Augmented Over-The-Top Technique for Revision Anterior Cruciate Ligament Reconstruction

Revision anterior cruciate ligament reconstruction is technically demanding, particularly in cases with femoral tunnel malposition or tibial tunnel enlargement. The over-the-top (OTT) technique offers a single-stage solution by avoiding femoral tunnel drilling. However, its main limitation is the reduced graft diameter, typically between 5.5 and 7 mm, which may be insufficient in revision settings. This Technical Note describes an augmentation of the classic OTT technique using a peroneus longus tendon allograft wrapped around preserved-insertion hamstring tendons, achieving graft diameters exceeding 8 mm. Standard arthroscopic portals are used to prepare a standard tibial tunnel, whereas a lateral femoral approach is performed to prepare the OTT point. Femoral fixation is secured with staples, and a lateral extra-articular tenodesis is performed to enhance rotational stability. This combined intra- and extra-articular reconstruction allows single-stage revision even in the presence of tunnel enlargement, improving biomechanical strength and potentially accelerating biological integration through preservation of the tibial insertion. The described technique offers a reliable, reproducible, and cost-effective option for complex anterior cruciate ligament revisions.