the anterior cruciate ligament. The third mechanism (posterior violence), on the other hand, caused no demonstrable damage to other structures, but it was impossible to be certain that stretching of other structures, either gross or microscopic, had not occurred. Another mechanism possibly causing isolated injury to the anterior cruciate ligament was suggested by the review of our fifty patients with proved tears of the anterior cruciate ligament. This mechanism was internal rotation of the tibia on the femur. Seven of the fifty patients gave a definite history of an injury causing internal rotation of the tibia with on the femur injury and at arthrotomy were found to have tear an anterior cruciate tear, capno associated in six and with an accompanying of the posterolateral

sule in one. However, laboratory using cadaver subjected ligament. either ligament
VOL.

five consecutive auempts knees which were placed force applied the ligament where

to reproduce this mechanism in the in from 15 to 20 degrees of flexion and to tear the anterior taut, but in every applied before rupture cruciate instance of the

to an internal rotation In these experiments the femur occurred.


NO.2, MARCH 1974

to the tibia failed became extremely the clamps were

or the tibia

fractured

56-A,

228 Case Report


S.W.
,

J.

C.

KENNEDY,

H.

W.

WEINBERG,

AND

A.

S.

WILSON

that internal
4). Her initial

a girl (Case 28), injured her right knee while skiing. An analysis of the injury described suggested rotation of the tibia on the femur had occurred while the knee was flexed from 15 to 20 degrees (Fig.
treatment included aspiration of blood from the knee and immobilization in a plaster cast for three

weeks. further
tive

Thereafter. evaluation
drawer

she had a persistent effusion, symptomatic instability was carried out, eighteen months after injury, clinical
sign with no medial or lateral opening of the joint

of her knee, examination


when

anterior

space

and increasing pain. When revealed a markedly posistress was applied. Evaluation

on the testing
Medial
Anterior Medial Lateral

machine
opening
tibial

revealed
(valgus
condyle

the following:
stress) 2.0 millimeters on the femur 18.5 millimeters
millimeters

(normal, (normal,

3.5) 5.0)

displacement tibialcondyle (varus

of the tibia

17.8 millimeters
stress) 2.7

(normal,
(normal,

5.0)
3.5)

Lateral
The
there was

opening

displacement
no abnormal

of the tibia
medial

forward ligament

on the femur was visualized,

was

almost
When

four

times

the upper reconstruction

limit of normal
was performed,

while
a

or lateral opening

of the knee.

surgical

torn and attenuated

anterior

cruciate

but no other

abnormality

was noted.

Isolated

tear

Antertor

Cruciate

FIG.

Possible

mechanism

of injury

causing

an isolated

tear of the anterior


may least

cruciate

ligament.

With

internal

rotation

of the tibia on the femur, femoral or tibial attachment, occurred in the mid-portion

as shown, or by

the anterior rupture in

cruciate ligament its mid-region. At

be disrupted by avulsion of bone from its 72 per cent of the ruptures in our series

of the ligament.

Morphological
Site of Anterior Cruciate

Studies

Tear

Avulsion of bone at one of the attachments of the anterior cruciate ligament is uncommon in our experience. It occurred twice in this series of fifty cases, both times at the tibial attachment. In several recent series the common site was described as the proximal end of the ligament near the femur, but with no bone avulsion. In our fifty patients, however, the mid-portion of the ligament was the most common site, as follows: upper end, nine patients (18 per cent); mid-substance, thirty-six (72 per cent); lower end, two (4 per cent); The confines and unknown, tear of the of the synovial three anterior (6 per cent). cruciate and ligament hence may be very be shredded difficult and hidden within the

to localize accurately. We have classified as mid-substance tears all those occurring in the middle two centimeters of the four-centimeter cruciate ligament, an area where reattachment of the ligament to its femoral origin is either technically impossible or impractical.
ThE JOURNAL OF BONE AND JOINT SURGERY

membrane,

ANATOMY

AND

FUNCTION

OF

THE

ANTERIOR

CRUCIATE

LIGAMENT

229

The Blood

and Nerve

Supply

ofthe

Anterior

Cruciate

Ligament

middle

The major genicular

blood supply to the anterior artery. The largest branch

cruciate ligament comes from branches of the to the ligament reaches it near its upper end and at a point as the tibial proximal to the tibial spine. This intercondylar artery, ultimately is structures autopsy of the knee joint, material by Gardneurovascu-

descends along its dorsal surface, bifurcating branch ofthe middle genicular artery, known distributed The as shown
ner

to both tibial condyles 17 rest of the blood and nerve supply of intra-articular in cats by Freeman and Wyke (1967) and in human
,

