The Rizzoli Orthopedic Institute presents a technical review focused on Over-the-top (OTT) plus Lateral Extra-articular Tenodesis (LET) anterior cruciate ligament (ACL) reconstruction, a procedure continuously performed since 1993 with more than 6000 surgeries completed and clinical follow-up reported up to 25 years.

The review highlights ten practical recommendations developed through three decades of surgical experience, aimed at preventing and managing intra-operative complications during ACL reconstruction.

Particular emphasis is placed on preserving graft biology, achieving accurate anatomic positioning and protecting neurovascular structures through standardized surgical steps. Key technical aspects include tibial tunnel placement, preparation of the OTT femoral pathway, controlled graft passage and safe execution of the LET procedure.

The experience developed at the Rizzoli Orthopedic Institute confirms that OTT plus LET ACL reconstruction remains a reliable, reproducible and biologically favourable technique, capable of ensuring joint stability while reducing femoral tunnel–related complications.

These ten technical recommendations provide a practical framework to optimise surgical outcomes and improve intra-operative safety in ACL reconstruction surgery.