Chinese expert consensus on anterior cruciate ligament reconstruction using the over-the-top technique (2025 edition)_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 The Consensus Formulation Group for Anterior Cruciate Ligament Reconstruction using the Over-the-top Technique ,  The Knee Group of the Chinese Society of Sports Medicine ,  The Arthroscopy Group of the Chinese Association of Orthopaedic Surgeons

Corresponding?author：

The Consensus Formulation Group for Anterior Cruciate Ligament Reconstruction using the Over-the-top Technique, Email: zhangxintao@163.com; The Knee Group of the Chinese Society of Sports Medicine, Email: wjqsportsmed@l63.com; The Arthroscopy Group of the Chinese Association of Orthopaedic Surgeons, Email: cshiyi@163.com

Keywords：

Anterior cruciate ligament; reconstruction; over-the-top; rotational stability; clinical efficacy; expert consensus

DOI：

10.7507/1002-1892.202512095

Video：

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Objective Initiated by the Knee Group of the Chinese Society of Sports Medicine and the Arthroscopy Group of the Chinese Association of Orthopaedic Surgeons, domestic experts in the field were organized to develop a Chinese expert consensus on anterior cruciate ligament (ACL) reconstruction using the over-the-top (OTT) technique, based on the latest clinical practices and research advancements. This consensus aims to standardize and promote the application of this technique in ACL reconstruction. Methods The consensus was reached using the modified Delphi method and was completed through two rounds of online questionnaire surveys and one round of face-to-face expert meeting discussions. The consensus was jointly formulated by 43 sports medicine experts from grade Ⅲ class A hospitals across 20 provinces, autonomous regions and municipalities of China. Among them, 7 experts served as guiding experts. The consensus drafting team drafted the first draft of the consensus based on evidence-based evidence and transformed it into questionnaire items. The second draft was revised according to the feedback from the first round of questionnaires and discussed, revised and voted on item by item in face-to-face meetings. Items with an approval rate of ≥85% were recognized as having reached a consensus. The consensus terms were categorized as “strong” (approval rate: 95.0%-100%), “moderate” (approval rate: 90.0%-94.9%), and “basic” (approval rate: 85.0%-89.9%). Results All 43 experts completed the entire process and participated in the face-to-face meeting. Ultimately, 9 consensus statements were agreed upon, including 8 highly-consensus items and 1 general consensus item, covering surgical indications, technical key points, and postoperative rehabilitation. Conclusion The ACL OTT reconstruction technique does not require the establishment of a femoral tunnel and demonstrates favorable outcomes in adolescent ACL reconstruction and adult ACL revision, making it a viable surgical option for such patients. However, whether OTT reconstruction should be routinely recommended for primary ACL reconstruction in adults requires further clinical research to confirm its standardized application and ensure clinical efficacy.

Citation： The Consensus Formulation Group for Anterior Cruciate Ligament Reconstruction using the Over-the-top Technique, The Knee Group of the Chinese Society of Sports Medicine, The Arthroscopy Group of the Chinese Association of Orthopaedic Surgeons. Chinese expert consensus on anterior cruciate ligament reconstruction using the over-the-top technique (2025 edition). Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(2): 167-175. doi: 10.7507/1002-1892.202512095 Copy

