Anatomical rectangular tunnels identified with the arthroscopic landmarks result in excellent outcomes in ACL reconstruction with a BTB graft.

Purpose: To elucidate tunnel locations and clinical outcomes after anatomic rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) graft.

Methods: Sixty-one patients with a primary unilateral ACL injury were included. Tunnels were created inside the ACL attachment areas after carefully removing the ACL remnant and clearly identifying the bony landmarks. Using 3-dimensional computed tomography (3-D CT) images, the proportion of the tunnel apertures to the anatomical attachment areas was evaluated at 3 weeks. The clinical outcomes were evaluated at 2 years postoperatively.

Results: Geographically, the 3-D CT evaluation showed the entire femoral tunnel aperture; at least 75% of the entire tibial tunnel aperture area was consistently located inside the anatomical attachment areas surrounded by the bony landmarks. In the International Knee Documentation Committee (IKDC) subjective assessment, all patients were classified as 'normal' or 'nearly normal'. The Lachman test and pivot-shift test were negative in 98.4% and 95.1% of patients, respectively. The mean side-to-side difference of the anterior laxity at the maximum manual force with a KT- 1000 Knee Arthrometer was 0.2 ± 0.9 mm, with 95.1% of patients ranging from - 1 to + 2 mm.

Conclusion: By identifying arthroscopic landmarks, the entire femoral tunnel aperture and at least 75% of the entire tibial tunnel aperture area were consistently located inside the anatomical attachment areas. With properly created tunnels inside the anatomical attachment areas, the ART ACLR using a BTB graft could provide satisfactory outcomes both subjectively and objectively in more than 95% of patients.

Level of evidence: Case series, Level IV.