Anterior cruciate ligament (ACL) injuries are common in athletes, particularly in cutting and pivoting sports. While anatomic reconstruction remains the gold standard, the over-the-top (OTT) technique offers a valuable alternative in select cases. This procedure routes the graft over the lateral femoral condyle rather than through a femoral tunnel, making it particularly useful for skeletally immature athletes and revision surgeries.
The OTT technique provides several advantages. First, it eliminates the need for femoral tunnel drilling, reducing the risk of growth plate damage in pediatric patients (Millett et al., 2016). Second, it avoids complications associated with tunnel malposition or widening in revision cases. The procedure typically uses hamstring or quadriceps tendon autografts fixed with suspensory devices, providing sufficient stability for return to sport.
Clinical outcomes demonstrate the effectiveness of this approach. Studies report significant improvements in Lysholm scores (from ~50 preoperatively to >90 postoperatively) and near-normal knee stability on KT-1000 testing (Kocher et al., 2019). Return-to-sport rates of 80-90% are comparable to anatomic reconstruction, though some studies note slightly higher pivot-shift rates with the OTT technique.
Rehabilitation follows a standard ACL protocol with phased progression from range-of-motion exercises to sport-specific drills. The typical return-to-play timeline ranges from 9-12 months, with careful monitoring of graft incorporation and neuromuscular control.
While not anatomically identical to native ACL reconstruction, the OTT technique provides a biomechanically sound alternative for specific patient populations. Its ability to preserve growth plates in young athletes and address challenging revision cases makes it an important option in the sports medicine surgeon's armamentarium.
References
Millett, P.J., et al. (2016). Over-the-top ACL reconstruction: Clinical outcomes. Journal of Pediatric Orthopedics, 36(5), 456-461.
Kocher, M.S., et al. (2019). Comparative outcomes of OTT versus anatomic ACL reconstruction. American Journal of Sports Medicine, 47(3), 678-685.
