Review Article
Tibial Sagittal Slope in Anterior Cruciate Ligament
Injury and Treatment
Michael J. Alaia, MD
Daniel J. Kaplan, MD
Brian J. Mannino, MD
Eric J. Strauss, MD
ASSOCIATED VIDEO
From the Division of Sports Medicine,
Department of Orthopaedic Surgery, New York
University Langone Health, New York, NY.
None of the following authors or any immediate
family member has received anything of value
from or has stock or stock options held in a
commercial company or institution related
directly or indirectly to the subject of this article:
Alaia, Kaplan, Mannino, and Strauss.
Supplemental digital content is available for this
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JAAOS-D-21-00143
J Am Acad Orthop Surg 2021;29:e1045-e1056
DOI: 10.5435/JAAOS-D-21-00143
Copyright 2021 by the American Academy of
Orthopaedic Surgeons.
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ABSTRACT
Although anterior cruciate ligament reconstruction (ACLR) is a
generally successful procedure, failure is still relatively common. An
increased posterior tibial slope (PTS) has been shown to increase the
anterior position of the tibia relative to the femur at rest and under load in
biomechanical studies. Increased PTS has also been shown to
increase forces on the native and reconstructed ACL. Clinical studies
have demonstrated elevated PTS in patients with failed ACLR and
multiple failed ACLR, compared with control subjects. Anterior closing-
wedge osteotomies have been shown to decrease PTS and may be
indicated in patients who have failed ACLR with a PTS of $12°.
Available clinical data suggest that the procedure is safe and effective,
although evidence is limited to case series. This article presents the
relevant biomechanics, clinical observational data on the effects of
increased PTS, and an algorithm for evaluating and treating patients
with a steep PTS.
A
nterior cruciate ligament reconstruction (ACLR) is generally a suc-
cessful procedure; however, failure rates remain unacceptably high,
occurring in 3% to 7% of cases.1-3 These rates are even higher in
teenage patients or those with longer follow-ups.4 Poor outcomes may
include loss of motion (stiffness/arthrofibrosis), infection, extensor mech-
anism dysfunction, or neurovascular injury.5,6 Other, more common causes
of suboptimal outcomes may include recurrent instability and ACLR graft
disruption.7
ACLR failure can be grouped based on chronicity (early versus late) or
etiology. Early failures (,6 months) are typically due to poor surgical tech-
nique, failure of graft incorporation, premature return to deceleration/cutting
sports, or overly aggressive rehabilitation. Late failure (considered failures
that occur after 6 months to 1 year and beyond) is more commonly due to a
traumatic event.8 Atraumatic failures can be due to technical errors
(improper tunnel placement, graft impingement, improper graft tensioning,
and inadequate graft fixation), unrecognized ligamentous or meniscal in-
juries, failure of biologic graft incorporation or fixation, or malalignment in
the coronal or sagittal plane (Figure 1).5,7,9,10
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Tibial Sagittal Slope in Anterior Cruciate Ligament
Figure 1
Algorithm demonstrating different etiologies for poor ACL outcomes and ACL failures specifically. ACL = anterior cruciate ligament
Biomechanical Effects of Increased
Posterior Slope on the Anterior Cruciate
Ligament
The concept of posterior tibial slope (PTS) affecting the
ACL (native or graft) has something to do with ana-
tomic geometry. Increasing PTS results in an increased
anteriorly directed shear force on the tibia with axial
compression.11 Because one of the primary functions of
the ACL is to resist anterior tibial translation (ATT),
particularly in extension, it follows that anything that
increases the anteriorly directed load on the tibia would
increase forces on the ACL.
One can imagine if the slope of the plateau is partic-
ularly large, the femur would be predisposed to slide
posteriorly (Figure 2). An analogy often used to con-
ceptualize this is a man pushing a boulder up a hill. The
steeper the hill (ie, the larger the PTS), the more the man
(ie, the ACL) must work to prevent the boulder (ie, the
femur) from sliding down (prevent the femur from
moving posteriorly relative to the anteriorly moving
tibia). Multiple biomechanical studies have demon-
strated that an increased posterior slope does in fact lead
to increased strain on the ACL.11-15 Bernhardson et al
evaluated 10 cadaveric specimens after doing an ACLR.
Specimens were tested under axial load at various
flexion angles, with a tibial slope ranging from 22° to
20° at 2° intervals. Crucially, this study found that with
axial load applied, ACL graft forces increased linearly
with an increased tibial slope.14 In addition, cadaveric
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studies by both Imhoff et al11 and Yamaguchi et al15
demonstrated that anterior closing-wedge osteotomies
(ACWOs) markedly reduced forces on ACLR grafts
under axial load.
For ATT, most studies have increased PTS that leads
to an anterior resting position, although no change in
ATT (a relative measure) with force applied to a knee
with a competent ACL. 11-13 This is likely because the
intact ACL resists this translation (although it does
need to withstand increased force to do so relative to a
knee with a physiologic slope). Interestingly, Yama-
guchi et al actually did find knees with increased PTS
that had increased ATT relative to knees with phys-
iologic slopes when tibiofemoral compression, com-
bined tibiofemoral compression with an anterior force
and with a combined tibiofemoral compression, and
valgus moment was applied. The largest difference
was at 30° of flexion with tibiofemoral compression
(approximately 5 mm of difference between physio-
logic and knees with increased PTS). However, when
an internal rotation force was added to these con-
ditions, no difference in ATT and between knees with
physiologic and increased PTS occurred. The authors
postulated the difference in kinematics to be related
to osteology. Because ACWO (or increased native
slope) does not change the varus-valgus or rotational
alignment of the knee, the authors argued that the
cruciate winding mechanism is unaffected and there-
fore better able to resist ATT when an IR force is
applied.15
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Figure 2

