Rizzoli Over-The-Top ACL Reconstruction

This is a collection of literature on the Over-the-Top (OTT) ACL Reconstruction Technique.

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The Rizzoli Over-the-Top ACL Reconstruction: When the leading technical cause of ACL failure is femur tunnel malposition, the most reliable solution may be simple: Don’t drill one. The OTT technique offers reproducible stability with 20+ year follow-up.

OTT 🔪 Technique Guides and Videos
OTT 📈 Outcome Studies
Prof Zaffagnini ⚽️ Case Series
OTT 🩸 Vascularity and Graft Healing
OTT 🎯 is Close-to-Anatomic
OTT 🎙️ Special Editorials/ Commentaries
OTT🔬 Biomechanical Studies
OTT ✅ Comparison Studies
🪛Understanding Femur Tunnel Malposition

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START HERE!

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25 Years of Rizzoli OTT Review 🎉 (JEO 2023, Zaffagnini et al.)

OTT 🔪 Technique Guides and Videos

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📹 Original Standard OTT Technique Guide (KSSTA 1998, Marcacci et al.)

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📹 Revision Achilles Allograft OTT Technique (Arthroscopy Techniques 2022, Zsidai et al.)

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📹 Augmented Over-The-Top for Revision ACL (Arthroscopy Techniques 2025, Perelli et al.,)

OTT for Paediatric Techniques

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1️⃣ [Do we need surgery?] BABY-Knee Algorithm: MRI-Guided Decision Tool for Pediatric ACL Injuries (JEO 2025, Grassi et al.)

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2️⃣ [Which surgical technique?] OTT ACL Algorithm for Skeletally Immature Patients (KSSTA 2025, Grassi et al.)

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3️⃣ Paediatric ACL Injury: Current Concepts (JEO 2025, Grassi et al.)

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📹 Supraphyseal OTT Video (AAOS Video Theatre 2014, Marcacci et al.)

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📹 Supraphyseal OTT Video (AAOS Video Theatre 2026 Award-Winner Grassi et al.)

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📹 Extraphyseal OTT - Without Hardware And Tunnels (WHAT) Technique (Arthroscopy Techniques 2025, Grassi et al.)

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📹 OTT + Anterolateral Ligament (ALL) Reconstruction (Arthroscopy Techniques 2025, Helito et al.)

OTT Plus Procedures

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📹 OTT + Slope Reducing HTO (Arthrosc Tech 2022, Zsidai et al.)

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📹 OTT + Closing Wedge HTO (Zaffagnini et al.)

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Youtube Playlist

OTT 📈 Outcome Studies

General Population

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2 Year Outcomes (KSSTA 1998, Marcacci et al.)

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10-Year PROMs & Survivorship (AJSM 2021, Grassi et al.)

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Contralateral ACL Injury More Common Than Graft Failure After OTT Reconstruction (AJSM 2020, Grassi et al.)

Ultra Long Term Follow Up

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5–7 Year Follow-up (KSSTA 2003, Marcacci et al.)

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10–13 Year Follow-up (AJSM 2009, Marcacci et al.)

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20 Year Follow-up (AJSM 2017, Zaffagnini et al.)

Elite Athletes Follow Up

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12 Year Follow up in Pro Soccer Players (KSSTA 2022, Bonanzinga et al.)

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Return to Sport in Elite Soccer Players (OJSM, 2025, Grassi et al.)

Pediatric Athletes Follow Up

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Skeletally Immature 2 Year Follow-up (KSSTA 2019, Fu et al.)

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Supraphyseal OTT 4 year Follow- up (KSSTA 2018, Roberti di Sarsina et al.)

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Physeal Sparing OTT 8 years Follow-up (International Orthopaedics 2020, Lanzetti et al.)

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Physeal-sparing OTT 8–17 Year Follow-up (OJSM 2025, Grassi et al.)

Revision ACL Reconstruction Follow Up

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Revision 2 Year Follow-up (KSSTA 2019, Fu et al.)

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OTT Allograft Salvage in Multiple Revision ACL; 3 Year F/U (AJSM 2013, Buda et al.)

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OTT Revision ACL Provides Acceptable Mid-Term Outcomes (Joints 2017, Zanovello et al.)

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OTT Compared to SB Revision with separate LET (KSSTA 2019, Grassi et al.)

OTT + Lateral Closing Wedge HTO Follow Up

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OTT + Lateral Closing Wedge HTO: 14-Year Outcomes (KSSTA 2023, Agostinone et al.)

Prof Zaffagnini ⚽️ Case Series

Trusted at the Highest Level (Public Sources)

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Many More

OTT 🩸 Vascularity and Graft Healing

Anatomical Dissection

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Vascularity & Neuroreceptors of the Pes Anserinus (Clinical Anatomy 2003, Zaffagnini et al.)

Animal Studies

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Attached vs Detached Semitendinosus ACL Graft Rabbits (AJSM 2018, Liu et al.)

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Preserving Tibial Insertion Prevents Early Graft Necrosis in Rabbits (KSSTA 2007, Papachristou et al.)

In-Vivo MRI Studies

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Tibial Insertion Preservation Enhances MRI Ligamentization (Eur J Orthop Surg Traumatol 2016, Ruffilli et al.)

