Tunnel malposition is a frequent complication of anterior cruciate ligament (ACL) reconstruction. We evaluated whether the tibial tunnel location of patients who underwent anatomical single-bundle ACL reconstruction with hamstring tendons affected knee stability, muscle strength, and clinical outcomes. We retrospectively evaluated operated and normal knee magnetic resonance imaging (MRI) scans of 34 patients who underwent anatomical single-bundle ACL reconstruction technique with hamstring tendons. Tibial tunnel location was measured according to two techniques: anatomical landmarks of the tibial footprint and contralateral normal knee ACL anatomical scans. The effect of tibial tunnel location on knee stability, isokinetic and single-leg hop test (SLHT) results, and Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC-2000) scores was evaluated. For tunnel position evaluated by anatomical landmark methods, patients were defined as regular footprint in 23 patients, anterior in 5, and posterior in 6. Similarly, tibial tunnel positions evaluated by contralateral footprint: 20 patients were grouped as regular, 4 as anterior, 6 as posterior, and 4 as medial tibial tunnel position. Groups were compared according to both techniques. KOOS pain scores were significantly different in posterior tunnel position patients compared to patients with regular position (p = 0.023). No significant difference was found between the pivot shift, Kneelax 3 anterior translation, and SLHT, and leg symmetry index (LSI). Isokinetic test results and IKDC and other KOOS scores of all groups were similar. The kappa value between two measurement techniques was 0.681, and the agreement between techniques was 82% (p < 0.001). Tibial tunnel position may not be optimal because of technical reasons. Tunnel malposition does not significantly affect the stability and clinical outcomes of the patients in mid-term results. We can evaluate the tibial tunnel only with the operated knee's routine control MRI scans.

Received: 10 August 2025

Accepted after revision: 29 May 2026

Accepted Manuscript online:
04 June 2026

Article published online:
11 June 2026

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