( 1948)

is derived

from

a much

more

extensive

projection

of periarticular

lar components into the joint workers provided a stimulus Wladmirow


Material and

than earlier descriptions had suggested. The findings of these for the more recent detailed studies of Scapinelli ( 1968) and

(1968).
Methods of Tissue Preparation

In the reference per cent fixation,


thickness with silver Three

present to age,

study and both solution.

three One

fresh ofthe parallel were


method

adult cruciate

male

human

cadavera were removed

were and

selected immersed after

without in 10 of

anterior

ligaments

formalin was

six specimens,

selected

at random

one week

sliced in planes of fifty micrometers,


according to the

to its longitudinal axis. Frozen sections, cut at a obtained from these slices and either impregnated of Schofield or stained by direct immersion in were used of each to prepare ligament. at five transverse The tissue micrometers, sections blocks so and

methylene through obtained


stained

blue. of the were

other

ligament middle,
and

specimens and distal portions

the proximal,
with hematoxylin

dehydrated,

embedded
eosin.

in paraffin,

sectioned

The two remaining ligaments were bisected first longitudinally and then transversely to produce four portions of approximately equal size. Sections of these portions were then processed as described, the sections stained with hematoxylin and eosin being used to study blood vessels while the silver and methylene-blue preparations were used to identify nerve vidual ligament revealed contain revealed paravascular (Fig. 7).
of Morphological Findings

fibrils. Macroscopically fasciculi being

the

ligament

was

found either

to be a multifascicular in spiral fashion around

structure, the long

its indiaxis of the studies which

variously

directed

or passing directly that each individual

from femoral to tibial fasciculus is separated

attachment. The histological from its neighbors by spaces

loose connective tissue and tortuous blood vessels (Fig. nerve fibers in all regions of the anterior cruciate ligament in position but some ramifying freely among

5). Silver impregnation (Fig. 6), most of them elements

the connective-tissue

Implications

The

structural

characteristics

of the anterior

cruciate

ligaments

indicate

their

suitabil-

ity to withstand

the multi-axial stresses of normal function. The irregular arrangement of the fasciculi provides interfascicular areolar spaces for the passage of neurovascular components from one region to another within the ligament. The tortuosity of the vessels is also in keeping with the demands of a joint movements. The vascular supply, although what with age, was by no means sparse even appeared The those tion. The impulses,
VOL.

mechanism characterized by very complex not profuse and presumably varying somewithin the deeper layers of the ligament, and to occur concerned vessels throughout its whole extent. with vasomotor control, but may serve some that other funcsuggestion accompanies they transmit injuries to the

to be adequate paravascular ramify diameter giving


MARCH

for healing nerve fibers

of the ligament are presumably from demonstrable

which

at a distance

of these fibers was consistent with the rise to the slow pain which usually
1974

56-A, NO.2,

230

J. C.

KENNEDY,

H.

W.

WEINBERG,

AND

A.

S. WILSON

FIG. A neurovascular (N. F.) and a bundle vessel close are to the periphery of the

5
anterior cruciate ligament. A fasciculus of nerve fibers

(V.P.)

shown

in a longitudinal

section

of

the

ligament

(hematoxylin

and

eosin,

x 400).

FIG.

A neurovascular and companion stain, x 250).

bundle in the more dense central portion of the anterior cruciate nerve bundle (N.F.) are seen between cords of dense connective

ligament.

A vessel

(V.P.)

tissue

(silver

impregnation

cruciate

ligaments.

There

is also a possibility the primary are believed of joints has not been Clinical

that these

fibers

are of the type

first described

by Adrian in 1943. These fibers, rather than the cerebral cortex, Adrian exact demonstrated source of these that impulses

central destination of which to participate in subcortical evoke potentials indentified. Study


cruciate it is often ligament were

is the cerebellum reflex activity. but the

movements

in the cerebellum,

The to the

fifty

patients

with

tears

of the

anterior because

selected

according

previously

mentioned

criteria,

difficult,

if not

impossible,

to

ANATOMY

AND

FUNCTION

OF

THE

ANTERIOR

CRUCIATE

LIGAMENT

231

FIG.

