Posterior Slope Reducing Osteotomy With Concomitant Anterior Cruciate Ligament Reconstruction

Modern techniques for graft choice, preparation, and fixation for anterior cruciate ligament (ACL) reconstruction demonstrate excellent longevity and return-to-play rates; however, up to 10% to 18% of cases continue to suffer reruptures, with even higher rates in specific subsets of patients.

Normally, the posterior tibial slope is measured between 7° and 10°, with biomechanical and observational studies showing that posterior slope greater than 12° increases the risk of graft failure by 5× by allowing for increased anterior tibial translation, putting increased stress on the graft. The primary indication for a slope correction osteotomy with a revision ACL reconstruction is a patient with tibial slope greater than 12° who has failed prior ACL reconstruction.

In our preferred technique, we illustrate a slope reducing anterior closing wedge proximal tibial osteotomy with concurrent revision ACL reconstruction rather than a staged ACL reconstruction.

The primary benefit of this technique is the ability to correct the tibial slope and reconstruct the ACL in one setting, which decreases recovery time, costs, and risks to the patients by eliminating an additional procedure.

In cases of ACL reconstruction failure, particularly in patients with multiple failures, an increased posterior tibial slope may be a contributing factor. Anterior closing wedge osteotomy has been shown to be an effective treatment, in patients with a native slope greater than 12°. A slope reducing anterior closing wedge proximal tibial osteotomy with concurrent revision ACL reconstruction rather than a staged ACL reconstruction has a wide array of benefits.