Who is John Lachman?

by Joseph S. Torg, MD

In reviewing the Lachman test from a historical perspective, perhaps the first matter to be addressed is the question "Who is John Lachman?"

A graduate of both Temple University and its School of Medicine , Dr. Lachman also completed his orthopaedic residency at that institution under John Royal Moore, M.D., the first professor and chairman of the Department of Orthopaedic Surgery. Remaining on the faculty at Temple following his residency, in 1956 he succeeded Dr. Moore as professor and chairman.

An apolitical person, thoroughly at ease with himself and his role in life as he sees it, Dr. Lachman's relative obscurity has been self-imposed. He has completely dedicated his life to serving two purposes: God and orthopaedics. A devout Catholic, he attends mass daily and is a strong supporter of his church. In the conduct of his professional life, Dr. Lachman has been totally devoted to excellence in orthopaedics and to the education of medical students and residents, John Lachman is an extraordinary individual, both from the standpoint of his superior intellect and his pervasive personal qualities. By his residents, colleagues, and friends he is loved, respected, admired, and affectionately referred to as "Latch." His long-term colleague, Howard Steel, himself a unique and extraordinary character who has a marvelous way of putting things into perspective, refers to John Lachman as Sebastian (as in Saint Sebastian of Biblical fame).

A proponent of the concept of meticulous attention to detail, early in his career, Dr. Lachman noticed that certain patients with a torn anterior cruciate ligament demonstrated passive anterior subluxation of the proximal tibia in relationship to the femur that was apparent while lying supine. Exploring this observation further, he demonstrated that anterior cruciate ligament insufficiency was determined easily by stressing the knee in extension rather than in the manner of the classic anterior drawer test.

My first exposure to this observation occurred as a resident when presenting a patient to the chief on rounds. Upon turning back the covers, he simply looked at the patient's knee and stated, "He has a torn anterior cruciate." The patient's anterior drawer test was unremarkable; however, surgical findings indicated a complete tear of the anterior cruciate ligament. Thus, a clinical "pearl" had been simply passed on, as Dr. Lachman had done hundreds if not thousands of times before to his students and residents.

Upon completion of my residency in 1968, 1 too remained on the faculty at Temple and, in these early days, began to develop a practice in sports medicine and knee surgery. To put things in historical perspective, at that time, with the exception of John Feagin and the late John Marshall, all the sports medicine mavens and self-appointed knee experts virtually denied the existence of the anterior cruciate ligament. Other than acknowledging its presence in the knee joint and its role as a part of O'Donoghue's "unholy triad," the fact that it tore either as an isolated structure or was associated with injury to the menisci was unrecognized, unappreciated, and denied. A review of the literature of this period reveals unequivocally that those who were writing on knee injuries and knee surgery not only denied, but also demeaned, the importance of the anterior cruciate ligament.

Using this simple maneuver of stressing for cruciate laxity with the knee slightly flexed, it soon became apparent to me that not only did the anterior cruciate ligament tear either in isolated manner or in conjunction with a meniscal injury, but also that this phenomenon occurred frequently. I had the opportunity of presenting a paper entitled "Clinical Diagnosis of Anterior Cruciate Ligament Instability in the Athlete" before the annual meeting of the American Orthopaedic Society for Sports Medicine in 1976 in New Orleans .  In addition to describing the Lachman test as a procedure preferable and much more reliable than the classic anterior drawer test, I also reported on the frequency of injury to the anterior cruciate ligament associated with injuries to other structures. Specifically, reporting on anatomic lesions observed in surgery in 250 consecutive  knees in a population of recreational and collegiate athletes, 172 (69%) had tears of the medial meniscus and 62 (25%) had tears of the lateral meniscus. Again, a review of the literature will clearly indicate that this study, subsequently published in the American Journal of Sports Medicine in April 1976, was the first to identify the frequent association of anterior cruciate ligament and meniscal lesions.

Again, considering the orthopaedic/sports medicine mind-set of this period, it is interesting to note that the critique of the presentation indicated that it was the consensus of the audience that the paper "had no clinical relevance." However, the Lachman test has not only withstood the test of time, but it is now generally recognized as the most sensitive clinical test for the determination of anterior cruciate ligament integrity. Although some may fail to understand both the significance of the test and the eponym, it is clear that both the sign and the term "Lachman test" are firmly engraved in the contemporary orthopaedic vocabulary.  As long as young men and women continue to tear their anterior cruciate ligaments, the eponym will prevail, and John Lachman will be memorialized for his contributions as a teacher.