Evaluation of Graft Tensioning Effects in Anterior Cruciate Ligament Reconstruction between Hamstring and Bone–Patellar Tendon Bone Autografts

Abstract

This article investigates the clinical, functional, and radiographic outcomes in anterior cruciate ligament (ACL) reconstruction patients over 7 years to determine the effects of initial graft tension on outcomes when using patellar tendon (bone–tendon–bone [BTB]) and hamstring tendon (HS) autografts. Ninety patients, reconstructed with BTB or HS, were randomized using two initial graft tension protocols: (1) normal anteroposterior (AP) laxity (“low-tension”; n = 46) and (2) AP laxity overconstrained by 2 mm (“high-tension”; n = 44). Seventy-two patients had data available at 7 years, with 9 excluded for graft failure. Outcomes included the Knee Injury and Osteoarthritis Outcome Score, Short-Form-36 (SF-36), and Tegner activity scale. Clinical outcomes included KT-1000S and International Knee Documentation Committee examination score; and functional outcomes included 1-leg hop distance and peak knee extensor torque. Imaging outcomes included medial joint space width, Osteoarthritis Research Society International radiographic score, and Whole-Organ Magnetic Resonance Score. There were significantly improved outcomes in the high-tension compared with the low-tension HS group for SF-36 subset scores for bodily pain (p = 0.012), social functioning (p = 0.004), and mental health (p = 0.014) 84 months postsurgery. No significant differences in any outcome were found within the BTB groups. Tegner activity scores were also significantly higher for the high-tension HS group compared with the low-tension (6.0 vs. 3.8, p = 0.016). Patients with HS autografts placed in high tension had better outcomes relative to low tension for Tegner activity score and SF-36 subset scores for bodily pain, social functioning, and mental health. For this reason, we recommend that graft fixation be performed with the knee at 30-degree flexion (“high-tension” condition) when reconstructing the ACL with HS autograft.

Evaluation of Anterior Cruciate Ligament Surgical Reconstruction Through Finite Element Analysis

“…Further increase in the knee flexion angle led to an upsurge of laxity. Similar optimal graft fixation angles can be found in literature 107,108 , although a commonly used fixation angle is at 30°1 09,110 . Nonetheless, the optimal knee flexion angle during graft fixation is still a controversial topic amongst clinicians.…”

Long‐term outcomes of anterior cruciate ligament reconstruction surgery: 2020 OREF clinical research award paper

“…Although graft type was not randomized, a subsequent analysis was performed to explore the effects of graft type and tension on outcomes. 11 Several retrospective analyses (ancillary studies) were also performed using the Tension Trial database. 8,[12][13][14][15]17 3 | RESULTS…”

“…In the subsequent analysis evaluating the effects of graft type and tensioning on outcomes, 11 it was determined that patients reconstructed with HS autografts under the high-tension condition had better SF-36 scores (bodily pain, social functioning, and mental health scores; P < .014) than those HS patients reconstructed under low-tension, though there were no differences in any other outcome measures. Likewise, no differences in any outcome measures were found between the two graft tension conditions in those patients receiving BTB autografts.…”

“…To better understand PTOA development in the ACLR knee and the impact of initial graft tension on surgical outcomes, a prospective randomized controlled trial (RCT) was performed [NCT00434837]. [9][10][11] The primary objective of the "Tension Trial" was to compare clinical, functional, patient-reported, and PTOA-related imaging outcome measures 7 years postsurgery between two common "laxity based" graft tensioning protocols. The RCT was performed in patients with acute isolated ACL injuries.…”

A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients)

“…Yasuda et al 37 compared sideto-side knee laxity at 2 years with initial graft tension at 20 N, 40 N, or 80 N in 70 patients and reported that 38 compared manual cyclical loading with the use of a tensioner at 1-year follow-up in 50 patients and reported no difference in laxity but better Lysholm score at short-term follow-up. Finally, DeFroda et al 39 also compared low-tension with high-tension (overconstrained by 2 mm) in 90 patients and reported on 72 patients at 7 years' follow-up using hamstrings or BPTB autografts. There were no differences in the BPTB group but statistically significant differences were reported favoring the high-tension group when the hamstrings grafts were used.…”