1.	Wang LJ, Zeng N, Yan ZP, et al. Post-traumatic osteoarthritis following ACL injury. Arthritis Res Ther, 2020, 22(1): 57. doi: 10.1186/s13075-020-02156-5.
2.	Calisti M, Mohr M, Federolf P. Motion capture data of six jump-landings, fatigued and non-fatigued, after anterior cruciate ligament injury. Sci Data, 2025, 12(1): 1645. doi: 10.1038/s41597-025-05934-5.
3.	Tomsan H, Gorbachova T, Fritz RC, et al. Knee MRI: Meniscus roots, ramps, repairs, and repercussions. Radiographics, 2023, 43(7): e220208. doi: 10.1148/rg.220208.
4.	Baez S, Harkey M, Birchmeier T, et al. Psychological readiness, injury-related fear, and persistent knee symptoms after anterior cruciate ligament reconstruction. J Athl Train, 2023, 58(11-12): 998-1003.
5.	Steiner M. Anatomic single-bundle ACL reconstruction. Sports Med Arthrosc Rev, 2009, 17(4): 247-251.
6.	Sroufe MD, Sumpter AE, Thompson XD, et al. Comparison of patient-reported outcomes, strength, and functional performance in primary versus revision anterior cruciate ligament reconstruction. Am J Sports Med, 2023, 51(8): 2057-2063.
7.	Hurley ET, Fried JW, Kingery MT, et al. Antero-lateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 764-771.
8.	Mitsou A, Vallianatos P, Piskopakis N, et al. Anterior cruciate ligament reconstruction by over-the-top repair combined with popliteus tendon plasty. J Bone Joint Surg (Br), 1990, 72(3): 398-404.
9.	Sarraj M, de Sa D, Shanmugaraj A, et al. Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2019, 27(2): 427-444.
10.	Grassi A, Macchiarola L, Lucidi GA, et al. Ten-year survivorship, patient-reported outcome measures, and patient acceptable symptom state after over-the-top hamstring anterior cruciate ligament reconstruction with a lateral extra-articular reconstruction: Analysis of 267 consecutive cases. Am J Sports Med, 2021, 49(2): 374-383.
11.	Niederberger M, K?berich S, members of the DeWiss Network. Coming to consensus: the Delphi technique. Eur J Cardiovasc Nurs, 2021, 20(7): 692-695.
12.	Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650): 924-926.
13.	Demange MK, Camanho GL. Nonanatomic anterior cruciate ligament reconstruction with double-stranded semitendinosus grafts in children with open physes: minimum 15-year follow-up. Am J Sports Med, 2014, 42(12): 2926-2932.
14.	Roberti di Sarsina T, Macchiarola L, Signorelli C, et al. Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes. Knee Surg Sports Traumatol Arthrosc, 2019, 27(2): 498-506.
15.	Lanzetti RM, Pace V, Ciompi A, et al. Over the top anterior cruciate ligament reconstruction in patients with open physes: a long-term follow-up study. Int Orthop, 2020, 44(4): 771-778.
16.	Nagai K, Rothrauff BB, Li RT, et al. Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings. Knee Surg Sports Traumatol Arthrosc, 2020, 28(2): 538-543.
17.	Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. Surgical technique. J Bone Joint Surg (Am), 2006, 88 Suppl 1 Pt 2: 283-293.
18.	Frank JS, Gambacorta PL. Anterior cruciate ligament injuries in the skeletally immature athlete: diagnosis and management. J Am Acad Orthop Surg, 2013, 21(2): 78-87.
19.	Pierce TP, Issa K, Festa A, et al. Pediatric anterior cruciate ligament reconstruction: A systematic review of transphyseal versus physeal-sparing techniques. Am J Sports Med, 2017, 45(2): 488-494.