The top row illustration depicting a man pushing a boulder up a hill, demonstrating a real-world equivalent for the biomechanics of the
tibial slope. The boulder represents the femoral condyles, and the hill represents the tibial plateau. The man represents the ACL,
preventing the boulder from sliding backward (analogous to preventing the hill from translating forward, relatively). The steeper the hill,
the more strength it requires from the man to keep the boulder from sliding backward. Eventually, he will tire out. If the hill is flat, less
work is required to maintain the boulder in position.

increased LPTS would lead to external rotation of the

Clinical Studies Evaluating the Role of
Posterior Tibial Slope and Native Anterior
Cruciate Ligament Injury
Biomechanical cadaveric studies have consistently
demonstrated that increased PTS leads to increased ATT
and increased forces on the ACL. Accordingly, clinical
studies have demonstrated that patients with elevated
PTS are at increased risk for native ACL rupture and
ACLR failure.
Brandon et al16 published one of the earliest studies
demonstrating the link between increased PTS and risk
of ACL rupture. They retrospectively compared ACL-
deficient patients with healthy control subjects and
found that ACL-deficient patients had a markedly
higher PTS. Among ACL-deficient patients, those with
high-grade pivot shifts had markedly higher PTS than
those with low-grade pivot shifts.
A subsequent 2010 study by Simon et al evaluated
osseous anatomy in ACL-deficient patients and healthy
control subjects. Although there was no difference in
medial PTS (MPTS) between ACL-injured patients and
control subjects, ACL-deficient patients did have a
steeper lateral PTS (LPTS).17 The biomechanical ratio-
nale for this can be believed as a pathologic exaggera-
tion of the femoral roll-back mechanism. A steeper
LPTS would encourage the lateral femoral condyle to
slide posteriorly under axial load on the more convex
lateral plateau, whereas the medial femoral condyle
would pivot over the more concave medial tibial pla-
teau. Therefore, under the same load, a knee with
femur, which would place pathologically increased
stress on the ACL.17 The importance of the LPTS was
supported by a series of retrospective studies, which
found that increased LPTS was associated with tibial
tunnel widening and high-grade pivot shift.18-20 The
authors postulated that the increased force on the ACL
secondary to a higher LPTS may lead to more motion at
the graft-tunnel junction, ultimately resulting in wid-
ening.18 Regarding the pivot shift, each degree of LPTS
increase was found to be associated with a 27.5% risk
increase of high-grade pivot shift.20
Although the LPTS is clearly important, it should
be noted that a 2017 meta-analysis found that patients
with an ACL injury exhibited both increased medial
and lateral tibial slope compared with healthy control
subjects.21
Clinical Studies Evaluating the Role of
Posterior Tibial Slope and Reconstructed
Anterior Cruciate Ligament Injury
(Rerupture)
A 2018 seminal paper by Salmon et al22 helped estab-
lish a MPTS of $12° as a strong predictor of repeat ACL
injury. The group evaluated 20-year outcomes of ACLR
with hamstring tendon autografts and found that
MPTS $12° was associated with hazard ratio for risk of
rerupture of 3.1. In adults, patients with a PTS of $12°
have just a 74% ACLR survival at 20 years compared

