Slope-reducing osteotomies: a narrative review

Slope-reducing osteotomies are designed to decrease an excessive posterior tibial slope (PTS), primarily in the setting of anterior cruciate ligament (ACL) deficiency or failed ACL reconstruction (ACLR). Four main approaches exist with variable indications and outcomes. Currently, no comparative randomized studies exist on slope-reducing osteotomies for revision ACLR. This study aims to provide a narrative review of the current literature on slope-reducing osteotomies for revision ACLR and ACL deficiency, emphasizing distinct techniques and their associated indications, advantages and limitations, and outcomes. A treatment algorithm based on the indications of the different techniques is also proposed.

A review of the current literature on slope-reducing osteotomies in the setting of ACL reconstructions and revisions was conducted, including key studies on the techniques, indications, and outcomes. The evidence is primarily based on retrospective studies and technical reports.

Slope-reducing anterior-based supratuberosity, infratuberosity, and transtuberosity osteotomies demonstrate encouraging outcomes for the treatment of elevated proximal tibial slopes in the setting of ACL graft retears. Differences among approaches exist regarding their impact on extensor mechanisms, patellar placement, recovery rates, and skill level requirements. Patient-specific instrumentation (PSI) in this patient population remains insufficiently documented, although reports of outcomes among cohorts with other indications for osteotomies are promising. The standardization of preoperative planning will also be critical to optimize patient outcomes and better inform the proper surgical technique.

As the field evolves, slope-reducing osteotomies continue to show promising outcomes among patients with ACL reconstruction failures. However, heterogeneity amongst study methods and reported outcomes within the current literature limits precludes any definitive conclusions. Therefore, the choice of a slope-reducing osteotomy approach should be based on patient-specific anatomy, clinical presentation, and surgeon experience. Future steps should standardize approaches to preoperative planning, including PTS measurements, and better characterize long-term outcomes for each slope-reducing osteotomy approach.