Review on tension in the natural and reconstructed anterior cruciate ligament

This article reviews the methodology and results of published studies concerned with tension in the natural and reconstructed anterior cruciate ligament (ACL). This also includes studies of fiber length changes with knee motion and the relationships between graft tunnel placements and isometricity. Little work has been done in vivo: in humans, length changes of the anterior ACL fibers have been measured at operation, while animal longitudinal studies have been few and have given conflicting results. Work in vitro has used many methods to study ACL tension directly or indirectly, via length changes in fibers, but many authors have reported variable results, caused partly by inter-specimen differences and lack of control of forces or kinematics. It seems likely that different grafts require different peroperative tensions to restore normal stability when measured immediately after application at one knee position. But graft placement and the angle at which tensioning is performed also matter. Over-tensioning constrains knees under load cycling. Similarly, it is difficult to measure and therefore also to decide how tension should be distributed between an ACL graft and and augmentation to the graft. It was concluded that the published studies provide many guidelines for the effects of different graft placements or tensioning protocols but, overall, there is little firm evidence on which to recommend any particular ACL reconstruction protocol.