20.	Chambers CC, Monroe EJ, Allen CR, et al. Partial transphyseal anterior cruciate ligament reconstruction: Clinical, functional, and radiographic outcomes. Am J Sports Med, 2019, 47(6): 1353-1360.
21.	?zbek EA, Winkler PW, Nazzal EM, et al. Failure rates and complications after multiple-revision acl reconstruction: Comparison of the over-the-top and transportal drilling techniques. Orthop J Sports Med, 2023, 11(7): 23259671231186972. doi: 10.1177/23259671231186972.
22.	Zanovello J, Rosso F, Bistolfi A, et al. Combined intra- and extra-articular technique in revision anterior cruciate ligament reconstruction. Joints, 2017, 5(3): 156-163.
23.	Buda R, Ruffilli A, Di Caprio F, et al. Allograft salvage procedure in multiple-revision anterior cruciate ligament reconstruction. Am J Sports Med, 2013, 41(2): 402-410.
24.	Marcacci M, Zaffagnini S, Bonanzinga T, et al. Over-the-top double-bundle revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2012, 20(7): 1404-1408.
25.	Lim S, Park KH, Park DY, et al. Rotational stability can be enhanced in revision anterior cruciate ligament reconstruction using the over-the-top augmentation technique compared to single bundle technique. BMC Sports Sci Med Rehabil, 2023, 15(1): 111. doi: 10.1186/s13102-023-00724-1.
26.	Marcacci M, Zaffagnini S, Iacono F, et al. Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons. Knee Surg Sports Traumatol Arthrosc, 1998, 6(2): 68-75.
27.	Bonanzinga T, Grassi A, Altomare D, et al. High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings. Knee Surg Sports Traumatol Arthrosc, 2022, 30(11): 3681-3688.
28.	Ruffilli A, Buda R, Pagliazzi G, et al. Over-the-top anterior cruciate ligament reconstruction using single- or double-strand hamstrings autograft. Orthopedics, 2015, 38(7): e635-e643.
29.	Zaffagnini S, Bruni D, Marcheggiani Muccioli GM, et al. Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc, 2011, 19(3): 390-397.
30.	Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, et al. Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: Prospective evaluation with 20-year minimum follow-up. Am J Sports Med, 2017, 45(14): 3233-3242.
31.	Zaffagnini S, Marcheggiani Muccioli GM, Signorelli C, et al. Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis. Am J Sports Med, 2014, 42(3): 708-715.
32.	Zaffagnini S, Lucidi GA, Macchiarola L, et al. The 25-year experience of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: the story so far. J Exp Orthop, 2023, 10(1): 36. doi: 10.1186/s40634-023-00599-8.
33.	Du H, Li L, Qin Z, et al. Over-the-top technique for ACL reconstruction: Advantages, disadvantages, and postoperative complications. Orthop Surg, 2025, 17(2): 333-347.
34.	Guo J, Zhang P, Lv M, et al. Over-the-top double-bundle revision anterior cruciate ligament reconstruction technique with hybrid hamstring tendon autograft-allograft and associated lateral extra-articular tenodesis. Arthrosc Tech, 2024, 13(5): 102944. doi: 10.1016/j.eats.2024.102944.
35.	Zsidai B, Engler ID, Pujol O, et al. Over-the-top technique for revision ACL reconstruction with Achilles allograft and associated lateral extra-articular tenodesis. Arthrosc Tech, 2022, 11(9): e1633-e1640.
36.	Gaunder C, Campbell S, Sciortino M, et al. Incidence of anterolateral ligament tears in the anterior cruciate ligament-deficient knee: A magnetic resonance imaging analysis. Arthroscopy, 2018, 34(7): 2170-2176.
37.	Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med, 2020, 48(2): 285-297.
