Graft tensioning practices in anterior cruciate ligament reconstruction amongst orthopaedic surgeons in Australia: a national survey

PURPOSE: The application of graft tension during anterior cruciate ligament reconstruction is considered an important feature of ACLR. However, wide variation exists in relation to graft tensioning practice limiting the ability to determine the best approach. Thus, the primary aim of this study was to describe current clinical practice amongst Australian orthopaedic surgeons with respect to graft tensioning and explore influencing factors.

MATERIALS AND METHODS: A survey was developed to address the aims of the study and pilot testing was completed to confirm validity and reliability. The survey population was defined as Australian orthopaedic surgeons, associated with the Australian Orthopaedic Association sub-specialty of knee to target surgeons likely to perform ACLR. The final sampling frame consisted of 192 surgeons.

RESULTS: Manual tensioning was the most common method (80.5 %), with a maximum one-handed pull the most frequent description and estimated tension ranged between 41 and 60 N with the knee positioned near full extension. Surgeons using a tensioning device tended to use a higher tension (mean 81.85 N), with the knee positioned at 30° flexion (40 %). Sixteen percent reported individualising tension on viscoelasticity of the graft, graft diameter, patient anthropometry and age. Patient outcomes and available evidence were the primary factors influencing tensioning protocol.

CONCLUSION: Tensioning practices appear to consist of three main approaches, (1) manual tension using a sustained maximum one-handed pull, with tension estimated as 41-60 N, applied near full extension, (2) tensioning device, mean tension of 81.85 N, at 30° knee flexion, (3) individual approach based on size and viscoelastic properties of the graft, patient anthropometry, contralateral comparison to the other knee and age of the patient.