Special Populations Follow-Up

https://pubmed.ncbi.nlm.nih.gov/35451640/

• 👥 Patient population: 28 professional male footballers (33 ACLRs), mean age 25.3 years; mean follow-up 12.6 years. All reconstructions used hamstrings with over-the-top techniques
• ⚽ Return to play:
• 97% returned to sport
• 94% played an official match
• First match at 8.0 ± 3.6 months
• 📊 Long-term function:

Mean Lysholm 94.2 ± 8.3 at >12 years

• 🔁 Re-rupture rate:

3/33 ACLRs (9%) overall; 6% ipsilateral revision at 1–5 years

• 🔄 Contralateral risk:

21% sustained contralateral ACL injury during follow-up; 32% had bilateral ACL injury across career

• 🏆 Career durability:

82% still competing professionally at 3 seasons; many sustained long careers despite high pivoting demands

https://pmc.ncbi.nlm.nih.gov/articles/PMC12678718/

📚 Study design

• Retrospective case series (Level IV)
• 58 elite professional soccer players undergoing ACL reconstruction at Rizzoli.

🔧 Technique

• Hamstring autograft ACL reconstruction
• Techniques included Over-the-Top (OTT) ± lateral tenodesis and double-bundle reconstructions.

⚽ Return to play

• 96.6% returned to play
• 6.4 months to training, 7.5 months to official match.

📈 Performance

• 53% played >20 matches in season 1
• 65% played >20 matches in season 2
• Most athletes recovered pre-injury participation by the second season.

⚠️ Second ACL injury

• 15.8% overall second ACL injury rate
• Contralateral injury (10.5%) > graft failure (5.3%).

⏱ Key risk factor

• Returning to match before 5 months significantly increased reinjury risk, especially in athletes <21 years.

✅ Takeaway

• ACL reconstruction using hamstring grafts with OTT techniques enables near-universal return to elite sport with durable outcomes.

https://pubmed.ncbi.nlm.nih.gov/31549207/

• 👥 Patient population: 35 patients, mean follow-up 2.2 years
• 14 skeletally immature adolescents (primary ACLR; age 14±1)
• 21 skeletally mature adults (revision ACLR; age 25±8)
• No previous lateral extra-articular tenodesis performed
• 📏 Anterior laxity significantly improved:
• Adolescents: 3.9 → 1.2 mm SSD (p=0.040)
• Revision: 4.2 → 1.2 mm SSD (p<0.001)
• 🔄 Rotatory stability restored:

Significant improvement in Lachman and pivot-shift grades in both groups

• 💥 Graft failure rate:
• Adolescents: 14.3% (2/14)
• Revision: 4.8% (1/21)

All due to new trauma ≥1 year post-op

• 🦴 Key advantage:

Avoids femoral physeal violation in adolescents and enables one-stage revision in cases with tunnel widening or overlap

https://pubmed.ncbi.nlm.nih.gov/30209520/

• 👥 Patient population: 20 athletes (age 8–13 years, Tanner I–IV) with open proximal tibial physes; mean follow-up 54 months.
• 📊 Marked clinical improvement:
• Lysholm improved from 40 → 100
• KOOS improved from 59 → 99
• 19/20 IKDC A; 1 IKDC B
• 📏 Excellent objective stability:
• Median KT-1000 side-to-side difference: 0.0 mm
• All pivot shift grade I
• No patient with >5 mm laxity
• ⚽ Return to sport:
• 100% returned to sport
• 60% returned to pre-injury level
• 30% returned to competitive level
• 🦴 Growth disturbances:
• 3 minor cases (≤1 cm LLD or ≤4° varus)
• No graft failures reported
• 🎯 Takeaway:

The all-epiphyseal OTT + lateral tenodesis technique provides excellent stability, high return-to-sport, and minimal growth disturbance risk in pediatric patients.

https://pubmed.ncbi.nlm.nih.gov/31993711/

👥 Patient population

• 42 skeletally immature patients with ACL rupture
• 30 males, 12 females
• Mean age 12.5 years (range 11–14).

🔧 Technique

• Over-the-Top ACL reconstruction with lateral extra-articular tenodesis (LET)
• All surgeries performed by a single surgeon with standardized rehabilitation.

⏱ Follow-up

• Mean follow-up 96.1 months (~8 years).

📊 Clinical outcomes

• Tegner-Lysholm improved from 55 → 94.8
• Pedi-IKDC improved from 40 → 94.78
• Mean side-to-side laxity 1.2 mm (KT-1000).

⚽ Return to sport

• 22 patients returned to pre-injury sport level
• Average return to sport 7.3 months.

⚠️ Safety

• No instability or leg-length discrepancy reported
• Low complication rate and no hardware failure.

💡 Key message

• Physeal-sparing OTT ACL reconstruction with LET provides excellent long-term outcomes and appears safe and effective in skeletally immature patients.

https://pmc.ncbi.nlm.nih.gov/articles/PMC12673041/

👥 Patient population

• 43 skeletally immature patients (mean age 13.3 years)
• Treated with physeal-sparing OTT ACL reconstruction + LET
• Mean follow-up: 11 years (range 8–17 years).

📈 Graft survivorship

• 90% survivorship from ACL revision at 10 and 15 years
• Revision ACL reconstruction occurred in 9% of patients.

🔧 Reoperations

• 26% required ipsilateral reoperation
• Most common reason: staple removal due to local discomfort.

⚠️ Second ACL injuries

• 28% experienced a second ACL injury (including contralateral)
• Mean time to second injury ≈4 years after surgery.

