Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review
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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.
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.
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).
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
KeywordsOver-the-top Non-anatomic ACL ACL reconstruction Anterior cruciate ligament
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This review did not involve primary data collection from patients.
For this type of study formal consent is not required.
- 3.Asai S, Maeyama A, Hoshino Y, Goto B, Celentano U, Moriyama S, Smolinski P, Fu FH (2014) A comparison of dynamic rotational knee instability between anatomic single-bundle and over-the-top anterior cruciate ligament reconstruction using triaxial accelerometry. Knee Surg Sports Traumatol Arthrosc 22:972–978CrossRefGoogle Scholar
- 7.Buda R, Verni E, Ferruzzi A, Di Caprio F, Giannini S (2005) Anterior cruciate ligament replacement with distally inserted doubled hamstring graft: prospective clinical and instrumental evaluation. Med Sport (Roma) 58:303–311Google Scholar
- 11.Eck CFV, Schkrohowsky JG, Ramirez C, Irrgang JJ, Fu FH, Working Z (2011) Failure rate and predictors of failure after anatomic ACL reconstruction with allograft (SS-61). Arthroscopy 27:e62–e63Google Scholar
- 15.Imbert P, Lustig S, Steltzlen C, Batailler C, Colombet P, Dalmay F, Bertiaux S, D’ingrado P, Ehkirch FP, Louis ML, Pailhé R, Panisset JC, Schlaterrer B, Sonnery-Cottet B, Sigwalt L, Saragaglia D, Lutz C (2017) Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society. Orthop Traumatol Surg Res 103:S215–S221CrossRefGoogle Scholar
- 17.Jonsson H, Elmqvist LG, Kärrholm J, Fugl-Meyer A (1992) Lengthening of anterior cruciate ligament graft. Roentgen stereophotogrammetry of 32 cases 2 years after repair. Acta Orthop Scand 63:587–592Google Scholar
- 20.Kung J, Chiappelli F, Cajulis OO, Avezova R, Kossan G, Chew L, Maida CA (2010) From systematic reviews to clinical recommendations for evidence-based health care: validation of revised assessment of multiple systematic reviews (R-AMSTAR) for grading of clinical relevance. Open Dent J 4:84–91PubMedCentralGoogle Scholar
- 22.Lertwanich P, Kato Y, Martins CAQ, Maeyama A, Ingham SJM, Kramer S, Linde-Rosen M, Smolinski P, Fu FH (2011) A biomechanical comparison of 2 femoral fixation techniques for anterior cruciate ligament reconstruction in skeletally immature patients: over-the-top fixation versus transphyseal technique. Arthroscopy 27:672–680CrossRefGoogle Scholar
- 26.Motohashi M, Uematsu H, Takemura K (1999) Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons with a modified over-the-top method. J Orthop Surg Hong Kong 7(1):47Google Scholar
- 27.Muren O, Dahlstedt L, Dalén N (2003) Reconstruction of acute anterior cruciate ligament injuries: a prospective, randomised study of 40 patients with 7-year follow-up. No advantage of synthetic augmentation compared to a traditional patellar tendon graft. Arch Orthop Trauma Surg 123:144–147CrossRefGoogle Scholar
- 29.Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC (2013) Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy 29:98–105CrossRefGoogle Scholar
- 35.Shantanu K, Kushwaha SS, Kumar D, Kumar V, Singh S, Sharma V (2016) A comparative study of the results of the anatomic medial portal and all-inside arthroscopic ACL reconstruction. J Clin Diagn Res JCDR 10:RC01–RC03Google Scholar
- 39.Svantesson E, Sundemo D, Senorski EH, Alentorn-Geli E, Musahl V, Fu FH, Desai N, Stålman A, Samuelsson K (2017) Double-bundle anterior cruciate ligament reconstruction is superior to single-bundle reconstruction in terms of revision frequency: a study of 22,460 patients from the Swedish National Knee Ligament Register. Knee Surg Sports Traumatol Arthrosc 25:3884–3891CrossRefGoogle Scholar
- 42.Verdano MA, Pedrabissi B, Lunini E, Pellegrini A, Ceccarelli F (2012) Over the top or endobutton for ACL reconstruction? Acta Bio-Medica Atenei Parm 83:127–137Google Scholar
- 45.Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, Roberti di Sarsina T, Raggi F, Signorelli C, Urrizola F, Spinnato P, Rimondi E, Marcacci M (2017) Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up. Am J Sports Med 45:3233–3242CrossRefGoogle Scholar
- 46.Zaffagnini S, Signorelli C, Lopomo N, Bonanzinga T, Marcheggiani Muccioli GM, Bignozzi S, Visani A, Marcacci M (2012) Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 20:153–159CrossRefGoogle Scholar