Bone patellar tendon bone grafts for anterior cruciate ligament reconstruction: The effects of graft pretensioning

Viscoelastic creep is a well-know phenomenon associated with collagenous soft tissues under sustained tensile load. Despite our understanding of this phenomenon and the potential for ''loosening'' of the graft over time, pretensioning of bone-patellar tendon-bone (B-PT-B) grafts for reconstruction of the anterior cruciate ligament (ACL) to eliminate this elastic deformation is not commonly practiced. This investigation quantified viscoelastic creep in B-PT-B grafts using both an in vivo and an in vitro model. In vivo, 10-mm B-PT-B grafts were procured and prepared in a standard manner for arthroscopically assisted ACL reconstruction. A total of 153 grafts were evaluated. During preparation, each graft was tensioned using a commercially available graft preparation board (Smith & Nephew DonJoy). An initial tensile load of 2.25 N (0.5 lb) was applied to the graft and a measurement was taken between bone-tendon junctions at either end, A sustained load of 89 N (20 lb) was then applied for a minimum of 4 minutes and the measurement repeated. In the in vitro model, grafts were harvested in a standard manner, then placed in a servohydraulic for tensile loading. A differential variable reluctance transducer was implanted in each graft to quantify net displacement during 15 minutes of sustained tensile loading at 89 N (20 lb). A total of 13 specimens were evaluated. In the in vivo model, mean pretension bone-tendon junction length was 43.6 mm (range, 29 to 64 mm; SD, +/- 6.7). Mean post-tension bone-tendon length was 49.6 mm (range, 33 to 71 mm; SD, +/- 7.1), representing a mean increase in length of 6.0 mm (range, 2 to 12; SD, +/- 2.1) or 14.0% (range, 3.8 to 28.6; SD, +/- 5.2). In the in vitro model, the mean pretension tendon length was 42.81 mm (range, 35.20 to 51.48; SD, 4.54). The mean posttension length was 47.11 mm (range, 38.05 to 56.23; SD, +/- 5.04) representing a mean increase of 4.30 mm or 10.12%. These data would seem to support the hypothesis that without pretensioning, significant postimplantation graft creep will occur.