📊 Functional outcomes

• KOOS scores exceeded Patient Acceptable Symptom State thresholds across all domains
• 84% achieved successful long-term clinical outcomes.

✅ Key message

• Physeal-sparing OTT ACL reconstruction with LET demonstrates excellent long-term durability and functional outcomes in skeletally immature patients.

https://pubmed.ncbi.nlm.nih.gov/31549207/

• 👥 Patient population: 35 patients, mean follow-up 2.2 years
• 14 skeletally immature adolescents (primary ACLR; age 14±1)
• 21 skeletally mature adults (revision ACLR; age 25±8)
• No previous lateral extra-articular tenodesis performed
• 📏 Anterior laxity significantly improved:
• Adolescents: 3.9 → 1.2 mm SSD (p=0.040)
• Revision: 4.2 → 1.2 mm SSD (p<0.001)
• 🔄 Rotatory stability restored:

Significant improvement in Lachman and pivot-shift grades in both groups

• 💥 Graft failure rate:
• Adolescents: 14.3% (2/14)
• Revision: 4.8% (1/21)

All due to new trauma ≥1 year post-op

• 🦴 Key advantage:

Avoids femoral physeal violation in adolescents and enables one-stage revision in cases with tunnel widening or overlap

https://pubmed.ncbi.nlm.nih.gov/23292987/

• 👥 Patient population:

24 male athletes (mean age 30 years) with ≥2 prior failed ACL reconstructions

1. 20 had 2 prior reconstructions
2. 4 had 3 prior reconstructions

Mean follow-up: 3.3 years

• 🛠 Technique:

Non-anatomic over-the-top femoral route + lateral extra-articular plasty

Achilles (37.5%) or tibialis posterior (62.5%) fresh-frozen allograft

Designed to avoid staged femoral tunnel grafting

• 📊 Clinical outcomes:
• IKDC subjective improved from 40.8 → 81.3 (P < .005)
• 83% IKDC objective A/B
• 📏 Stability:
• Mean KT-2000 side-to-side difference: 3.1 mm
• 8% objective failures (2 patients)
• 🏃 Return to sport:
• 71% returned to pre-injury level
• Traumatic failures had significantly better outcomes than atraumatic failures
• 🎯 Key insight:

OTT + LET allows single-stage revision in complex femoral tunnel situations with outcomes comparable to other revision series, though mild residual laxity was relatively common

https://pmc.ncbi.nlm.nih.gov/articles/PMC5738484/

• 👥 Patient population:

24 patients (mean age 31.9 ± 11.2 years) undergoing revision ACL reconstruction with the over-the-top (OTT) technique; mean follow-up 30.7 ± 18.9 months

• 📊 Objective stability improved significantly:
• 72% IKDC objective A/B postoperatively (vs 0% pre-op)
• Mean KT-1000 side-to-side difference: 3.1 ± 2.4 mm
• 📈 Subjective outcomes:
• IKDC subjective improved significantly (51.1 → 63.7, p = 0.0027)
• KOOS, Lysholm, Tegner improved (not statistically significant)
• ⚽ Return to sport:
• 81.8% returned to sport
• 44.4% returned to same pre-injury level
• ACL-RSI psychological readiness strongly associated with RTP (p = 0.0168)
• ⚠️ Complications & survivorship:
• 14.3% failure prevalence
• Kaplan–Meier survivorship ~81% at 60 months
• 21.5% required staple removal
• 🎯 Key advantage:

The main benefit highlighted: avoiding femoral tunnel management in revision cases with tunnel widening or malposition

https://pubmed.ncbi.nlm.nih.gov/31324964/

• 851 patients, mean age 28.8 years, mean follow-up 4.9 years; overall failure rate 3.6%, complication rate 8%.
• Three OTT series (Buda, Zaffagnini, Zanovello) used a femoral over-the-top graft passage, avoiding femoral tunnel management.
• OTT studies reported ~3 mm side-to-side laxity, high IKDC A/B rates, and acceptable mid-term survivorship (~80–85%).
• Other techniques (Lemaire, Coker-Arnold ITB tenodesis) required standard femoral tunnel drilling but showed similar pooled outcomes: 83% negative pivot shift and 2.6 mm mean arthrometric difference.
• No clear superiority demonstrated; however, OTT uniquely avoids femoral tunnel issues, making it particularly useful in complex revision cases.

https://pubmed.ncbi.nlm.nih.gov/37386198/

• 👥 32 varus, ACL-deficient knees with medial OA

Mean age at surgery: 38.6 years

72% available at final follow-up

Mean follow-up: 14.3 ± 2.2 years

• 🔧 Technique:

Lateral closing wedge HTO + Over-the-Top ACL reconstruction (Marcacci–Zaffagnini) using hamstrings with extra-articular ITB fixation.

• 📈 Clinical improvement sustained long term:

Significant improvement in VAS, WOMAC, Tegner, and IKDC from pre-op to mid-term (p < 0.001).

VAS and IKDC remained stable at long term; some decline in Tegner and WOMAC over time.

• 🦴 Alignment correction maintained:

Significant correction in HKA and MPTA, with lateral shift of mechanical axis maintained at final follow-up.

• 📉 OA progression expected but delayed:

Medial compartment degeneration progressed early; lateral and patellofemoral OA increased between mid- and long-term follow-up.

• ⏳ Survivorship:

95.7% at 5 years

82.6% at 10 years

72.8% at 15 years

(Failures defined as arthroplasty, revision, or >5 mm laxity)

Takeaway

For young, varus, ACL-deficient knees with medial OA, OTT ACL + lateral closing wedge HTO provides durable stability and alignment correction, delaying arthroplasty for over a decade in most patients.