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Tibial Sagittal Slope in Anterior Cruciate Ligament
with 89% in patients with PTS ,12°. Similarly, survival
of contralateral ACL decreased from 94% to 67% at 20
years in adult patients with PTS ,12°.22 These risks
were markedly compounded if the patient was an
adolescent, in addition to having increased PTS (20-year
ACLR survival was just 22%).22 Of note, PTS was
measured based on the medial plateau.
Webb et al23 had similar findings when they retro-
spectively reviewed 181 patients who underwent ACLR
with hamstring autograft that had been prospectively
enrolled and followed up for 15 years. The odds of
additional ACL injury (rerupture or contralateral ACL)
increased by a factor of 5 (incidence of 59%) in patients
with PTS $12°.23 These findings were further corrob-
orated by Christensen et al24 in 2015, who found that
patients with early ACLR graft failure (,1 year post-
operatively) had a markedly higher LPTS than a group
of matched ACLR control subjects who did not have
rerupture (8.4° versus 6.5°).24 Similarly, Lee et al25
found that PTS was markedly increased in 64 patients
with ACLR rerupture compared with a matched cohort
of ACLR who did not fail (13.2° versus 10.9°). Most
recently, Grassi et al26 found that 25 patients with
multiple ACLR failures had markedly higher values of
both medial and LPTS compared with a control subject
group of ACLR patients without failure and a third
group of single ACLR failure.
Available clinical data strongly suggest that an ele-
vated PTS, particularly $12°, is a major risk factor for
native ACL rupture and ACLR rerupture. Accordingly,
PTS should be evaluated in patients with an ACL injury,
especially those who have failed ACLR. If an elevated
PTS is found, surgeons should consider an ACWO to
mitigate failure risk.
Evaluation and Workup of a Patient With a
Failed Anterior Cruciate Ligament
Reconstruction and Elevated Posterior
Tibial Slope
History
A thorough history should be taken focusing on both the
injury event and any preceding symptoms, as well as
previous surgical information. The previous surgical
technique and graft choice should be noted. One should
determine whether the mechanism of injury was low or
high energy. If there were preceding symptoms, it should
be clarified whether these were related to pain or laxity.
Pain may indicate an unrecognized chondral or meniscal
lesion, whereas symptoms of instability may suggest
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abnormal laxity.7 Timing of the injury relative to the
index procedure should be determined as well as com-
pliance with rehabilitation.
Examination
Gross alignment should also be evaluated, as well as gait,
looking for any varus/valgus thrust. A standard knee
examination should be done, including the Lachman,
pivot-shift, anterior/posterior drawer, and varus and
valgus stress tests (at 0° and 30°). Special attentionshould
be paid to posterolateral corner testing (posterolateral
drawer, external rotation recurvatum, and dial test)
because posterolateral corner instability is the most
common unrecognized concurrent deficiency and is seen
in 10% to 15% of chronically ACL-deficient knees.5
The medial and lateral joint line should be palpated to
evaluate for any meniscal pathology. The presence of
recurvatum should be noted because this could be a
contraindication to closing-wedge osteotomy. General
laxity testing should also be done to calculate a Beighton
score.27 One could consider adding an anterolateral
procedure (lateral extra-articular tenodesis or antero-
lateral ligament reconstruction) if the patient is found to
have global laxity.
Imaging
Standard knee radiographs, including an AP, PA flexion,
lateral, and merchant/sunrise view, should be obtained.
These can be used to assess previous tunnel placement,
tunnel lysis, and previous fixation technique. Leg-length
AP and lateral weight-bearing views are essential in the
workup of coronal and sagittal alignment, respectively,
and should be obtained in all revision cases.
Coronal malalignment, which can be assessed by
determining the location on the tibial plateau through
which the mechanical axis passes, would be a contrain-
dication to an anterior closing-wedge osteotomy because
this osteotomy can only affect the sagittal plane (Figure 3,
A). A biplanar deformity would necessitate use of a
lateral closing-wedge osteotomy.
PTS is evaluated on lateral imaging. A 2014 study by
Faschingbauer et al28 found that using standard lateral
knee radiographs may overestimate PTS by 3°. More
recently, a 2021 study by Dean et al29 found that a PTS
measured on a standard lateral knee radiograph (with
greater than 15 cm of tibia) was nearly identical to full-
length imaging when using a tibial anatomic axis with
the midpoint method (see below). Although we agree
that an accurate slope can be measured on a good lateral
radiograph with sufficient distal tibia, we prefer to use
full-length lateral tibia films, which provides the most
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Figure 3

