Flattening the slope let every one of these athletes back onto the pitch

Design

Retrospective case series, two centres, level of evidence 4

Population

19 elite athletes with failed ACL reconstruction and posterior tibial slope 10 degrees or more

Primary outcome

Return to pre-injury level of sport, with clinical, functional and radiographic outcomes

Effect

100% returned at a mean 12.1 months; slope 14.9 to 4.5 degrees; IKDC 44.2 to 92.3 and Lysholm 46.8 to 96.9 (both P < .001); no graft failures

Nineteen elite athletes with a failed anterior cruciate ligament reconstruction and a posterior tibial slope of 10 degrees or more underwent revision reconstruction combined with supratuberosity slope-reducing osteotomy at two centres between 2011 and 2023. Mean follow-up was 58.8 months, with a range extending to 169.

All 19 returned to competition at their pre-injury level, at a mean of 12.1 months (range 10 to 20). Mean slope fell from 14.9 degrees to 4.5 degrees, with no significant change in coronal alignment or patellar height. IKDC rose from 44.2 to 92.3 and Lysholm from 46.8 to 96.9, both at P < .001. Mean postoperative Tegner was 9.7, consistent with elite participation, and mean ACL-RSI was 87.2 - a psychological readiness score that often lags behind physical recovery and here did not. There were no graft failures and no major complications; the only reoperations were staple removals for local discomfort.

The result is striking and the design is level 4. A case series of 19 athletes selected at two specialist centres cannot tell you what revision reconstruction alone would have achieved in the same knees, and elite athletes return to sport at rates no general population matches. What it does establish is that adding an osteotomy to a revision did not prevent return to elite sport, and did not generate the complications that concern people about doing so. For a surgeon weighing whether a steep slope justifies a second procedure, that is the question that was open.

• Measure posterior tibial slope on a true lateral before any revision reconstruction, not after the graft fails twice
• A slope of 10 degrees or more is the threshold this series used to select patients
• Counsel on a 10 to 20 month return, not the shorter timeline of a primary reconstruction
• Warn about staple prominence - it was the only reason anyone went back to theatre
• Do not extend this to primary reconstruction; every patient here had already failed one

Why it matters

It answers whether the extra morbidity of an osteotomy costs an elite athlete their return - and it did not.

Don't overread it

Level 4 case series with no comparison group, in 19 elite athletes at two specialist centres.

The statistics, in plain English

The confidence intervals quoted alongside the IKDC and Lysholm improvements describe the size of the before-and-after change within the same patients, not a comparison against anyone else. With no control arm, the improvement from 44.2 to 92.3 includes everything that revision reconstruction and 12 months of elite rehabilitation would have achieved anyway. A 100% return-to-sport rate in 19 selected athletes also has a wide true uncertainty: with this sample size, the data are compatible with a real rate meaningfully below 100%.

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