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Failure Rates and Complications with Multiple-Revision Anterior Cruciate Ligament Reconstruction: Comparison of Anatomic Femoral Tunnel and Over The Top Technique

Failure Rates and Complications with Multiple-Revision Anterior Cruciate Ligament Reconstruction: Comparison of Anatomic Femoral Tunnel and Over The Top Technique

Emre Anıl Özbek, MD, TURKEY Philipp W. Winkler , MD , AUSTRIA Ehab M Nazzal, MD, UNITED STATES Balint Zsidai, HUNGARY Nicholas P Drain, MD, UNITED STATES Janina Kaarre, MD, MSc, UNITED STATES Andrew Sprague, PT, PhD, DPT, UNITED STATES Bryson P. Lesniak, MD, UNITED STATES Volker Musahl, MD, Prof., UNITED STATES

University of Pittsburgh Orthopaedic Surgery Dep. Sports Medicine Div., Pittsburgh, PA, UNITED STATES

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Summary: The current study identified satisfactory results in terms of failure and complication rates following with multiple-revision ACL-R performed with the Over the Top Technique.


Multiple-revision anterior cruciate ligament reconstruction (ACL-R) presents several technical challenges, often due to residual hardware, tunnel widening, or malposition. The aim of this study was to compare complication rates between over-the-top (OTT) and anteromedial portal drilling (AMD) techniques in patients undergoing multiple-revision ACL-R.


A retrospective cohort study comprised of patients undergoing multiple-revision ACL-R was performed by four sports medicine fellowship trained surgeons in a single institute. Patients with two or more revision ACL-Rs performed with the OTT or AMD techniques were included. Data on patient demographics, graft characteristics, number of revisions, concomitant procedures, complications (arthrofibrosis, septic arthritis, cyclops lesion), and failures were collected. Between-group comparisons of continuous and categorical variables were conducted with independent samples t- tests and Fisher’s exact or the chi-squared test, respectively. Level of significance was set at p < 0.05.


A total of 101 patients undergoing multiple revision ACL-R with OTT (n=37, 37%) and AMD (n=64, 63%) techniques were identified. The mean follow-up period was 60 months (range: 12-196). No statistically significant differences were found in age, gender, body mass index, laterality, or follow-up length (p > 0.05) between the groups. Allograft was the most frequently used graft (n=64, 67.3%) with no significant differences between groups in terms of graft diameter. There were no statistically significant differences between groups regarding rate of concurrent medial meniscus, lateral meniscus, cartilage, or lateral extra-articular tenodesis procedures (p > 0.05). There was also no statistically significant difference in complication rate (OTT: n=2 (5.4%); AMD: n=8 (13%); p > 0.05) or graft failure rate (OTT: n=4 (11%); AMD: n=14 (22%); p > 0.05) between groups.


The results of this study showed notably elevated failure and complication rates in challenging multiple-revision ACL-R. Complication and failure rates were lower in the OTT compared to the AMD technique, however, there were no significant between group differences in these outcomes. In the setting of multiple-revision ACL-R, surgeons may consider the use of the OTT technique.

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