Accurate anatomic diagnosis has always been our quest and a right of the patient. The past three decades emphasize the progress we have made in this quest. The biomechanical principles of primary and secondary restraints were established by Butler et al.¹ The concepts of rotatory laxity and the pivot shift were promulgated by Slocum and Larson,² Liorzou,³ Losee,⁴ Losee et al.,⁵ and Kocher et al.⁶ Documentation as directed by the International Knee Documentation Committee, direct view by arthroscopy and imaging by magnetic resonance imaging, computed axial tomographic scanning, and technetium scanning have empowered us with the ability to make a three-dimensional anatomic diagnosis of the highest order of accuracy at both macroscopic and microscopic levels. We should expect no less.

Too long, we have been “hung up” on form. We have not been precise enough in considering functional competence. A patient who did not complain was considered functionally intact. We now see many patients who had reconstructed anterior cruciate ligaments (ACLs) 15 to 20 years previously and who returned to a high level of function and are now showing degenerative changes with an excess of medial compartment loading.

We do need to integrate into the rather static equation, a dynamic understanding of which way the pathologic process is heading and how fast, that is, is Mother Nature doing her utmost to heal the insult of overuse or has the process played out and a biologic stimulus, such as microfracture, is needed? Certainly when we look at fracture imaging, this is uppermost in our minds. Should it not be the same where soft tissue and the knee are involved? Is postoperative osteoarthrosis a concomitant of surgical intervention, or have we failed to restore kinematic competence? I wish I knew the answer with certainty. I suspect both are implicated and related. On postoperative physical examination, if I can elicit some anatomic flaw that affects kinematic competence, whether this will be in limited mobility of the patellofemoral joint or as a subtle pivot glide with increased varus-valgus laxity, I know these are related to a less-than-perfect ACL construct.

Our goal should be to seek kinematic competence as well as anatomic form. Our methods of measurement have improved so that we are now able to measure restoration of anatomic form. We can now demand much more from our kinematic knowledge base. The best example of past failures that exemplifies this concept is our extra-articular repairs,⁷ which featured so prominently in our surgical techniques of the 1980s.