38.	Pfeiffer TR, Burnham JM, Kanakamedala AC, et al. Distal femur morphology affects rotatory knee instability in patients with anterior cruciate ligament ruptures. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1514-1519.
39.	Shiwaku K, Suzuki T, Shino K, et al. A biomechanical comparison of 2 over-the-top anterior cruciate ligament reconstruction techniques: A cadaveric study using a robotic simulator. Orthop J Sports Med, 2022, 10(12): 23259671221139876. doi: 10.1177/23259671221139876.
40.	O’Brien DF, Fones L, Stoj V, et al. Confirming proper button deployment of suspensory fixation during ACL reconstruction. Orthop J Sports Med, 2021, 9(1): 2325967120974349. doi: 10.1177/2325967120974349.
41.	Richards JA, Mays LM, Woodard DR, et al. Modified macintosh (over-the-top iliotibial band autograft) technique for pediatric anterior cruciate ligament reconstruction using knotless all-suture anchor fixation. Arthrosc Tech, 2024, 14(2): 103204. doi: 10.1016/j.eats.2024.103204.
42.	Steiner ME, Wing D, Walley KC, et al. Hyperflexion and femoral interference screw insertion in ACL reconstruction. Orthop J Sports Med, 2018, 6(8): 2325967118788810. doi: 10.1177/2325967118788810.
43.	Chen CF, Qian SY, Li T, et al. Which graft is associated with better outcomes in ACL reconstruction? A systematic review and network meta-analysis of randomized controlled trials. Clin Orthop Relat Res, 2025, 483(12): 2334-2349.
44.	Jia ZY, Zhang C, Cao SQ, et al. Comparison of artificial graft versus autograft in anterior cruciate ligament reconstruction: a meta-analysis. BMC Musculoskelet Disord, 2017, 18(1): 309. doi: 10.1186/s12891-017-1672-4.
45.	Mascarenhas R, Erickson BJ, Sayegh ET, et al. Is there a higher failure rate of allografts compared with autografts in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses. Arthroscopy, 2015, 31(2): 364-372.
46.	Romanini E, D’Angelo F, De Masi S, et al. Graft selection in arthroscopic anterior cruciate ligament reconstruction. J Orthop Traumatol, 2010, 11(4): 211-219.
47.	Nedder VJ, Raju AG, Moyal AJ, et al. Impact of psychological factors on rehabilitation after anterior cruciate ligament reconstruction: A systematic review. Sports Health, 2025, 17(2): 291-298.
48.	Milewski MD, Traver JL, Coene RP, et al. Effect of age and sex on psychological readiness and patient-reported outcomes 6 months after primary ACL reconstruction. Orthop J Sports Med, 2023, 11(6): 23259671231166012. doi: 10.1177/23259671231166012.
49.	Kamei G, Nakamae A, Nakata K, et al. Comparison of clinical outcomes between anterior cruciate ligament reconstruction with over-the-top route procedure and anatomic single-bundle reconstruction in pediatric patients. J Pediatr Orthop B, 2023, 32(2): 178-184.
50.	Rousseau R, Labruyere C, Kajetanek C, et al. Complications after anterior cruciate ligament reconstruction and their relation to the type of graft: A prospective study of 958 cases. Am J Sports Med, 2019, 47(11): 2543-2549.
51.	Kamei G, Nakamae A, Ishikawa M, et al. Equivalent outcomes of ACL revision with over-the-top single and double-bundle reconstruction using hamstring tendon compared to anatomical single and double-bundle reconstruction. J Exp Orthop, 2022, 9(1): 33. doi: 10.1186/s40634-022-00472-0.
52.	Min BH, Song HK, Park KH, et al. Biomechanical evaluation of modified ACL reconstruction with over-the-top augmentation technique. Indian J Orthop, 2022, 56(5): 812-820.

