Seventy-seven patients undergoing ACL reconstruction with either patellar tendon or hamstring autografts were randomized to receive either high initial graft tension (n=21) or low initial graft tension (n=26). A matched control group of thirty uninjured individuals was also included. The primary outcome of interest was medial joint space width (mJSW) to assess radiographic PTOA. Secondary outcomes included OARSI and WORMS imaging scores, KOOS composite and subscale scores, and measures of AP knee laxity, functional performance (single-leg hop), and clinical examination (IKDC). Outcomes were assessed 15 years postoperatively. Overall, the results of the study revealed no significant differences in PTOA-related outcomes between the high- and low-tension groups, but both groups showed worse imaging and symptomatic outcomes compared to controls. These findings suggest that ACL reconstruction, regardless of graft tension, increases the risk of developing PTOA and symptomatic knee dysfunction over time.