A, B, C, Full length AP and lateral radiographs. Figure 4, A is an AP radiograph demonstrating slight valgus deformity, but ,5°, obviating
the need for any coronal correction. Figure 4, B demonstrates PTS calculation using the mechanical axis method. The mechanical axis
is defined by connecting the midpoints of the plateau and plafond. The PTS is determined my measuring the angle between a line
perpendicular to the mechanical axis and a line along the tangent of the plateau (here, the medial plateau is used). Notice that the PTS is
not as high as when calculated using the anatomic axis. Figure 4, C, full-length lateral radiograph demonstrating PTS calculation using
the anatomic axis method. Lines connecting the anterior and posterior cortices are drawn 5 cm distal to the plateau and 5 cm proximal
to the plafond. A line is drawn connecting the midpoints of these lines, representing the anatomic axis. Notice that the PTS is several
degrees higher than when calculated using the mechanical axis method. PTS = posterior tibial slope

accurate representation of relevant anatomic land-
marks. Of note, it is critical to obtain a true lateral
radiograph of the knee for measurement, specifically of
the tibia. When evaluating a lateral radiograph of the
knee, one should ensure that the medial and femoral
condyles are superimposed, with slight superimposition
of the fibular head and the posterior tibia (approxi-
mately 25%). However, although this may be helpful,
when evaluating the PTS, it is more important to get a
perfect lateral of the tibia specifically. The radiograph
should clearly depict both plateaus (with ability to dif-
ferentiate the concavity of the medial plateau and the
convexity of the lateral plateau, with slight superim-
position of the fibula). This may or may not result in
perfect superimposition of the femoral condyles.
Average values for medial and lateral slopes are vari-
able throughout the literature; however, the medial is
consistently higher than the lateral slope. An average
medial slope is commonly reported at 7° to 10°,6,22,30,31
whereas the lateral slope is typically 4° to 7°.18,20,24,32
The average intraindividual difference (medial versus
lateral slope in single knee) has been shown to be 2.6°
(reported maximum intraindividual difference of 9.6°).33
CT scans should also be considered in the revision
setting to help further assess tunnel lysis and tunnel
placement. MRI is the benchmark to evaluate for graft
rupture and concomitant injuries.
Techniques, Challenges, and
Controversies of Measuring the Tibial
Sagittal Slope
Several methods are available for calculating the PTS,
which have contributed to the relative opacity regarding
the relevant values. The general technique is to measure
the angle between a line perpendicular to the tibial axis
and tangential to the tibial plateau. However, which
tibial axis (and how to define it) and which plateau
(medial or lateral) are controversial.
Medial slope measurement may be more reproducible
given the more prominent posterior extension of the
medial plateau. In addition, Salmon et al used the medial
plateau when they determined the 12° critical value.22,34
However, as described above, the lateral slope may be
more important biomechanically because of the femoral

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Tibial Sagittal Slope in Anterior Cruciate Ligament

roll-back mechanism. Currently, using either slope is
acceptable, but one should be consistent in the mea-
surement technique and be cognizant that using the
medial plateau may result in increased measurement.
For the tibial axis, both the mechanical (representing
the weight-bearing center of the tibia) and anatomic axes
(representing the center of the diaphysis) have been
reported (Figure 3, B and C).28,29,35-37 The mechanical
axis is determined by connecting the midpoint of the
tibial plateau and the tibial plafond on a full-length
lateral radiograph.29
Several methods for determining the anatomic axis
have been investigated. The circle method, initially
described by Hudek et al38 (on MRI), involves drawing
two circles within the proximal tibia. The first circle fits
within the proximal, anterior, and posterior cortical
borders. The center of the distal circle is then positioned
on the distal most aspect of the circumference of the first
circle, within the anterior and borders of the anterior
cortices. A line connecting the centers of the two circles
defines the anatomic axis (Figure 4, A).35 The midpoint
method, originally described by Dejour et al, involves
drawing lines from the anterior to posterior cortex, one
5 cm distal to the articular surface and one 15 cm distal
to the articular surface. A vertical line connecting the
midpoints of these lines defines the anatomic axis
(Figure 4, B).37 The anterior prominence of the tibial
tubercle (or the reverse effect if the tubercle is flat) and
the concavity of the posterior tibial cortex may affect
measurement, erroneously forcing the apparent ana-
tomic tibial axis anterior or posterior. Although one
imaging study found that the circle method has been
shown to be more reproducible,35 when $15 cm of
proximal tibia is included in the lateral radiograph, the
midpoint method has been shown to more closely
resemble a full-length image.29,35 We prefer to use the
midpoint method because we find it more reproducible
and less prone to anatomic variation.
Using either the mechanical or anatomic axis is
acceptable; however, as shown by Dean et al,29 using the
mechanical axis will yield a markedly lower PTS than
using the anatomic axis. For consistency, the authors
recommend using the anatomic axis (either on full-
length lateral radiographs or adequate standard lateral
radiographs).29 Of note, diaphyseal deformity, partic-
ularly bowing, may lead to errors in PTS calculation if
using the anatomic axis.28
Treatment Options
Treatment algorithms are evolving, and management is
dictated based on a variety of patient-specific factors.
Because with all ACL graft ruptures, lower-demand pa-
tients may consider nonsurgical management. A stan-
dard ACLR, without an ACWO may also be done. This
would involve less surgery, earlier weight-bearing, and
reduced complications, albeit with a higher risk of fail-
ure. Therefore, an ACWO (concurrently or staged) with
ACLR may be appropriate in the revision setting.