7 within vessel an (silver interfascicular impregnation, space x in 1000). the depths of the

A myelinated
anteriorcruciate

fiber (NJ)
ligament.

in There

a longitudinal is no apparent

section companion

runs

diagnose nineteen cruciate


ligament were twenty average Fourteen athletes. was also In the and

a torn were
ligament (four

anterior treated,
by knees), repair

cruciate
that

ligament
is, an attempt tear

on clinical
was (five made knees),

grounds
to restore immediate

alone.

Of the fifty
of the knees); reconstruction

knees,
anterior of the

function (ten

of an acute an extra-articular knees, The years treated of the

and

pes anserinus
the torn and treated were examined anterior untreated and females. personally. thirty

transfer
cruciate groups years The

thirty-one

untreated. thirty-one excised was untreated in eleven. twenty-seven nineteen group were in both three

ligament
were in the

was
comparable. untreated

ignored
group.

in
The

treated in the patients and

age

of the In each the same

and twenty-one

of the thirty-one

untreated
postoperative Forty-seven

patients
management had

were

groups. interviewed stability

All

patients

measurements on the clinical strength on the cable tensiometer


was forty-four was months thirty (range, years (range, assessment

stress machine strength-testing


seven months seventeen

and forty-three were tested for muscle table. The average length of follow-up
to ten years), if the and years). patient had no limitation of the average age at final to sixty-one

The activity,
good

clinical

results

were

classified

as excellent

sional heavier

no discomfort, and no signs or symptoms that would identify the injured knee; as if the patient carried out normal activity and had returned to sports, but had occaor recurring mild episodes of discomfort or instability; and as poor if the patient discomfort which or instability received while doing normal work, or required a brace patients for (77

had persistent

work. In the group

no treatment,

twenty-four

of the thirty-one

per cent) had a good the nineteen patients patients, treated

or excellent result, while in the group which was treated, sixteen of (84 per cent) had similar results. It therefore appears that four or five knowledgeable in the management of knee-joint injuries, will at

by those

232

J. C.

KENNEDY,

H.

W.

WEINBERG,

AND

A.

S. WILSON

least
cruciate

temporarily
ligament

have

an acceptable

result

(excellent

or good)

whether

the

tear

in the

is meticulously

suring,
Functional

although
Result

our follow-up
in Relation tests, with

repaired was short.


to Muscle

or totally

ignored.

This

observations

is reas-

Strength patients, being the quadriceps and hamstring

In the strength
muscles developed were tested in a single used

performed the knee

on forty-three in 45 and voluntary contraction

90 degrees (Fig.

of flexion,
recorded

the maximum
by a cable

tension
tensiome-

maximum

ter of the type limb


was

developed
as a control.

in the

aircraft

industry

8).

In each

instance limb

the opposite was 70 per cent between

In all patients,

strength

in the two muscle in the normal limb. and the functional

groups There result

in the involved

or more of that of the muscle the amount of muscle power

was no apparent correlation in the patients tested.

FIG. Cable tensiometer table recording quadriceps

8 power during isometric contraction.

Functional

Result

in Relation

to Measured knees were

Instahilit tested on our clinical stress machine I. From for anterior, these data, it is

valgus,

Forty-seven of the fifty and varus laxity The findings for anterior

instability

are summarized

in Table

evident that there was a definite correlation between the clinical result and the amount of anterior instability. The previously established amount of five millimeters was used as the upper limit of normal for anterior displacement Of the forty-seven patients tested, only eleven had normal anterior displacement six, laxity was either present right after injury at final evaluation. In the remaining thirtyor developed during the ensuing months or
THE JOURNAL OF BONE AND JOINT SURGERY

ANATOMY

AND

FUNCTION

OF

THE TABLE

ANTERIOR I
ON

CRUCIATE

LIGAMENT

233

RESULTS

IN

FORTY-SEVEN

KNEES

TESTED

CLINICAL

STRESS

MACHINE

Anterior

Result
Excellent

0 to
7

Instability 5.1 to 8
5

Expressed

in

Millimete

rs
11.1 or more 0

8.1 to 11 2

Good Poor
Total

4
0
11

12
3
20

6
3
11

2
3
5

years. result, lated tenor excellent


varus

No patient with from zero to five millimeters of anterior displacement and none with over eleven millimeters of displacement had an acceptable The presence of valgus or varus laxity in addition to anterior laxity with the functional outcome. Twenty patients had minor or moderate laxity (up to 8. 1 millimeters) and no varus or valgus laxity. results. Thirteen patients with a similar degree or valgus laxity had inconsistent results, ranging patients with greater than 8 1 millimeters It would therefore seem that the presence how a damaged well
is not

had a poor result. correof anor with four-

was also degrees

All twenty

had good

teen remaining sistent results. laxity


unless

of anterior laxity associated from excellent to poor. The

of anterior laxity also had inconor absence of varus or valgus cruciate provide result instability
Although

does
the

not determine
anterior instability

a knee
severe

with
(under

anterior ligament

will

perform
our early

8. 1 millimeters).

