Evaluating Tibial Tunnel Landmarks in Anterior Cruciate Ligament Reconstruction: Remnant Versus Lateral Meniscus Anterior Horn

<b>Background:</b> We sought to compare the anatomical accuracy and clinical outcomes of two intraoperative landmarks, the anterior cruciate ligament (ACL) tibial remnant and the anterior horn of the lateral meniscus (LMAH), for tibial tunnel placement in single-bundle ACL reconstruction. <b>Methods:</b> This retrospective comparative study included 74 patients who underwent single-bundle ACL reconstruction using either the ACL tibial remnant (Group 1, <i>n</i> = 35) or the LMAH (Group 2, <i>n</i> = 39) as the primary intraoperative landmark. Tunnel positioning was evaluated using post-operative MRI. Clinical outcomes included the Lysholm score, subjective IKDC, Tegner activity scale, Lachman and pivot-shift tests, KT-2000 arthrometer measurements, and return-to-sports status. <b>Results:</b> Group 1 demonstrated slightly more anterior sagittal tunnel placement (44.57%) compared to Group 2 (46.87%) (<i>p</i> = 0.036). Coronal tunnel positioning did not differ significantly between the groups (<i>p</i> = 0.215). Functional scores, stability tests, and return-to-sports rates were similar across groups. MRI-based tunnel measurements in sagittal and coronal planes had excellent inter- and intraobserver reliability. <b>Conclusions:</b> Both the ACL tibial remnant and LMAH are reliable landmarks for tibial tunnel placement in ACL reconstruction. Although minor variations in sagittal tunnel positioning were identified, they did not affect functional or stability outcomes.