Tibial graft fixation with residual tension controlled in anterior cruciate ligament reconstruction

It is essential to secure the graft to the tibia with controlled tension during anterior cruciate ligament (ACL) reconstruction to achieve successful outcomes. Although various fixation devices, including button, screw post, staple and interference screw (IFS) have been utilized, they could not provide controllability of the remaining tension in the graft after its fixation due to post-fixation load relaxation of the construct. In contrast to them, pullout suture technique with the Double Spike Plate (DSP) or Bone Plug Tensioning and Fixation (BTF) system allows controlling the graft tension during or after its fixation, because these devices are designed to be used after load relaxation of the construct by in situ pre-tensioning, that is, to perform pre-tensioning and fixation separately. Concretely, (I) manually apply the initial tension while monitoring the graft tension using a tensioner attached to a tensioning boot fixed on the tibia; (II) pull the tensioning suture repeatedly with strong manual force to cause maximal load relaxation of the construct, monitoring the tensioner. Consequently, this in situ pre-tensioning technique enables the graft to be fixed under the intended tension that will be maintained after fixation. Then, the graft fixation is completed using the DSP system for hamstring grafts, or either the DSP system or the BTF system for bone-patellar tendon-bone (BTB) grafts.