Over-The-Top Technique for ACL Reconstruction: Advantages, Disadvantages, and Postoperative Complications

Abstract

Anterior cruciate ligament (ACL) injuries are the most common knee joint injuries related to sports activities in clinical practice. For treating ACL injuries, anatomical reconstruction surgery is often the preferred method. The over-the-top (OTT) technique is a surgical approach that eliminates the need for creating a femoral tunnel. According to the existing literature, the OTT technique offers distinct advantages, particularly for skeletally immature individuals and in revision cases. Currently, femoral tunnel failure is the most common cause of ACL reconstruction failure, which can lead to less than optimal postoperative performance of the ACL and a higher likelihood of needing a revision. Additionally, mistakes in the placement of the femoral tunnel and the subsequent risk of tunnel enlargement can increase the complexity of revision procedures, ultimately reducing the long-term clinical effectiveness for patients. In contrast, the OTT technique has shown excellent biomechanical performance, avoids the need for bone tunnels, is economically practical, and has been proven to provide satisfactory therapeutic outcomes both in the short and long term, especially for skeletally immature individuals and in revision cases. The OTT technique is deemed a safe and effective surgical method for treating ACL injuries. In summary, the OTT technique has unique benefits for skeletally immature individuals and in revision cases, making it a viable option worth considering. Level of evidence V.

Keywords: advantages; anterior cruciate ligament reconstruction (ACLR); complication; disadvantages; over‐the‐top (OTT).

FIGURE 1

Bertrand Zarins et al.'s OTT single‐bundle technique. Reprinted with permission from Reference [14] Copyright (1986).

FIGURE 2

Anteroposterior view of the combined reconstruction at the end of the procedure. Reprinted with permission from Reference [15] Copyright (1998).

FIGURE 3

The long bundle (blue) is introduced back to the femoral tunnel outside‐in forming an over‐the‐top sling structure of the allograft in over‐the‐top augmentation technique using an Achilles tendon allograft in revision ACL reconstruction. Reprinted with permission from Reference [24] Copyright (2023).

FIGURE 4

The technique used by Roberto Buda et al. in patients undergoing multiple revisions. Reprinted with permission from Reference [23] Copyright (2013).

FIGURE 5

Schematic illustration of the over‐the‐top anterior cruciate ligament reconstruction technique performed using an Achilles tendon allograft with bone block and lateral extraarticular tenodesis. Reprinted with permission from Reference [7] Copyright (2022).

FIGURE 6

(A) Illustration showing that, in the single‐strand hamstrings graft reconstruction group, the remnant part of the graft fixed at the level of the lateral femoral condyle with 1 titanium staple was then resected (red dashed line). (B) Illustration showing that, in the double‐strand hamstrings graft reconstruction group, the graft is retrieved outside the tibial tunnel and fixed at the level of the pes anserinus using nonresorbable stitches. Reprinted with permission from Reference [25] Copyright (2020).

FIGURE 7

The lateral view shows the different orientations of the two reconstructed bundles. This different orientation is performed to obtain better kinematic graft performance. Reprinted with permission from Reference [26] Copyright (2003).

FIGURE 8

Anterior cruciate ligament reconstruction with hamstring tendons plus extra‐articular plasty. (A) anteroposterior view; (B) lateral view. Reprinted with permission from Reference [28] Copyright (2017).