Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 2, pp 427–444 | Cite as

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

  • Mohamed Sarraj
  • Darren de SAEmail author
  • Ajaykumar Shanmugaraj
  • Volker Musahl
  • Bryson P. Lesniak



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



Over-the-top Non-anatomic ACL ACL reconstruction Anterior cruciate ligament 



No funding

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This review did not involve primary data collection from patients.

Informed consent

For this type of study formal consent is not required.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.DeGroote School of MedicineMcMaster UniversityHamiltonCanada
  2. 2.UPMC Center for Sports MedicinePittsburghUSA
  3. 3.Faculty of Health SciencesMcMaster UniversityHamiltonCanada

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