Over-The-Top Technique for Revision ACL Reconstruction with Achilles Allograft and Associated Lateral Extra-articular Tenodesis

Revision anterior cruciate ligament reconstruction (ACL-R) is made challenging by the frequent presence of rotatory instability, tunnel malpositioning and widening, and limited autograft options. Lateral extra-articular tenodesis (LET), alternative tunnel routing, and the use of allograft tissue can be used to manage these challenges. This Technical Note describes revision ACL-R using the over-the-top (OTT) technique with Achilles tendon allograft with concomitant LET. The surgical approach involves routing the graft around the posterior aspect of the lateral femoral condyle, and then deep to the iliotibial band to a site just medial to Gerdy’s tubercle, with staple fixation on the lateral femur for the ACL-R and anterolateral tibia for the LET. The OTT technique with LET provides a versatile approach for the management of failed ACL-R by circumventing challenges in revision ACL-R and addressing rotatory instability, a contributing factor to prior graft failure. Video 1 This video demonstrates the over-the-top (OTT) technique for revision anterior cruciate ligament (ACL) reconstruction with an associated lateral extra-articular tenodesis (LET). The procedure begins with preparation of the allograft. The tendinous portion of the graft is cut to length and a diameter of 10 or 11 mm. The end of the graft is bulletized and a 10- or 11-mm diameter bone block is prepared. An incision is made at the distal aspect of the lateral thigh, taken down to the IT band, and flaps are developed. An incision is made longitudinally, 1 centimeter anterior to the posterior aspect of the IT band. Cautery is used to maintain hemostasis. Dissection is taken down to the posterior aspect of the lateral femoral condyle. Diagnostic arthroscopy may then be performed. The remnant ACL graft is debrided. A Kelly clamp is advanced through the anteromedial portal and around the posterior aspect of the lateral femoral condyle in the OTT position. The Kelly clamp holds the end of a looped wire, which is then grasped out of the lateral thigh incision. As displayed, the prior ACL tunnel with the associated graft is malpositioned. The tibial tunnel is drilled in the anatomic position. A wire shuttles a suture, and this is withdrawn down the tibia. A suture is then used to shuttle the graft into the OTT position, and the graft is secured over the lateral aspect of the distal femur, just posterior to the lateral epicondyle, using two Richards staples (Smith & Nephew, Andover, MA). Further fixatio