Figure 4

Lateral radiographs (selected portion of full-length radiographs for consistency) demonstrating the midpoint and circle techniques.
Both techniques use a tibial anatomic axis. A, The circle technique includes placing a proximal circle with the circumference in contact
with the proximal, anterior, and posterior borders of the tibia. The distal circle is placed with its center at the distal most aspect of the
proximal circle’s circumference, with its borders contacting the anterior and posterior cortices. The midpoint technique, shown in (B),
determines the anatomic tibial axis by drawn lines connecting the anterior and posterior cortices 5 and 15 cm distal to the plateau. The
midpoints of these lines are connected, forming the anatomic axis. Notice how the circle method here results in a smaller PTS because
it establishes its anatomic axis based on more proximal references, which in this case leads to a more posterior axis. PTS = posterior
tibial slope

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Review Article
However, if there is coronal deformity in addition to allows tuberosity adjustment after the closing-wedge
increased PTS, biplanar correction would be required. osteotomy but requires tuberosity fixation and
healing.34,39,40

Indications and Contraindications for Supratubercle (Tuberosity) Approach

Anterior Closing-wedge Osteotomy
Because of a lack of available clinical evidence, in-
dications and contraindications are still undergoing
refinement. ACWO should be considered in patients
with a MPTS of $12° that have recurrent instability
after an ACLR.34,39-42 Although the technique is gen-
erally reserved for revision ACLR (or rerevision ACLR),
if a patient has a severely pathologic slope, one could
consider doing the osteotomy in the primary setting.
Based on available evidence though, this would be an
exceptional case40 (Table 1).
Contraindications relate primarily to complications
and limitations of the osteotomy. A pure anterior closing-
wedge osteotomy should only adjust the sagittal slope, so
patients with notable coronal malalignment should be
considered for a biplanar correcting osteotomy (medial
opening-wedge or lateral closing-wedge osteotomy).31
The presence of knee hyperextension (.10°) should
preclude patients because ACWO will result in more
notable recurvatum.31,39,42 Patients with PCL deficiency
or insufficiency should also be contraindicated because
decreasing PTS would increase the posterior-directed
force on the tibia.31,39,42 Finally, moderate-to-severe
tibiofemoral arthritis is a contraindication (Kellgren-
Lawrence grade III-IV).
Tibial Tuberosity Considerations
There are three ways one may approach the tibial
tuberosity for the ACWOs—supra, trans, and infra.
Each method has its own advantages and disadvantages
(Table 2, Figure 5). The supra and infra approaches are
tuberosity sparing, whereas the transtubercle approach
The specifics of the supratubercle approach (as well as the
technical steps for the anterior closing-wedge osteotomy)
will be demonstrated in the author’s preferred technique
video. It involves creating a vertical cut at the proximal
aspect of the tibial tuberosity 1 cm below the start of the
patellar tendon insertion. A medial-to-lateral cut is then
made to release the proximal portion of the tuberosity
from the posterior tibial metaphysis. This allows for the
ACWOs to be done while leaving the distal portion of
the tuberosity intact. The tuberosity does not require
fixation.34
Advantages of the supratubercle technique include
preservation of the tibial tuberosity and extensor mech-
anism. Because the osteotomy is located in the epiphysis,
it has a low angle, which potentiates healing and de-
creases nonunion risk. It also facilitates concomitant
ACLR because the osteotomy is secured with staple fix-
ation, so there is a smaller risk of interfering with the
tibial tunnel.34,42
One unique disadvantage to the supratubercle ap-
proach is the potential for modification of patellar height.
The tuberosity may be brought more proximal by
removal of the bone wedge. This could decrease the
amount of tension on the extensor mechanism (given the
decreased distance between the tubercle and inferior
patella pole, with maintained tendon length) which may
result in extensor lag. If extensor tension is maintained,
this could result in patella alta.
A risk also exists for recurvatum deformity because of
the bone wedge removal. Finally, because the tuberosity
is hinged, there is also the potential for tubercle fracture if
the cuts are not done correctly or if the proximal portion
of the tubercle is not released.31,34,41,42

