Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 12, pp 3690–3698 | Cite as

Device-assisted tensioning is associated with lower rates of graft failure when compared to manual tensioning in ACL reconstruction

  • Laura Morrison
  • Chloe Haldane
  • Darren de SA
  • Fawaz Findakli
  • Nicole Simunovic
  • Olufemi R. Ayeni



To describe (1) the current graft tensioning practices in ACL reconstruction (ACLR) and, (2) the failure rates with the use of manual tensioning, or device-assisted tensioning at the time of graft fixation.


The electronic databases MEDLINE, EMBASE, and PubMed were searched independently by two reviewers from database inception to search date on January 21, 2017. Inclusion criteria were studies reporting graft tensioning method and rate of graft failure. The definition of graft failure used was: (1) side-to-side instrumented laxity > 5 mm, (2) Lachman 2 +, (3) positive pivot-shift testing, (4) MRI-confirmed graft rupture or, (5) need for revision surgery.


A total of 3379 patients and 3380 knees were treated with ACL reconstruction and followed for an average of 41.7 months (range 4–145 months). ACLR with manual tensioning was performed on 1518 (51.9%) patients and device-assisted tensioning was performed on 1802 (48.1%) patients. The average knee position reported was 29.2° in single-bundle ACLR and 22.9° in double-bundle ACLR. The median amount of tension used in manual tensioning was ‘maximum manual tension’ and 50 N in device-assisted tensioning. Overall, the failure rate in studies reporting manual tensioning was 8.9% compared to 4.3% in device-assisted tensioning.


Both manual tensioning and device-assisted tensioning are associated with low overall failure rates (< 10%) in ACLR; however, there is a higher rate of reported failure with manual tensioning compared to device-assisted tensioning. These findings highlight the need to investigate variations in graft tensioning practice, such as specific tension devices and their parameters, with high-quality, randomized controlled trials to elucidate details of their clinical impact.

Level of evidence

Level IV, systematic review of level I–IV studies.


Anterior cruciate ligament (ACL) Reconstruction Graft Tension Manual Device 




Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

This is a systematic review of the literature and no ethics approval is required.

Informed consent

For this type of study informed consent is not required.

Supplementary material

167_2018_4951_MOESM1_ESM.docx (19 kb)
Supplementary material 1 (DOCX 19 KB)
167_2018_4951_MOESM2_ESM.docx (28 kb)
Supplementary material 2 (DOCX 28 KB)


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Laura Morrison
    • 1
  • Chloe Haldane
    • 1
  • Darren de SA
    • 2
  • Fawaz Findakli
    • 3
  • Nicole Simunovic
    • 3
  • Olufemi R. Ayeni
    • 4
  1. 1.Michael G. DeGroote School of MedicineHamiltonCanada
  2. 2.UPMC Center for Sports MedicinePittsburghUSA
  3. 3.Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonCanada
  4. 4.Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical CentreMcMaster UniversityHamiltonCanada

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