Original Article

Tibial tunnel malposition is a risk factor for osteoarthritis following ACL reconstruction at long term follow up: a retrospective study

¹ Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, F-69622, Lyon, France
² Orthopaedics surgery and Sports Medicine Department, FIFA medical center of excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France
³ Ortopedia e Traumatologia, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
⁴ LIBM – EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France

^* Corresponding Author: This email address is being protected from spambots. You need JavaScript enabled to view it.

Received: 17 November 2025
Accepted: 26 January 2026

Abstract

Purpose: This study aimed to compare long-term radiographic OA development after ACLR according to tunnel positioning assessed on 3D postoperative CT scans. Methods: Tunnel positioning was studied using 3D reconstructions, and tunnels were considered malpositioned if femoral tunnels were classified as type II or III (F), and tibial tunnels had an anteroposterior (AP) gap ≥ 5 mm and/or a mediolateral (ML) gap ≥ 2 mm compared to the native ACL location. Advanced radiographic OA was stages C and D according to the IKDC classification. Results: In this retrospective study, 76 consecutive patients who underwent ACLR were evaluated at a mean follow-up of 10.4 years. The mean age was 34.0 years. At the last follow-up, 18.4% of the patients had an advanced radiographic stage of OA. The distribution of malpositioned tunnels was as follows: 30.3% F, 17.1% AP, 19.7% ML, 11.8% AP+ML, and 5.3% AP+ML+F. There was a significant association between AP+ML (p = 0.022) and AP+ML+F (p < 0.001) tunnels and the IKDC C/D group. Conclusion: The malpositioning of tibial tunnels, specifically the combination of ML and AP displacement, is significantly associated with an advanced radiographic stage of OA at a follow-up of 10 years, regardless of femoral tunnel malposition. Level of Evidence: Level II.