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Preserving Hamstring Tibial Insertion Improves Early MRI Graft Maturity (AJSM 2018, Liu et al.)

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Better Early MRI Features with Tibial Insertion Preserved (KSSTA 2020, Grassi et al.)

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Earlier and More Stable Graft Maturation With Insertion-Preserved Hamstrings (Am J Sports Med 2020, Zhang et al.)

OTT 🎯 is Close-to-Anatomic

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Is Over-The-Top Reconstruction Anatomical?

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Answer 👇

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Coming

OTT 🎙️ Special Editorials/ Commentaries

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“Keep it simple. Keep it safe.” (Arthroscopy 2021, Zaffagnini et al.)

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“No femur tunnel. No malposition. No tunnel-driven failure.” (Arthroscopy 2024, Lucidi et al.)

OTT🔬 Biomechanical Studies

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OTT Reduces Coupled Tibial Translation (KSSTA 2009, Bignozzi et al.)

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OTT vs Non-Anatomic Double Bundle (NADB): Static Similar, Dynamic Different ( KSSTA 2012, Zaffagnini et al.)

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OTT vs Single Bundle vs NADB: OTT Provides Greater Static Laxity Reduction Than SB and Non-Anatomic DB (Clin Biomech 2019, Grassi et al.)

OTT ✅ Comparison Studies

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20-Year RCT: OTT vs SB-HT vs BPTB (OJSM 2025, Lucidi et al.)

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Systematic Review: OTT vs Traditional ACL Reconstruction (KSSTA 2018, Sarraj et al.)

🪛Understanding Femur Tunnel Malposition

Femur Tunnel Malposition - No. 1 Cause of Technical Failure

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Tunnel Placement Was the Leading Technical Cause of ACL Graft Failure (Clin Orthop Relat Res 1996, Johnson, Swenson, Irrgang, Fu, Harner)

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Femoral Tunnel Malposition as a Major Cause of ACL Reconstruction Failure (The Knee 2004, Taggart et al.)

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Tunnel Malposition in Failed ACL Reconstructions (Arthroscopy 2006, Garofalo et al.)

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Femur Tunnel Malposition is leading cause of technical ACL failure (AJSM 2010, MARS Group)

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Femoral Tunnel Malposition Is the Leading Cause of Failed ACL Reconstruction (KSSTA 2011, Trojani et al.)

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Femur Tunnel Malposition in Revision ACL Reconstruction (J Knee Surg 2012, Morgan et al.)

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Femur Tunnel Malposition Drives Technical Failure (Arch Orthop Trauma Surg 2018, Jaecker et al.)

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Femur Tunnel Malposition Increases Risk of Revision ACLR (KSSTA 2021, Byrne et al.)

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Femur Tunnel Malpostion Increases Long-Term ACL Failure (KSSTA 2022, de Mees et al.)

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Femur Tunnel Malposition Influences ACL Failure Risk (The Knee 2022, Tecame et al.)

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Femur Tunnel Malposition Predicts ACLR Failure (Arthroscopy 2024, Shi et al.)

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Tunnel Malposition in 18.8% of Failed ACL Reconstruction (Medicine 2025, Jin et al.)

Why? High Variability in Femur ACL Footprint

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Complex Anatomy of the ACL Femoral Footprint (Am J Sports Med 2006, Zantop et al.)

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Variability in Arthroscopic Femoral Tunnel Landmarks (Arthroscopy 2012, Piefer et al.)

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Large Variability in the Native ACL Femoral Footprint (Arthroscopy 2011, Kopf et al.)

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The Native ACL Has a Ribbon-Like Femoral Attachment (Am J Sports Med 2014, Śmigielski et al.)

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High Variability of the Femur ACL Center Challenges Surgeons (Knee 2021, Dimitriou et al.)

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Population Differences in the ACL Femoral Footprint (OJSM, Wang et al. 2025)

Why? Surgeons Cannot Identify Femur ACL Footprint Reliably

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Surgeons Cannot Reliably Identify Femur ACL Landmarks on 3D Models (Arthrosc Sports Med Rehabil 2020, Laverdiere et al.)

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3D MRI Shows Surgeons Often Misses the Native Femur Footprint (AJSM 2017, Hart et al.)

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Reliability of Identifying the Femoral ACL Footprint on MRI (BMC Musculoskeletal Disorders 2021, Zee et al.)

Does AM portal drilling address this? Yes. But not consistently.

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Deep Femoral Tunnel Position Can Be Achieved With Different Techniques (Arthroscopy 1999, Giron et al.)

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Increased Revision Risk With AM Femoral Tunnel Drilling (Arthroscopy 2013, Rahr-Wagner et al.)

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High Rates of Non-Anatomic Tunnel Placement in both TT and AM drilling (Arch Orthop Trauma Surg 2017, Jaecker et al.)

“Anatomic” ACL Reconstruction?

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Rebranding the “Anatomic” ACL Reconstruction (J ISAKOS 2023, Borque et al.)

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Isn’t It Time to Stop Pretending Ligament Reconstructions Are “Anatomic”? (Sports Health 2025, Williams & Borque)

Solution: Consider Rizzoli OTT

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👉 “No femur tunnel. No malposition. No tunnel-driven failure.” (Arthroscopy 2024, Lucidi et al.)