1. Wang LJ, Zeng N, Yan ZP, et al. Post-traumatic osteoarthritis following ACL injury. Arthritis Res Ther, 2020, 22(1): 57. doi: 10.1186/s13075-020-02156-5.
2. Calisti M, Mohr M, Federolf P. Motion capture data of six jump-landings, fatigued and non-fatigued, after anterior cruciate ligament injury. Sci Data, 2025, 12(1): 1645. doi: 10.1038/s41597-025-05934-5.
3. Tomsan H, Gorbachova T, Fritz RC, et al. Knee MRI: Meniscus roots, ramps, repairs, and repercussions. Radiographics, 2023, 43(7): e220208. doi: 10.1148/rg.220208.
4. Baez S, Harkey M, Birchmeier T, et al. Psychological readiness, injury-related fear, and persistent knee symptoms after anterior cruciate ligament reconstruction. J Athl Train, 2023, 58(11-12): 998-1003.
5. Steiner M. Anatomic single-bundle ACL reconstruction. Sports Med Arthrosc Rev, 2009, 17(4): 247-251.
6. Sroufe MD, Sumpter AE, Thompson XD, et al. Comparison of patient-reported outcomes, strength, and functional performance in primary versus revision anterior cruciate ligament reconstruction. Am J Sports Med, 2023, 51(8): 2057-2063.
7. Hurley ET, Fried JW, Kingery MT, et al. Antero-lateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 764-771.
8. Mitsou A, Vallianatos P, Piskopakis N, et al. Anterior cruciate ligament reconstruction by over-the-top repair combined with popliteus tendon plasty. J Bone Joint Surg (Br), 1990, 72(3): 398-404.
9. Sarraj M, de Sa D, Shanmugaraj A, et al. Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2019, 27(2): 427-444.
10. Grassi A, Macchiarola L, Lucidi GA, et al. Ten-year survivorship, patient-reported outcome measures, and patient acceptable symptom state after over-the-top hamstring anterior cruciate ligament reconstruction with a lateral extra-articular reconstruction: Analysis of 267 consecutive cases. Am J Sports Med, 2021, 49(2): 374-383.
11. Niederberger M, K?berich S, members of the DeWiss Network. Coming to consensus: the Delphi technique. Eur J Cardiovasc Nurs, 2021, 20(7): 692-695.
12. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008, 336(7650): 924-926.
13. Demange MK, Camanho GL. Nonanatomic anterior cruciate ligament reconstruction with double-stranded semitendinosus grafts in children with open physes: minimum 15-year follow-up. Am J Sports Med, 2014, 42(12): 2926-2932.
14. Roberti di Sarsina T, Macchiarola L, Signorelli C, et al. Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes. Knee Surg Sports Traumatol Arthrosc, 2019, 27(2): 498-506.
15. Lanzetti RM, Pace V, Ciompi A, et al. Over the top anterior cruciate ligament reconstruction in patients with open physes: a long-term follow-up study. Int Orthop, 2020, 44(4): 771-778.
16. Nagai K, Rothrauff BB, Li RT, et al. Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings. Knee Surg Sports Traumatol Arthrosc, 2020, 28(2): 538-543.
17. Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. Surgical technique. J Bone Joint Surg (Am), 2006, 88 Suppl 1 Pt 2: 283-293.
18. Frank JS, Gambacorta PL. Anterior cruciate ligament injuries in the skeletally immature athlete: diagnosis and management. J Am Acad Orthop Surg, 2013, 21(2): 78-87.
19. Pierce TP, Issa K, Festa A, et al. Pediatric anterior cruciate ligament reconstruction: A systematic review of transphyseal versus physeal-sparing techniques. Am J Sports Med, 2017, 45(2): 488-494.
20. Chambers CC, Monroe EJ, Allen CR, et al. Partial transphyseal anterior cruciate ligament reconstruction: Clinical, functional, and radiographic outcomes. Am J Sports Med, 2019, 47(6): 1353-1360.
21. ?zbek EA, Winkler PW, Nazzal EM, et al. Failure rates and complications after multiple-revision acl reconstruction: Comparison of the over-the-top and transportal drilling techniques. Orthop J Sports Med, 2023, 11(7): 23259671231186972. doi: 10.1177/23259671231186972.
22. Zanovello J, Rosso F, Bistolfi A, et al. Combined intra- and extra-articular technique in revision anterior cruciate ligament reconstruction. Joints, 2017, 5(3): 156-163.
23. Buda R, Ruffilli A, Di Caprio F, et al. Allograft salvage procedure in multiple-revision anterior cruciate ligament reconstruction. Am J Sports Med, 2013, 41(2): 402-410.
24. Marcacci M, Zaffagnini S, Bonanzinga T, et al. Over-the-top double-bundle revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2012, 20(7): 1404-1408.
25. Lim S, Park KH, Park DY, et al. Rotational stability can be enhanced in revision anterior cruciate ligament reconstruction using the over-the-top augmentation technique compared to single bundle technique. BMC Sports Sci Med Rehabil, 2023, 15(1): 111. doi: 10.1186/s13102-023-00724-1.
26. Marcacci M, Zaffagnini S, Iacono F, et al. Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons. Knee Surg Sports Traumatol Arthrosc, 1998, 6(2): 68-75.
27. Bonanzinga T, Grassi A, Altomare D, et al. High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings. Knee Surg Sports Traumatol Arthrosc, 2022, 30(11): 3681-3688.
28. Ruffilli A, Buda R, Pagliazzi G, et al. Over-the-top anterior cruciate ligament reconstruction using single- or double-strand hamstrings autograft. Orthopedics, 2015, 38(7): e635-e643.
