Graft Tension and Knee Stability After Anterior Cruciate Ligament Reconstruction

Yoshiya, Shinichi; Kurosaka, Masahiro; Ouchi, K.; Kuroda, Ryosuke; Mizuno, Kosaku

doi:10.1097/00003086-200201000-00018

Cited by 77 publications

(72 citation statements)

References 17 publications

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“…Kim et al (2006), Yoshiya et al (2002) and van Kampen et al (1998) reported no significant difference between groups immediately post surgery or greater than 12 months post surgery. Nicholas et al (2004) reported significantly less STSD in anterior tibial displacement at 90N of tension when compared to 45N immeadiately post surgery (p=0.01).…”

Section: Side-to-side Difference In Anterior Tibial Displacementmentioning

confidence: 83%

“…STSD in anterior tibial displacement as measured by an arthrometer was reported in all five articles (Kim et al, 2006;Nicholas et al, 2004;van Kampen et al, 1998;Yasuda et al, 1997;Yoshiya et al, 2002). Kim et al (2006), Yoshiya et al (2002) and van Kampen et al (1998) reported no significant difference between groups immediately post surgery or greater than 12 months post surgery.…”

Section: Side-to-side Difference In Anterior Tibial Displacementmentioning

confidence: 92%

“…Application of optimal tension assists in the restoration of normal AP stability, restoration of normal knee kinematics and promotion of graft revascularisation and healing (Nicholas et al, 2004;Yoshiya, Kurosaka, Ouchi, Kuroda, & Mizuno, 2002). Insufficient tension will fail to restore stability and function while excessive tension will limit ROM, increase tissue strain, increase compressive joint forces, contribute to the failure of fixation method and increase the risk of graft failure (Fleming et al, 2013;Kim et al, 2006;Nicholas et al, 2004;Yasuda et al, 1997).…”

Section: Graft Tensionmentioning

confidence: 99%

“…The IKDC Subjective Knee Form was collected in two articles (van Kampen et al, 1998;Yoshiya et al, 2002). However, van Kampen et al (1998) was the only paper to report a comparison and showed no significant difference between 20N and 40N of tension.…”

Section: Additional Outcome Measuresmentioning

confidence: 99%

“…In recent years, attempts have been made to quantify graft tension with the introduction of tensioning devices (Nicholas et al, 2004;van Kampen et al, 1998;Yasuda et al, 1997;Yoshiya et al, 2002). The quantifying of graft tension has been proposed to result in an optimal biomechanical outcome as well as an ideal environment for graft healing and ligamentization (Friederich & O'Brien, 1998;Heis & Paulos, 2002;Tohyama & Yasuda, 1998).…”

Section: Introductionmentioning

confidence: 99%

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Graft tensioning in anterior cruciate ligament reconstruction

Kirwan¹

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BackgroundAnterior cruciate ligament reconstruction (ACLR) is an effective procedure for restoring stability and function. Being a technically demanding procedure, patient outcomes are highly dependent on numerous surgical factors, which are critical for success. The application of tension to the graft prior to tibial fixation is one such factor and is considered essential for the restoration of joint stability, normal knee biomechanics, graft revascularisation and patient function. In applying tension, a key factor is the amount of force applied to the graft. However, the method of applying the tension, position of the knee during tensioning, properties of the graft material, tunnel placement and graft fixation device can all influence the effect that graft tension has on outcomes. Despite the reported importance of graft tension there has been limited empirical evidence defining the best tensioning practice for restoring patient outcome post ACLR. AimsThe goal of this program of research was to explore the effect that different aspects of graft tensioning has on patient function post ACLR. To address the aims of the thesis, three studies were conducted. The first study was a systematic review aimed at examining if a particular amount of tension results in better functional outcomes post ACLR. The second study aimed to compare the effect of two methods of applying graft tension on patient function post ACLR. The study used a prospective randomised controlled trial to compare manual tensioning with the use of a tensioning device. The third study aimed to define current graft tensioning practices and explore the factors that influence surgical decision making. A national survey of Australian orthopaedic surgeons was conducted to achieve the aims of the study. ResultsThe systematic review (study one) revealed that a medium graft tension of 79N to 90N produced the least side-to-side difference (STSD) in anterior posterior (AP) tibial translation as measured by a KT-1000 when compared to tensions <79 or >90N. However, the heterogeneous use of functional outcomes inhibited the ability to draw conclusions on other patient specific functional outcomes.Furthermore, the review highlighted the lack of high quality studies, which also failed to discuss other aspects of graft tension such as the method of applying tension.iii Building on the findings of study one, the second study undertook a RCT to compare the functional outcomes of applying 80N of force with a tensioning device (TD) (n=10) to a manual tensioning method (MT) (n=13) using an estimated force described as a sustained maximum one handed pull.Patients were assessed at pre-surgery and two weeks, three months, six months and 12 months post Based on the findings of study one, tensioning between 79N and 90N appeared to improve the restoration of joint stability, when compared to higher and lower tensions. However, no effect on patient function within 24 months post surgery was apparent. Furthermore, study two observed that tension did not appear to have an...

