ACL surgery became a common procedure in the late 1980s and throughout the 1990s, driven largely by the rise of arthroscopic techniques that made the operation far less invasive. But the road to that point stretched back more than a century, with surgeons experimenting with different approaches long before the technology caught up to the idea.
Early Attempts at ACL Repair
Surgeons first became interested in the ACL as a source of knee instability in the mid-1800s, when anatomists began publishing clinical descriptions of the ligament and what happened when it tore. By the early 1900s, proposals appeared in medical literature for repairing torn ACLs by stitching the ligament back together or reconstructing it with other tissue. These early efforts were crude by modern standards, but they established the basic concept that a torn ACL could be surgically addressed rather than simply left alone.
Through the middle of the 20th century, surgeons experimented with different tissue sources to replace a torn ACL. In 1934, the Italian surgeon Riccardo Galeazzi described using a hamstring tendon to rebuild the ligament. Harold Macey followed with a similar technique in 1939. These operations required large, open incisions into the knee, which meant long recoveries, significant scarring, and a high risk of stiffness. The procedures worked in some cases, but they were far from routine. Most patients with torn ACLs were told to avoid demanding activity rather than undergo surgery.
The Patellar Tendon Graft Takes Hold
A major turning point came in the 1960s, when European surgeons began refining techniques that used part of the patellar tendon (the thick band connecting the kneecap to the shinbone) as a replacement graft. In 1966, a German surgeon named Brückner proposed harvesting the middle third of the patellar tendon for reconstruction. Around the same time, the French surgeon Albert Trillat refined the approach by drilling tunnels through the shinbone and thighbone to thread the graft into the correct anatomical position.
This patellar tendon graft eventually became what surgeons called the “gold standard” for ACL reconstruction because the small bone plugs on each end of the graft could heal directly into the bone tunnels, creating a strong, reliable fix. That reputation persisted for decades, and while hamstring and donor grafts have gained popularity since, the patellar tendon graft remains widely used today.
Arthroscopy Changed Everything
The single biggest reason ACL surgery went from uncommon to routine was the arthroscope. In 1962, the Japanese surgeon Masaki Watanabe developed a small, usable arthroscope and performed the first arthroscopic meniscus surgery with it. His invention gave surgeons a way to see inside the knee through tiny incisions rather than cutting the joint wide open.
It took nearly two decades for someone to apply that technology to ACL reconstruction. In 1980, British surgeon David Dandy performed the first arthroscopic-assisted ACL reconstruction, threading a graft into the knee with the help of a small camera. The technique was still experimental, and the graft material he used (carbon fiber) was eventually abandoned. But the core idea, performing the reconstruction through small incisions guided by a camera, proved transformative.
Through the early and mid-1980s, arthroscopic ACL reconstruction spread across orthopedic surgery programs in Europe and North America. Surgeons quickly realized the advantages: smaller incisions meant less tissue damage, less pain, shorter hospital stays, and faster initial recovery. By the late 1980s, arthroscopic techniques had largely replaced open surgery for ACL reconstruction in developed countries, and the number of procedures performed each year climbed sharply.
The 1990s Boom
The 1990s were the decade ACL surgery truly became mainstream. Several developments came together at once. Arthroscopic equipment improved in resolution and reliability. Surgeons had accumulated enough experience with the technique to refine tunnel placement and graft fixation. And a critical change happened on the rehabilitation side that made the whole process more appealing to patients.
Before the early 1990s, recovery from ACL surgery was notoriously slow. Patients were often immobilized in a cast or brace for weeks and told to avoid bending the knee. Full recovery could take a year or more, and many patients ended up with permanent stiffness. In 1992, orthopedic surgeon Donald Shelbourne published results from an accelerated rehabilitation protocol he had developed after operating on 800 patients. His approach emphasized early knee motion and weight-bearing rather than prolonged immobilization. Among the 450 patients who followed the accelerated program, the results were clear: less stiffness, better strength recovery, and no loss of knee stability compared to the traditional approach.
Shelbourne’s work helped shift the culture around ACL surgery. When patients learned they could reasonably expect to return to sports within six to nine months rather than spending weeks in a cast, the surgery became a much easier decision. The combination of minimally invasive arthroscopic technique and faster rehabilitation made ACL reconstruction one of the most commonly performed orthopedic procedures by the mid-to-late 1990s.
How Surgical Volume Has Grown
Today, an estimated 100,000 to 200,000 ACL reconstructions are performed in the United States each year, and the numbers are similar across Europe and other developed regions relative to population. The procedure is most common among people aged 15 to 45 who want to return to sports or physically demanding work. What was once a rare, open-knee operation with uncertain outcomes has become one of the most studied and standardized surgeries in all of orthopedics.
The shift happened in stages: early experimental repairs in the first half of the 1900s, refinement of graft techniques in the 1960s and 1970s, the arthroscopic breakthrough around 1980, and then rapid adoption through the late 1980s and 1990s. If you had torn your ACL in 1975, surgery would have been a major, somewhat unusual undertaking. By 1995, it was a well-established outpatient procedure with a predictable recovery timeline.