Table 2.

Pearls and Pitfalls of the Over-the-Top Technique of Revision ACL Reconstruction With Achilles Allograft and Associated Lateral Extra-Articular Tenodesis

Pearls	Pitfalls
•Indicated in patients with partially or nearly overlapping prior and planned femoral tunnels and/or extensive femoral tunnel widening	•Lateral knee dissection should not be in biceps femoris plane
•Prior femoral hardware may be removed, and prior tunnels may be bone grafted per surgeon preference	•Do not compromise tibial tunnel placement by using a malpositioned prior tunnel
•Achilles allograft bone block is sized based on tibial tunnel width; tendinous portion is cut to 23 cm length and tubularized	•Avoid skiving staples into bone or piercing the graft with the staple
•Graft placement site at the posterior lateral femoral condyle is rasped to stimulate healing	•Leaving staples proud may not secure the graft or irritate the IT band
•Staples for graft fixation should be perpendicular to the bone without piercing the graft, extra-articular, and appropriately seated, as confirmed on C arm	•Graft-tunnel mismatch may occur if the graft is fixed at the lateral femoral condyle with the bone block extruding from the tibial tunnel
•Order of fixation: staples at lateral femoral condyle, interference screw at tibial tunnel (20° of flexion and posterior drawer), staple just medial to Gerdy’s tubercle (60° of flexion in neutral rotation)	•Do not place tibial staple too close to the articular surface