29. Zaffagnini S, Bruni D, Marcheggiani Muccioli GM, et al. Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc, 2011, 19(3): 390-397.
30. Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, et al. Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: Prospective evaluation with 20-year minimum follow-up. Am J Sports Med, 2017, 45(14): 3233-3242.
31. Zaffagnini S, Marcheggiani Muccioli GM, Signorelli C, et al. Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis. Am J Sports Med, 2014, 42(3): 708-715.
32. Zaffagnini S, Lucidi GA, Macchiarola L, et al. The 25-year experience of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: the story so far. J Exp Orthop, 2023, 10(1): 36. doi: 10.1186/s40634-023-00599-8.
33. Du H, Li L, Qin Z, et al. Over-the-top technique for ACL reconstruction: Advantages, disadvantages, and postoperative complications. Orthop Surg, 2025, 17(2): 333-347.
34. Guo J, Zhang P, Lv M, et al. Over-the-top double-bundle revision anterior cruciate ligament reconstruction technique with hybrid hamstring tendon autograft-allograft and associated lateral extra-articular tenodesis. Arthrosc Tech, 2024, 13(5): 102944. doi: 10.1016/j.eats.2024.102944.
35. Zsidai B, Engler ID, Pujol O, et al. Over-the-top technique for revision ACL reconstruction with Achilles allograft and associated lateral extra-articular tenodesis. Arthrosc Tech, 2022, 11(9): e1633-e1640.
36. Gaunder C, Campbell S, Sciortino M, et al. Incidence of anterolateral ligament tears in the anterior cruciate ligament-deficient knee: A magnetic resonance imaging analysis. Arthroscopy, 2018, 34(7): 2170-2176.
37. Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med, 2020, 48(2): 285-297.
38. Pfeiffer TR, Burnham JM, Kanakamedala AC, et al. Distal femur morphology affects rotatory knee instability in patients with anterior cruciate ligament ruptures. Knee Surg Sports Traumatol Arthrosc, 2019, 27(5): 1514-1519.
39. Shiwaku K, Suzuki T, Shino K, et al. A biomechanical comparison of 2 over-the-top anterior cruciate ligament reconstruction techniques: A cadaveric study using a robotic simulator. Orthop J Sports Med, 2022, 10(12): 23259671221139876. doi: 10.1177/23259671221139876.
40. O’Brien DF, Fones L, Stoj V, et al. Confirming proper button deployment of suspensory fixation during ACL reconstruction. Orthop J Sports Med, 2021, 9(1): 2325967120974349. doi: 10.1177/2325967120974349.
41. Richards JA, Mays LM, Woodard DR, et al. Modified macintosh (over-the-top iliotibial band autograft) technique for pediatric anterior cruciate ligament reconstruction using knotless all-suture anchor fixation. Arthrosc Tech, 2024, 14(2): 103204. doi: 10.1016/j.eats.2024.103204.
42. Steiner ME, Wing D, Walley KC, et al. Hyperflexion and femoral interference screw insertion in ACL reconstruction. Orthop J Sports Med, 2018, 6(8): 2325967118788810. doi: 10.1177/2325967118788810.
43. Chen CF, Qian SY, Li T, et al. Which graft is associated with better outcomes in ACL reconstruction? A systematic review and network meta-analysis of randomized controlled trials. Clin Orthop Relat Res, 2025, 483(12): 2334-2349.
44. Jia ZY, Zhang C, Cao SQ, et al. Comparison of artificial graft versus autograft in anterior cruciate ligament reconstruction: a meta-analysis. BMC Musculoskelet Disord, 2017, 18(1): 309. doi: 10.1186/s12891-017-1672-4.
45. Mascarenhas R, Erickson BJ, Sayegh ET, et al. Is there a higher failure rate of allografts compared with autografts in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses. Arthroscopy, 2015, 31(2): 364-372.
46. Romanini E, D’Angelo F, De Masi S, et al. Graft selection in arthroscopic anterior cruciate ligament reconstruction. J Orthop Traumatol, 2010, 11(4): 211-219.
47. Nedder VJ, Raju AG, Moyal AJ, et al. Impact of psychological factors on rehabilitation after anterior cruciate ligament reconstruction: A systematic review. Sports Health, 2025, 17(2): 291-298.
48. Milewski MD, Traver JL, Coene RP, et al. Effect of age and sex on psychological readiness and patient-reported outcomes 6 months after primary ACL reconstruction. Orthop J Sports Med, 2023, 11(6): 23259671231166012. doi: 10.1177/23259671231166012.
49. Kamei G, Nakamae A, Nakata K, et al. Comparison of clinical outcomes between anterior cruciate ligament reconstruction with over-the-top route procedure and anatomic single-bundle reconstruction in pediatric patients. J Pediatr Orthop B, 2023, 32(2): 178-184.
50. Rousseau R, Labruyere C, Kajetanek C, et al. Complications after anterior cruciate ligament reconstruction and their relation to the type of graft: A prospective study of 958 cases. Am J Sports Med, 2019, 47(11): 2543-2549.
51. Kamei G, Nakamae A, Ishikawa M, et al. Equivalent outcomes of ACL revision with over-the-top single and double-bundle reconstruction using hamstring tendon compared to anatomical single and double-bundle reconstruction. J Exp Orthop, 2022, 9(1): 33. doi: 10.1186/s40634-022-00472-0.
52. Min BH, Song HK, Park KH, et al. Biomechanical evaluation of modified ACL reconstruction with over-the-top augmentation technique. Indian J Orthop, 2022, 56(5): 812-820.

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