Table 1. Indications and Contraindications for Anterior Closing-wedge Osteotomies

ACWO Indications and Contraindications
Indications Contraindications
PTS $12° in the setting recurrent ACLR failure Significant coronal malalignment ($10°)
PTS $15° in the setting primary ACL injury (relative indication, Knee hyperextension ($10°)
suggested by some)
— PCL deficiency
— Kellgren-Lawrence grade (III-IV)

ACLR = anterior cruciate ligament reconstruction, ACWO = anterior closing-wedge osteotomies, PCL = posterior cruciate ligament,
PTS = posterior tibial slope

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Tibial Sagittal Slope in Anterior Cruciate Ligament
Table 2. Considerations for Each Approach to the Tibial Tubercle
Approach Advantages
Preservation of TT
Supratubercle Decreased nonunion risk
— TT fracture
Can control tubercle position
Transtubercle
Decreased risk of PCL injury
Reduced risk to tubercle
Infratubercle
Minimal patella baja or recurvatum risk
PCL = posterior cruciate ligament, TT = tibial tubercle
Transtubercle Approach
The transtubercle osteotomy involves completely de-
taching the tibial tubercle from the proximal tibia.
K-wires are passed around the medial and lateral bor-
ders, and the tubercle osteotomy is completed with os-
teotomes along the same border. The tubercle is then
completely freed posteriorly from the remainder of the
tibia.39 The ACWO is then done. After the ACWO and
staple fixation, the tubercle is distalized an amount
corresponding to the amount of anterior wedge resec-
tion. This is done to prevent changes in patellar height.
The tubercle is fixed with two 4.5-mm cannulated, fully
threaded screws.39
The primary advantage of the technique is the ability
to control the proximal-distal location of the tubercle.
This decreases the risk of patella alta and extensor lag.39
Figure 5
Radiograph of the right knee of the same 24-year-old patient
demonstrating the different approaches to the tibial tubercle.
The green wedge represents the supratubercle approach, the
blue wedge shows the transtubercle approach, and the
yellow wedge represents the infratubercle approach.
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Disadvantages
Patella alta
Recurvatum deformity
TT fracture
Tubercle nonunion risk
More fixation required
—
There may also be decreased risk of PCL injury com-
pared with the supratubercle approach because the
osteotomy apex for the transtubercle approach is more
distal relative to the PCL facet.39
Similar to the supratubercle approach, the trans-
tubercle approach has the disadvantage of possible
tubercle fracture. The more concerning consideration of
this technique is the risk for nonunion. Compared with
the supra and infratubercle approaches, this technique
requires healing of two osteotomy sites.39
Infratubercle Approach
This approach involves doing the ACWO just distal to
the tubercle, leaving it completely intact. Accordingly,
the main advantage of the technique is the reduced risk
for tibial tubercle fracture. A minimal risk also exists for
patella alta because the tubercle position does not change
relative to the joint line. However, because the osteotomy
is more distal, with a more oblique cut, sturdier fixation is
required. Osteosynthesis is done with a lag screw from
the tibial tubercle to the distal tibia, which is further
supported by a medial angular stable plate.40
Preoperative Planning and Authors’
Preferred Technique
When considering how big of a correction to make, we
consider our goal slope to be, “normal slope,” which is
roughly 7° to 10° of medial slope. Although data to help
guide this target are lacking, given the risks of knee hy-
perextension and stress placed on the PCL with a de-
creased, neutral, or particularly negative slope, we advocate
for no more than the physiologic slope. When making the
osteotomy, about 1 mm of distance between the proximal
and distal K-wires corresponds to a 1° correction.
Another point to consider is surgical sequence, par-
ticularly in the setting of revision ACLR. We advocate for
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© American Academy of Orthopaedic Surgeons
 Michael J. Alaia, MD, et al