results timism, arthritic


Associated

in patients increasing changes


Meniscal

with

anterior instability

cruciate may

reason

for some

op-

anteroposterior
11.12#{149}

eventually

in disabling

osteo-

Tears

In our fifty patients age to the anterior


meniscus. It has

there
suggested

was ligament:

a high
that

incidence tears
presence

of meniscal of the medial


of a tear

tears
of the

associated and three


anterior

with

dam-

cruciate
been

nineteen
in the

of the lateral cruciate liga-

ment excision of a meniscus with a minimum tear may remove a stabilizing factor 20#{149} Anteroposterior or rotatory instability is reported to have become evident as the meniscus was excised. On the other hand, there is the possibility that after surgery a knee with an isolated rupture of the anterior cruciate ligament and a meniscal tear (whether minimum or otherwise) may become symptomatic, necessitating a second operation, as instability an acute isolated to be indicated. increases with time. tear of the anterior In fourteen of the fifty knees in this series there was cruciate ligament but meniscectomy was not considered

Only two of these fourteen knees, both with high instability measurements, had poor results. In ten other knees there was also an acute tear of the anterior cruciate ligament, but a meniscectomy was performed at the time of arthrotomy. None of these knees had a poor result and none progressed to the point of having major instability. From follow-up, dial or lateral, the findings appear in this that group any of twenty-four hesitancy about tear knees, removing with an admittedly meniscus, ligament, tears
cruciate

short meon the of the


lig-

it would

a damaged cruciate acute


to the

in the presence

of an isolated

of the anterior with supports


if damage

grounds that removal may cause instability, is unwarranted. The high incidence of meniscal damage associated anterior cruciate ligament (fourteen of the twenty-four) should be performed to confirm the diagnosis, even ament is to be totally ignored. Discussion The fifty
VOL.

isolated
anterior

the thesis

that arthrotomy

biomechanical with
MARCH

and tears

morphological of the anterior

data

from

this

study,

the early

results

in the ex-

patients
56-A,
NO.2,

proved
1974

cruciate

ligament,

and our accumulated

234 perience the anterior Patients suggest cruciate with Acute

J.

C.

KENNEDY,

H.

W.

WEINBERG,

AND

A.

S.

WILSON

the following ligament Tears ofthe

recommendations is torn. Anterior Cruciate

for treatment

of injured

knees

in which

Ligament

If the anterior cruciate ligament primary repair should be attempted, be excised. If the tear collateral of the ligament the cruciate

is torn or avulsed at its femoral or tibial attachment a but if the tear is in the middle portion the ends should with substantial damage to the capsular One should and

is associated tear

ligaments,

is of secondary instability transfer

importance.

proceed

immediately to repair of the latter structures. If at the time of arthrotomy external rotatory of the anterior cruciate ligament, a pes anserinus

exists in the presence of a tear may be performed. However,

one must be absolutely certain that no lateral instability exists. If there is lateral instability in the presence of a tear of the anterior cruciate ligament, a pes anserinus transfer may cause internal rotatory instability because structures. towards of underlying damage to the posterolateral repair capor sule and other reconstruction supporting lateral should be directed In this situation, attempts at surgical the weakened lateral structures. Cruciate Ligament

Patients with Known Damage to the Anterior with No or Insignificant Laxity


Such patients

must

be examined

at regular

intervals,

much

as patients

with

scoliosis

are followed, since anterior sociated with pain, effusion, bracing or reconstruction. Patients with Chronic

laxity increases with time 12#{149} If such or subjective instability, then stability

laxity begins to be asshould be provided by

Symptomatic reconstruction

Instability of the anterior cruciate ligament has been unrewarding

Intra-articular
in our

hands.

structures, encouraging, Bracing The instability treatment, the Lenox

An extra-articular has been introduced the length

fascial repair, reefing at our Center recently. makes evaluation

both medial and lateral capsular Although our initial impression is premature.

