Over the Top ACL Reconstruction Technique Combined with Anterolateral Ligament Reconstruction for An Unstable Chronic ACL Rupture: A Case Report

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Abstract

Introduction: Anterior cruciate ligament (ACL) rupture is a common injury, particularly among athletes involved in high-impact sports. It often results from sudden changes in direction, causing instability, pain, and functional limitations. Arthroscopic ACL reconstruction is now the gold standard for treatment of ACL injury, many techniques has been introduced with excellent results. One of the techniques is the over the top technique. Case Presentation: A young adult male patient presented with a chief complaint of an unstable left knee. He was injured four years prior while playing football, involving a pivoting motion that led to pain and swollen left knee. Initially, he went to a bone setter and physiotherapy but had no improvement. After the pain and swelling subsided, the patient felt his knee often giving away when walking. Physical examination revealed positive Lachman, anterior drawer, with gross pivot shift test. An MRI confirmed an isolated total rupture of the anterior cruciate ligament. The patient then underwent “over the top” ACL reconstruction combined with Anterolateral ligament reconstruction, using a peroneus longus tendon graft. Discussion: The indication for “over the top” ACL reconstruction combined with anterolateral ligament reconstruction in this case was based on the patient’s chronic case with significant instability. This technique was done using autograft peroneus longus tendon to achieve sufficient graft length and graft diameter. Previous literature had shown that this technique provides several advantages, including better rotational stability and reduced graft failure rates compared to other methods. However, challenges include technical complexity and the requirement for precise surgical execution to avoid complications such as graft impingement or inadequate tensioning. Conclusion: This case report highlights the successful application of “over the top” ACL reconstruction combined with Anterolateral ligament reconstruction using a peroneus longus tendon graft in an adult male with an unstable chronic ACL rupture. The procedure effectively addressed knee instability, providing the patient with improved functional outcomes. These results underscore the viability of this technique as a valuable option in the surgical management of ACL injuries, particularly in cases requiring enhanced rotational control.