Editorial Commentary: Different Levels for Posterior Tibial Slope Reducing Anterior Closing Wedge Osteotomy to Reduce...

It has become increasingly recognized that a steep posterior tibial slope is a modifiable risk factor for the failure of an anterior cruciate ligament reconstruction. An anterior closing wedge osteotomy (ACWO) may be performed to flatten the slope, and this osteotomy may be performed above, through, or below the tibial tuberosity. A supra-tuberosity technique may increase the patellar height. However, this increase may be modest, may not affect the clinical outcomes, and is only one risk that I would consider when deciding whether to perform an ACWO above, through, or below the tibial tuberosity. The short proximal fragment of supra-tuberosity ACWO mandates a short anterior cruciate ligament reconstruction tibial tunnel and may compromise fixation of the osteotomy. A trans-tuberosity ACWO usually requires a tibial tuberosity osteotomy, which requires slower postoperative mobilization and risks nonunion or fracture of the tibial tubercle. And, an infra-tuberosity ACWO has lesser healing potential than a more proximal osteotomy.