- Design
- Retrospective two-centre case series (level IV)
- Population
- 19 elite athletes with failed ACL reconstruction and posterior tibial slope ≥10°
- Primary outcome
- Return to pre-injury level of sport
- Effect
- 19/19 returned at mean 12.1 months; IKDC 44.2 → 92.3; slope 14.9° → 4.5°; no graft failures
A steep posterior tibial slope increases load on an ACL graft and is a recognised cause of failure. This retrospective two-centre case series described 19 elite athletes with a failed ACL reconstruction and slope of 10° or more who underwent revision with a supratuberosity slope-reducing osteotomy between 2011 and 2023.
All 19 returned to competition at their pre-injury level, after a mean of 12.1 months. At a mean of 59 months, IKDC improved from 44.2 to 92.3 and Lysholm from 46.8 to 96.9. Slope fell from 14.9° to 4.5° without changing coronal alignment or patellar height. There were no graft failures or major complications; reoperations were for staple removal.
The results are striking but come from 19 selected athletes treated by expert surgeons, without a comparison group. The useful message for every ACL surgeon is simpler: measure the slope on a lateral radiograph before a revision, because a steep slope left uncorrected is a reason the next graft may fail.
- Measure posterior tibial slope on a true lateral knee radiograph before any revision ACL reconstruction.
- Consider slope-reducing osteotomy when slope is 10° or more and the first graft has failed.
- Plan for about a year before return to competition after combined osteotomy and revision.
- Refer to a surgeon experienced in osteotomy rather than performing revision alone in a steep-slope knee.
Why it matters
A revision that leaves a steep slope uncorrected repeats one of the reasons the first graft failed.
Don't overread it
A case series of 19 elite athletes without controls; it cannot show osteotomy is better than revision alone.
The statistics, in plain English
With no comparison group, the improvements show what happened to these patients, not how much of it was due to the osteotomy rather than the revision itself or the athletes' motivation and rehabilitation.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for orthopaedics, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free