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Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To assess clinical outcomes of over-the-top (OTT) ACL reconstruction (ACLR) in skeletally mature patients, where physeal sparing is not a consideration. The hypothesis is that OTT will produce successful yet inferior outcomes compared to anatomic ACL approaches in both primary and revision settings.

Methods

Two reviewers searched two online databases (EMBASE and MEDLINE) from inception to October 2017 for literature on OTT ACLR in skeletally mature patients. The systematic screening process was completed in duplicate, independently, and based on predetermined criteria. An expert in the field was consulted to resolve disagreements for full-text screening. Quality assessment of included papers was performed independently and in duplicate.

Results

From 3148 initial studies, 16 eligible studies (three RCTs and 13 case series) satisfied inclusion criteria. Three focused on the revision setting. The mean age of patients undergoing primary reconstruction was 26.9 ± 3.6, with 21.3% female patients and 31.4 ± 1.2 (26.1% female) in revision settings. Of primary studies reporting return to sport (n = 151), 69% of patients returned to pre-injury sports participation, with a total 94% returning to any sports activity. In revision settings (n = 48), 52.1% of patients returned to pre-injury sports participation, 25.2% returned to a lower level and 12.5% ceased sporting activity. Primary reconstruction studies reported a mean post-operative Tegner score of 6.5 ± 0.5 (n = 181) and mean KOOS of 82.8 ± 8.1 (n = 96). Primary studies reported a total 13 graft failures (3.7%), seven of which were re-ruptures (2.0%). The revision failure rate was 8.4% (four patients).

Conclusion

Clinically important outcomes for OTT ACLR are comparable to literature figures for traditional all-inside, transtibial and/or anteromedial portal drilling techniques. This holds true in revision settings.

Level of evidence

IV.

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Authors and Affiliations

  1. DeGroote School of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada

    Mohamed Sarraj

  2. UPMC Center for Sports Medicine, 3200 S. Water St, Pittsburgh, PA, 15203, USA

    Darren de SA, Volker Musahl & Bryson P. Lesniak

  3. Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, Canada

    Ajaykumar Shanmugaraj

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  1. Mohamed Sarraj
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  2. Darren de SA
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  3. Ajaykumar Shanmugaraj
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  4. Volker Musahl
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Correspondence to Darren de SA.

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This review did not involve primary data collection from patients.

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Appendix

Appendix

See Tables 3, 4, 5, 6 and 7.

Table 3 Search strategy
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Table 4 Concomitant lesions and complications by paper
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Table 5 Surgical technique
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Table 6 Outcomes by graft type
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Table 7 Rehabilitation protocols
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Sarraj, M., de SA, D., Shanmugaraj, A. et al. Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review. Knee Surg Sports Traumatol Arthrosc 27, 427–444 (2019). https://doi.org/10.1007/s00167-018-5084-2

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