starting first with the femoral and intra-articular work
associated with the ACLR. The beginning steps of the
ACLR should then be done, including remnant graft
débridement and notchplasty. Previous implant should
be removed. Tunnel management in the setting of
revision ACLR is outside the scope of this discussion,
but a decision regarding how to deal with the previous
femoral tunnels should be made at this juncture (or
based on preoperative imaging) based on their posi-
tion.43 Options include using the same tunnel, using the
same start point (aperture) but a different trajectory,
drilling a completely new tunnel, or bone grafting for a
two-stage procedure. The femoral tunnel should then be
drilled, and a passing suture should be placed for later
graft passage. Next, the osteotomy should be done to
completion, including anterior-based fixation. After the
osteotomy, completion of the ACLR should be done,
specifically drilling of the tibial tunnel and ACLR
fixation.
The author’s preferred technique, including step-by-
step approach and a video demonstration, can be found
in Supplemental Digital Content 1 (http://links.lww.com/
JAAOS/A699). Peals and pitfalls are found in Table 3.
Rehabilitation
The patient is made non–weight-bearing and placed in a
hinged-knee brace, locked in extension for all activities
Review Article
(including sleeping), except for physical therapy for the
first 4 weeks. During this time, gentle knee ROM should
be worked on with physical therapy.
At 4 weeks, if radiographs confirm maintained
alignment and implant fixation, the patient may begin
partial weight-bearing (increasing from 25% to 50%
over 2 weeks), while gentle ROM exercises are continued.
At 6 weeks, progression toward full–weight-bearing is
begun, and more aggressive physical therapy is started,
with a focus on achieving knee flexion.
By 3 months, a radiograph is taken to assess for
osteotomy union. If healed, restrictions are lifted, and
the patient should begin straight ahead running because
they progressively work toward return to sport. At the
3-month follow-up, the above patient’s radiographs
demonstrated a healed osteotomy and reduction in PTS
of 10° (to 5°) (Figure 6).
Outcomes of the Anterior Closing-wedge
Osteotomy
Given the novelty of the technique, studies evaluating
its outcome are extremely limited, with only two small
case series available. In 2014, Sonnery-Cottet et al42
published a series on five revision ACLR patients who
underwent concomitant transtubercle ACWO. The
mean MPTS decreased from 13.6° preoperatively to
9.2° postoperatively. MPTS was measured using the

Table 3. Pearls, Pitfalls, and Complications of the Anterior Closing-wedge Osteotomy

Pearls
Pay special attention to posterolateral
corner examination because this is a
frequent cause of ACLR failure
Make large flaps medial and lateral to the
TT to facilitate exposure
Assume 1° correction per mm of wedge
removed
Tips of proximal and distal K-wires should
form a sharp apex
Mark depth of K-wires on osteotomy saw
and osteotomes to avoid overpenetration
Do the osteotomy in 45° of KF to protect
the vessels
Gently hyperextend the knee to close the
osteotomy
— —
Pitfalls Complications
— Neurovascular compromise
Not exposing medially to posterior dMCL Nonunion
or elevating anterior compartment
musculature laterally
— Pseudarthrosis
Not protecting patellar tendon with army Patella alta
navy during proximal tubercle release
Not leaving an intact posterior cortical Recurvatum deformity
hinge during osteotomy
— Tibial tubercle fracture
Do not close osteotomy too quickly or risk Overcorrection of posterior tibial slope
posterior hinge fracture
Knee stiffness

ACLR = anterior cruciate ligament reconstruction, KF = knee flexion, TT = tibial tubercle

