Tensioning of the anterior cruciate ligament graft

There remains a great deal in variability in the protocols for graft tensioning. The biologic studies have riot been conclusive as to the optimum tension for revascularization while minimizing stress relaxation. Preloading in full or nearly full extension limits the risk of pathologic stresses at full extension that can occur when the graft is tensioned at 30degrees, but adds the risk of increased laxity at that angle. We recommend tensioning the graft at 20degrees to 30degrees unless the graft tightens or shortens 5 mm or greater with knee extension. If so, then tension in extension. The magnitude of graft tensioning should be tissue specific. For bone-patellar tendon-bone autograft or allograft, 5 pounds of tension should be applied. For hamstring graft, we apply 15 pounds of tension with each bundle tensioned individually.