The Classic: On the Injuries to the Ligaments of the Knee Joint

A Great Name in the History of Cruciate Ligament Surgery When the history of knee ligament surgery is written, Ivar Palmer will be one of the most often quoted surgeons. The purpose of this presentation is, therefore, to honor one of the greatest knee surgeons, professor Ivar Palmer, Stockholm, Sweden. Ivar Palmer was born in 1897 in western Sweden. Soon afterward, his family moved to the province of Jämtland, in northern Sweden. His father was a minister. Ivar Palmer graduated from high school in 1915 and received his M.D. degree in Stockholm in 1923. He completed his residency in Stockholm at the Serafimer Hospital, which was then part of the Karolinska Institute. He served in northern Sweden until 1928. He then became chief of the Military Hospital at Karlsborg, in central Sweden. During the period from 1934 to 1939, he served as a senior staff member at the surgical department of the Sabbatsberg Hospital in Stockholm and wrote his famous thesis about knee ligament injuries, published in 1938.1 Having successfully defended his thesis, in 1939 he was appointed chief of a special section consisting of wards for trauma and military surgery in the newly opened Karolinska Hospital. He worked there from 1939 to 1942 and describes this in his autobiography as the most satisfactory period of his professional life.2 He was allowed to work as a “traumatologist.” In 1942 he became chief of surgery at the Sabbatsberg Hospital, and in 1947 was appointed chief of the Department of Surgery in the newly built Southern Hospital of Stockholm. He stayed there until he retired in 1962. Ivar Palmer is active and working as a consultant to an insurance company at the age of 85 years. He is married and has two children. His son, Björn Palmer, is chief of plastic surgery at the Malmö General Hospital in Malmö, Sweden. Some years ago I listened to a young orthopedic surgeon's presentation about resuture of the menisci and the importance of repairing the meniscotibial or meniscofemoral ligament. He spoke as though he had discovered it. When I kindly pointed out to him that Ivar Palmer had published all of this more than 40 years earlier and actually had given even better outlines for knowing when the meniscofemoral rather than the meniscotibial ligament was injured, he hardly believed my words. Ivar Palmer's book On the Injuries to the Ligaments of the Knee Joint is 282 pages long and summarizes a tremendous amount of clinical and experimental investigations. In nine chapters, Palmer discussed (1) the anatomy and physiology of the knee ligaments; (2) some interesting biomechanical studies on cadavers (pointing out, however, the limited vaue of experiments on cadavers and that the constitutional variations in tensile strength of the ligaments were very great in his studies, despite the preparations investigated having been taken from the knee joints of young or middle-aged people); (3) clinical observations on the mechanism of knee ligament lesions; (4) frequency, symptoms, and pathologic anatomy of the different types of injuries; (5) the case history of 30 fresh cases of knee ligament injuries; (6) the clinical picture of long-standing injuries to knee ligaments; (7) the case histories of 27 late reconstructions of knee ligament injuries; (8) different types of treatment and follow-up observations. Ivar Palmer also better described the different types of ruptures of the anterior cruciate ligament (ACL) than any earlier investigators. He pointed out the difference between the anteromedial and posterolateral parts of the ACL, and was the first to note that the ligament can rupture within its intact synovial sheath and that this injury can not be discovered unless the synovium is opened. He developed new instruments for the surgical repair of the cruciate ligaments and, together with the Swedish Stille-Werner Company, produced a drill guide that has been replicated in many countries. He provided a comprehensive description, with beautiful drawings of the different types of medial collateral ligament ruptures and how to repair them. Ivar Palmer also performed an autopsy on one of the patients with a Hey-Groves plasty, providing a careful histologic study on the fate of the pedicled graft from the iliotibial tract. He showed how the graft rapidly becomes synovialized and how vessels and connective tissue grow into the pedicled graft from the periphery. In the summary he stressed the need to diagnose acute knee injuries as soon as possible and to repair ACL injuries. Unfortunately, there are no more copies of his book available, so there has even been some discussion of publishing a second edition of his famous thesis. Ivar Palmer also has written other books: a Swedish textbook, Open Treatment of Fractures and Joint Injuries, published in 19623; several books of pure literature; an autobiography, Join Together2; a book on botany4 (one of his interests is gardening, and he has a wonderful collection of wild orchids); and a highly scientific and philosophic book about neurophysiology and the function of the brain.5 Moreover, he has always been a good painter, and in addition to the illustrations in his knee books, he has produced several paintings and many sculptures. Ivar Palmer created much interest in knee ligament surgery. His successors have taught a generation of young Swedish orthopedic surgeons to operate on knee ligaments, hence the renown of von Bahr, Johansson, Aronsson, Liljedahl, Wetterfors, Broström, Eriksson, Gillquist, Peterson and others in knee surgery. Interviewed in 1938 about his thesis, Ivar Palmer stated that the world's leading orthopedic surgeons at that time knew little about the diagnosis and repair of ACL injuries. The general procedure was to excise the ACL if it was torn or to do nothing, a treatment philosophy Ivar Palmer has protested his entire life. Much has been built on the foundation laid down by Ivar Palmer almost 50 years ago. Ejnar Eriksson, M.D.