Graft Tensioning in Anterior Cruciate Ligament Reconstruction: a Systematic Review of Randomized Controlled Trials

Purpose: The purposes of this study were to (1) perform a systematic review of randomized controlled trials evaluating graft tensioning in anterior cruciate ligament (ACL) reconstruction, and (2) determine the scientific quality of published randomized controlled trials evaluating graft tensioning in ACL reconstruction.

Methods: The search strategy included a computerized literature search, a citation search, and a manual search of key journals and conference proceedings. Eligible studies were randomized controlled trials evaluating the effect of graft tensioning on the outcomes of ACL reconstruction. Two reviewers independently performed the literature searches. The validity of the trials was scored using the Detsky quality scale. Consensus was achieved by a study committee of 3 investigators.

Results: Five randomized controlled trials met the inclusion criteria. The mean standardized Detsky score was 61.3 +/- 15.2%. Only 2 of the studies scored >or=75%. All trials consisted of autogenous graft sources, with 3 involving a bone-patellar tendon-bone graft, 1 involving a 5-strand semitendinosus-polyester (5STP) graft, and 1 involving a semitendinosus-gracilis-polyester (STGP) graft.

Conclusions: Based on the evidence in this systematic review, there is a trend that suggests that 80 N of tension is the most effective amount of tension to apply during ACL reconstruction using hamstring-polyester graft sources. For ACL reconstruction using semitendinosus-gracilis or patellar tendon graft sources, there is no clear trend in terms of statistically significant or clinically relevant differences in terms of the amount of applied tension to apply to the graft during graft fixation. We are unable to provide recommendations as to the amount of tension to apply to 4-strand semitendinosus-gracilis autografts without polyester augmentation because there has been no randomized clinical trial conducted to determine the most effective amount of tension to apply when using this graft source.