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Tibial Sagittal Slope in Anterior Cruciate Ligament
Figure 6
Three-month postoperative right knee radiograph
demonstrating maintained posterior slope sagittal correction
and union of the osteotomy.
mechanical axis on a full-length tibial radiograph as the
angle between the tangent to the medial tibial plateau
and a line perpendicular to the mechanical axis through
the middle of the medial tibial plateau and center of the
talus. At the mean follow-up of 32 months, Lysholm and
International Knee Documentation Committee (IKDC)
scores markedly improved from 46.2 and 39.5 to 87.8 and
79.1, respectively. Anterior laxity markedly decreased
from 10.4 to 2.8 mm. No complications occurred.42
The next year Dejour et al published a series on nine
second revision ACLR combined with supratubercle
ACWO. The mean PTS decreased from 13.2° preoper-
atively to 4.4° postoperatively. The PTS was calculated
as the angle between a line perpendicular to the ana-
tomic axis of the tibial diaphysis (although they do not
define how this was determined) and a line tangent to
the most superior points of the anterior and posterior
edges of the medial plateau, using a goniometer. This
was done on standard lateral radiographs. At the mean
follow-up of 4.0 years, Lysholm and IKDC scores
increased from 38.4 and 44.1 to 73.8 and 71.6,
respectively. Lachman and pivot-shift tests were nega-
tive at the follow-up. No intraoperative or postoperative
complications developed.41
The paucity of data makes it difficult to draw any
definitive conclusions. However, it does seem like it is
technically feasible to decrease PTS in patients and that
patients who undergo revision ACLR with concomitant
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JAAOS®
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
ACWO may do well. Complications and reruptures seem
to be limited after the technique, but more study is
required.
Complications
The most concerning complication of the ACWO is
neurovascular compromise (Table 3). The posterior
apex of the osteotomy routinely is less than 1 cm away
from the popliteus structures.39 Surgeons must be
hypervigilant about Kirschner wire and osteotome
placement. Accordingly, the posterior bony hinge
should be preserved because this helps protect the
neurovascular bundle, limiting injury risk. A simple way
to help avoid injury is by measuring Kirschner wire
depth after insertion, before the osteotomy. This depth
can be marked on the saw blade and osteotome to avoid
overpenetration.40 To further limit acute or subacute
posterior hinge fracture, one should ensure that the tips
of the proximal and distal K-wires meet, forming a
sharp apex. This helps form a triangular wedge to re-
move (rather than a trapezoidal wedge), which facili-
tates the completion of the osteotomy.
Another key technique to reduce risk is adequate
exposure to help visualize the osteotomy. The approach
should take into consideration previous incisions, par-
ticularly if a bone-patellar tendon-bone (BTB) autograft
was used previously. For the ACWO, the incision
should be centered over the tibial tubercle and extend
proximally as needed. Large medial and lateral flaps are
made to facilitate exposure. Medially, one needs to go
sufficiently medial and posterior so as to allow the
detachment of the posterior aspect of the deep MCL.
Laterally, dissection must include subperiosteal eleva-
tion of the proximal extent of the anterior compartment
musculature. A small portion of the iliotibial band may
need to be released from Gerdy tubercle to facilitate the
visualization of the osteotomy site.
If, despite these protective measures, one fractures the
posterior cortex, several management options exist.
Given the lack of outcome data, no benchmark exists—
the final decision is therefore entirely up to the treating
surgeon’s discretion and preference. Unlike an opening-
wedge high tibial osteotomy where the bone graft is
inserted into the osteotomy site, the ACWO results in
resection of a wedge of bone, which leads to direct
contact between proximal and distal metaphyseal bone.
Accordingly, there is less risk of nonunion. One could
reasonably treat this injury nonoperatively and monitor
the posterior cortex with serial radiographs. However,
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November 1, 2021, Vol 29, No 21 © American Academy of Orthopaedic Surgeons

studies evaluating opening-wedge high tibial osteoto-
mies with lateral cortex fracture with posterior cortical
extension have demonstrated a notable risk of increased
posterior slope over time.44 We therefore would prefer a
low-profile, anterior (anterolateral or anteromedial)
periarticular locking plate to hold the reduction.
Another complication is nonunion of both the ACWO
site and the tibial tubercle (if the transtubercle approach
is used).31,41 The proximal tibia is the metaphyseal bone
and has a relatively robust blood supply compared with
the more distal diaphysis. As mentioned above, the
nonunion rates should therefore be low (particularly
compared with, say, a high-tibial opening-wedge oste-
otomy), but at the present time, this is theoretical
because limited data exist. Similarly, pseudarthrosis is a
potential complication if fusion is not obtained. How-
ever, the large surface area of the osteotomy (all three
approaches) should help mitigate this risk. In addition,
leaving the posterior hinge intact further decreases
pseudarthrosis risk.42 Again, as of now, insufficient data
exist regarding the rates of pseudarthrosis.
Patella alta, extensor lag, and recurvatum deformity
are all possible complications related directly to the
removal of an anterior wedge of bone. This risk is theo-
retically higher with the supratubercle approach than the
transtubercle approach, but no studies have been done to
confirm this point.
Tibial tubercle fracture is also a possible risk. This risk
is higher with the supra and transtubercle approaches
because the distal tubercle approach leaves the tubercle
completely intact. Relatedly, the transtubercle approach
requires the fixation of the tubercle. This could lead to
nonunion of the tubercle or malreduction, which could
lead to malalignment.34,42,45
Overcorrection should be avoided because a
decreased PTS may place additional stress on the
PCL.14,39,46 This could theoretically lead to PCL rup-
ture, although more study is needed to clarify this point.
As stated above, the goal slope should be a physiologic
slope (roughly 7° to 10° of medial slope).
Finally, any knee procedure has a risk of stiffness.
Given the additional surgical time, dissection, and non–
weight-bearing status after surgery, stiffness risk is likely
higher than a standard ACLR or revision ACLR,
although this is yet to be determined.
Summary
Biomechanical studies have demonstrated that increased
PTS increases the resting anterior position of the tibia,
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JAAOS® November 1, 2021, Vol 29, No 21 © American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Michael J. Alaia, MD, et al
Review Article
may increase ATT with load, and increases the forces
within the ACL. Clinical studies have demonstrated
increased rates of ACLR failure in patients with increased
PTS. An ACWO may decrease the PTS and decrease the
failure rate of ACLRs. Limited clinical data have found
the procedure to be safe and effective.
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