Operation to Replace the Most Important Function of the Anterior Crucial Ligament of the Knee Joint when Rupture of the Ligament has Occurred

October 1918

A new external lateral ligament is formed in the following way. An incision is made beginning at lower and inner side of the tubercle of the tibia and carried upward and outward by the outer border of patella, then upwards for about 3½ inches, E.F. The outer flap is dissected up including the superfical fascia. The fascia lata is disclosed and a strip about ¼ inch in breadth and of sufficient length to reach just beyond the tubercle of the tibia is dissected up from the point, marked A. in Fig. 2. This is situated just above the junction of the posterior and inferior borders of the outer condyle. The free extremity of this band is now passed between the fascia and skin of the outer flap, entering at the point marked C. in Fig. 3, and traversing the flap for about 2 inches, then emerging at point marked D. It is then carried through a hole drilled through the tubercle of the tibia at upper part and quite superficially. The end is turned up and stitched in that situation by two fine silver wire sutures. The gap in the fascia lata is now closed, and the skin united according to the technique of the surgeon. Ruptured anterior crucial ligament causes frequent partial posterior dislocation of the lower end of femur, a matter of great discomfort and some danger to the patient. My attention was drawn to this subject by a returned soldier affected by this accident. I could only find operations in literature that had the inside of the joint for their objective. The criticisms on those operations were not of a character to encourage their adoption. I therefore experimented with dry bones by tacking a tape in various situations on the condyles of a femur and upper part of tibia. I found by placing one in the situation marked A. and B. in Fig. 2, that you could flex the femur easily, but it did not allow any backward displacement. Now the mechanical side of the puzzle being solved, the next item was how to make such a ligament from the anatomic structures in relation to the knee joint. Such a one, I believe, we have in that part of the fascia lata which is attached strongly to the femur in the very place where we want it for our operation. I believe that the suggested operation is sound mechanically, anatomically, and physiologically. I fail to see where it is likely to disappoint surgeon or patient. It has the great advantage of extreme simplicity, nor could it reasonably be a cause of danger to the joint. The various tendons passing the joint received my consideration, and might be made to serve the purpose.

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