of follow-up

Lenox Hill brace has been used on thirty-two of the knee. If a patient is middle-aged and or is a young competitive Hill brace is helpful. The athlete stability

patients at our Center not a good candidate

for chronic for surgical

in whom surgical treatment it provides, as determined

has failed, then by our patients

experience and by actual testing using the clinical stress machine, tory. Nine of the thirty-two patients who had chronic instability showed marked improvement in stability when their knees were illustrated
CASE

has been very satisfacand wore the brace tested in the brace, as

by the following

case

reports:
retired football player, suffered from marked anteroposterior laxity of

2. A.P., a twenty-six-year-old

his knee. Testing anteroposterior stability on the clinical stress machine revealed that the medial tibial condyle came forward ten millimeters and the lateraltibialcondyle, ten millimeters. Repeating the test after application of the Lenox condyle was Hill brace with the knee flexed to 90 degrees revealed that anterior displacement of the medial tibial reduced to zero and anterior

displacement

of the lateral

tibial condyle,

to 0.5 millimeter.

CASE 3. W.M., a middle-aged farmer, had marked clinical anteroposterior instability of his knee joint. When anteroposterior stability was tested on the stress machine, anterior displacement of the medial tibial condyle was

15.4 millimeters, while that of the lateral tibial condyle was fourteen millimeters. Repeating the test with the knee flexed to 90 degrees and the Lenox Hill brace applied demonstrated marked reduction in anterior displacement, the medial tibial condyle coming forward three millimeters and the lateral tibial condyle, one millimeter.

Conclusions 1. Tension in the anterior cruciate ligament varies


THE

greatly
JOURNAL

with

knee

flexion.
AND JOINT SURGERY

OF BONE

ANATOMY

AND

FUNCTION

OF

THE

ANTERIOR

CRUCIATE

LIGAMENT

235

2 Isolated tears of the anterior cruciate ligament do occur. 3 The anterior cruciate ligament contains both blood vessels sufficient to permit healing. 4. An acceptable result this specific ligament may result may be temporary.
cruciate

. .

and nerves

which

appear

following a tear ofthe anterior cruciate with or without repair of be anticipated in a high percentage of patients, although this injuries associated with isolated anterior

with

5. There is a high incidence of meniscal ligament damage. 6. Anterior instability in the presence ofa time. Continued observation is indicated, or bracing, or both, may

torn anterior cruciate ligament may increase and if symptoms develop an extra-articular

reconstruction

be necessary.

References
1. ABaorr,
ofthe L. C.; SAUNDERS, Knee Joint. J. Bone
E. D. : Afferent

J. B. DEC. and
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M.; BOST,

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ADRIAN, ALLMAN,
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FEAGIN, J. A.: Experience

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D.C.
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14.

PALMER,

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dinavica, Supplementum 53, 1938. 15. PRINGLE,J. H.: Avulsion of the Spineof the Tibia. Ann. Surg.,46: 169-178, 1907. 16. ROBICHON, J., and ROMERO, C.: The Functional Anatomy of the Knee Joint with Special Reference to the Medial Collateral and Anterior Cruciate Ligaments. Canadian J. Surg., 11: 36-39, 1968. 17. SCAPINELLI, R.: Studies on the Vasculature of the Human Knee Joint. Acta Anat., 70: 305-331, 1968. 18. SCHOFIELD, G. C.: Experimental Studies on the Innervation of the Mucous Membrane of the Gut. Brain, 83:490-514, 1960. 19. SLOCUM, D. B., and LARSON, R. L.: Rotatory Instabilityof the Knee. Its Pathogenesis and a Clinical Test to Demonstrate its Presence. J. Bone and Joint Surg., 50-A: 211-225, Mar. 1968. 20. SLOCUM, D. B., and LARSON, R. L.: Pes Anserinus Transplantation. A Surgical Procedure for Control of Rotatory Instability of the Knee. J. Bone and Joint Surg., 50-A: 226-242, Mar. 1968. 21. SMILLIE, I. S.: Injuries of the Knee Joint. Ed. 4, p. 154. Edinburgh and London, E. and S. Livingstone, Ltd., 1970. 22. WLADMIROW, B.: Arterial Sources of Blood Supply of the Knee Joint in Man. Acta Med., 47: 1-10, 1968.

VOL. 56-A,NO.

2, MARCH

1974