Over‐the‐top plus lateral extra‐articular tenodesis anterior cruciate ligament reconstruction: Ten tips for success

Purpose Over‐the‐top (OTT) plus Lateral Extra‐articular Tenodesis (LET) anterior cruciate ligament (ACL) reconstruction has been performed continuously at the Rizzoli Orthopedic Institute since 1993, with approximately 6000 procedures completed and long‐term follow‐up reported up to 25 years. Despite its durability and reproducibility, detailed technical updates have been limited. The purpose of this review is to summarise 10 practical tips aimed at preventing and managing intra‐operative complications during OTT ACL reconstruction. Methods This technical review is based on three decades of cumulative institutional experience with OTT plus LET ACL reconstruction across diverse patient populations, including skeletally immature patients, amateur athletes, elite professional soccer players and revision cases. Key technical steps are presented in a structured ‘Ten Tips’ format, emphasising strategies to preserve graft biology, ensure anatomic positioning and avoid intra‐operative pitfalls. Results Critical elements include preservation of distal hamstring vascularity, anatomic tibial tunnel placement, meticulous preparation of the OTT femoral pathway, safe lateral window development with protection of posterior structures, controlled graft passage to avoid clumping or kinking, precise anterior‐distal staple insertion to prevent posterior femoral cortical fracture and standardised completion of the LET. Attention to these principles minimises technical errors, protects the neurovascular bundle and PCL and promotes optimal graft orientation as demonstrated by magnetic resonance imaging‐based inclination parameters. Conclusion When performed with meticulous technique and adherence to reproducible surgical principles, OTT plus LET ACL reconstruction remains a versatile, economical and biologically favourable procedure capable of achieving anatomic graft positioning while avoiding femoral tunnel–related complications. These 10 technical recommendations provide a structured framework for reducing intra‐operative complications and optimising outcomes. Level of Evidence Level V, expert opinion.