Restoring the native anatomy of the anterior cruciate ligament (ACL) remains one of the greatest challenges in modern knee surgery. In this study, we explored how the over-the-top (OTT) ACL reconstruction technique reproduces graft orientation within the knee by using advanced MRI-based measurements and comparing postoperative alignment with the native ACL.

Through a detailed analysis of sagittal and coronal graft inclination angles, the study demonstrates that OTT reconstruction achieves a structural configuration that frequently falls within the MRI thresholds recommended by the ESSKA consensus. At the same time, the findings reveal that graft orientation remains significantly different from the native ACL, highlighting the complex balance between surgical reproducibility, anatomical restoration, and functional stability.

By combining highly reliable imaging measurements with objective structural evaluation, this work provides new insight into the biomechanical characteristics of OTT reconstruction and offers a deeper understanding of how this longstanding surgical technique positions the graft within the joint. Importantly, the study underlines that radiological similarity alone does not necessarily imply complete anatomical replication or equivalent clinical function, reinforcing the need to interpret imaging findings alongside long-term patient outcomes.

These results contribute to the ongoing debate surrounding anatomical ACL reconstruction and provide clinicians and researchers with a clearer framework for evaluating graft positioning using MRI-based assessment.