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Section: Side-to-side Difference In Anterior Tibial Displacementmentioning

confidence: 83%

Section: Side-to-side Difference In Anterior Tibial Displacementmentioning

confidence: 92%

Section: Graft Tensionmentioning

confidence: 99%

Section: Additional Outcome Measuresmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Graft tensioning in anterior cruciate ligament reconstruction

Kirwan¹

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In vitro comparison of tension and stiffness between hamstring tendon and patella tendon grafts

Elias¹,

Surya²,

Ciccone³

2008

Journal Orthopaedic Research

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Following anterior cruciate ligament reconstruction, grafts relax and warm from the temperature of the operating room to body temperature. The current study compared graft tension and stiffness between patella tendon and hamstring tendon grafts. Six quadruple strand hamstring tendon grafts and six patella tendon grafts were preconditioned and loaded to 105 N while at 208C. Graft tension and stiffness were measured after 15 min, after an additional 4 h, and after increasing the temperature to 348C. A two-way repeated-measures analysis of variance and a post hoc test were used to compare the measurements between the two types of graft and identify significant ( p < 0.05) changes for each type of graft. Tension was significantly larger for the patella tendon grafts, although the stiffness values were not significantly different ( p > 0.8). For both types of graft, tension and stiffness decreased significantly with time and the temperature increase. The lowest tension and stiffness measurements were 50 AE 11 N and 129 AE 35 N/mm, respectively, for the patella tendon grafts, compared to 18 AE 5 N and 115 AE 11 N/mm, respectively, for the hamstring tendon grafts. Both types of graft lose tension to relaxation and a temperature increase, but the tension loss is larger for hamstring tendon grafts. Initial tension is applied to autografts used for anterior cruciate ligament reconstruction to limit postoperative knee laxity. Recommended initial tension levels range from 20 to 90 N for patella tendon grafts [1][2][3][4][5] and from 70 to 80 N 1,6,7 for hamstring tendon grafts. Following reconstruction, viscoelastic relaxation decreases the tension within a graft. Hamstring tendon grafts are typically preconditioned on a graft board at approximately 89 N 8-11 to minimize the tension loss. Two in vitro studies that mimicked preconditioning and application of initial tension determined that the tension within hamstring tendon grafts decreases by more than 50% within an hour.10,12 Patella tendon grafts are not typically preconditioned outside the knee prior to reconstruction, presumably due to the belief that patella tendon grafts are less susceptible to relaxation. A 50% decrease in tension over 15 min has been measured for patella tendon grafts that were not preconditioned immediately prior to application of tension.13 As the graft tension decreases, the stiffness needed to maintain knee stability increases.14 The stiffness of hamstring tendon grafts has been shown to decrease as the tension decreases. 12 The relationship between stiffness and tension has not been determined for patella tendon grafts.Graft tension and stiffness can also decrease due to an increase in temperature. Autografts typically cool to the temperature of the operating room prior to implantation in the knee and warm to body temperature postoperatively. Following complete relaxation, an increase in temperature from operating room to body temperature has been shown to decrease the tension and stiffness of hamstring tendon grafts by approximately...

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