Over-The-Top Technique for Revision ACL Reconstruction with Achilles Allograft and Associated Lateral Extra-articular Tenodesis

Revision anterior cruciate ligament reconstruction (ACL-R) is made challenging by the frequent presence of rotatory instability, tunnel malpositioning and widening, and limited autograft options. Lateral extra-articular tenodesis (LET), alternative tunnel routing, and the use of allograft tissue can be used to manage these challenges. This Technical Note describes revision ACL-R using the over-the-top (OTT) technique with Achilles tendon allograft with concomitant LET. The surgical approach involves routing the graft around the posterior aspect of the lateral femoral condyle, and then deep to the iliotibial band to a site just medial to Gerdy's tubercle, with staple fixation on the lateral femur for the ACL-R and anterolateral tibia for the LET. The OTT technique with LET provides a versatile approach for the management of failed ACL-R by circumventing challenges in revision ACL-R and addressing rotatory instability, a contributing factor to prior graft failure.