Comparative outcomes of transtibial vs. anatomical ACL reconstruction with hamstring autografts: A decade-long retrospective cohort study

This decade-long retrospective cohort study compares the outcomes of transtibial and anatomic ACL reconstruction using hamstring autografts, addressing a critical gap in the evidence for technique selection, particularly in non-athletic populations. Data from 30 patients who underwent transtibial ACL reconstruction (2007-2009) in our clinic were compared with contemporary anatomic technique studies (2013-2023) to assess graft survival, functional outcomes, and complications. Results demonstrated equivalent graft survival rates (93.4% transtibial vs. 94.9% anatomical, p=0.32), though anatomical techniques outperformed in high-demand activities (Tegner scores, p=0.001). No significant differences were observed in patient-reported outcomes (Lysholm: 84.2 vs. 86.7, p=0.18; IKDC: 81.5 vs. 83.1, p=0.21). The transtibial cohort exhibited shorter operative times (87±23.4 vs. 104±18.6 minutes, p<0.01) and comparable complication rates (graft infection: 3.3%; donor-site morbidity: 13.3%), with failures predominantly linked to concurrent meniscectomy. Notably, transtibial techniques achieved similar mid-term stability despite non-anatomical femoral tunnel placement, though rotational stability was not assessed.  The study challenges the universal adoption of anatomical reconstruction, suggesting transtibial techniques remain viable for lower-demand patients, particularly in resource-limited settings. While anatomical approaches excel in restoring high-level function, transtibial methods offer cost-effective, time-efficient alternatives without compromising graft integrity or patient satisfaction in non-elite athletes. Limitations include shorter follow-up (19.3 vs. 64.5 months) and lack of rotational stability metrics. Future research should stratify outcomes by age and activity level to refine patient-specific recommendations.