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 A wire shuttles a suture, and this is withdrawn down the tibia.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 fixation is achieved with a second staple placed just distal to the first. An incision is then made just medial to Gerdy’s tubercle, and dissection is then taken down to the bone. Kelly clamps are used to define the tract for graph passage deep to the IT band from the proximal to distal incision. Kelly clamps are used to shuttle the suture and graft into the distal incision. Tension is placed on the tibial ACL sutures, and the graft is cycled with the knee at 20° of flexion and posterior drawer, as well as firm tension on the tibial ACL sutures. An interference screw (BioSure PK screw 11 mm × 25 mm, Smith & Nephew, Andover, MA) is placed for tibial graft fixation. The tibial aspect of the LET is fixed using a small Richards staple, which must be perpendicular to the bone, and extra-articular. The IT band and skin are closed in a standard layered fashion.
Over-the-Top ACL Reconstruction
Lateral Extra-articular Tenodesis
- Zaffagnini S.
- Roberti di Sarsina T.
- ICMJE author disclosure forms
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The authors report the following potential conflicts of interest or sources of funding: S.Z. reports consulting fees from Smith & Nephew and DePuy Synthes, outside the submitted work. V.M. reports educational support from Smith & Nephew , DePuy Synthes , Arthrex , and ConMed , outside the submitted work; he reports patent number 9,949,684 on April 24, 2018 to the University of Pittsburgh; and he is the Assistant Editor-in-chief of Knee Surgery, Sports Traumatology and Arthroscopy. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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