Purpose <p>Anterior cruciate ligament (ACL) injuries are commonly treated through ligament reconstruction, which necessitates precise placement of bone tunnels to mimic the original ligament’s position and tension. This study presents a novel approach to ACL reconstruction using a digital guide and smart handheld robot that enhances the accuracy of tibial tunnel placement without relying on preoperative computed tomography (CT) scans or fluoroscopic imaging.</p> Method <p>The system incorporates an optical navigation platform connected to a dexterous handheld drilling robot that features a six-axis end effector equipped with infrared optical ball trackers. Registration involves capturing the point cloud data of the tibial surfaces using standard arthroscopic techniques, allowing for the creation of a 3D tibial model based on a statistical shape model. After determining the tunnel exit point and tunnel angle, the system automatically generated a digital ACL guide for the robot.</p> Results <p>Our findings demonstrated that the tunnels created with our robotic system maintained angles within 4 degrees of the planned position, significantly outperforming traditional guide methodologies. The mean distance errors for entry and exit points were recorded as 1.14&#xa0;mm and 3.28&#xa0;mm, respectively.</p> Conclusion <p>This study provides compelling evidence that our integrated robotic navigation system can improve surgical outcomes in the ACL by achieving accurate bone tunnel placement, thus potentially reducing the risk of postoperative complications and enhancing recovery.</p>