{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T12:43:57Z","timestamp":1791636237830,"version":"4.3.4"},"reference-count":26,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T00:00:00Z","timestamp":1761609600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T00:00:00Z","timestamp":1761609600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["esskajournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Knee surg. sports traumatol. arthrosc."],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Anterior cruciate ligament (ACL) graft failure remains a relevant challenge, particularly in revision settings where anatomical and clinical risk factors converge to an increased retear risk. Posterior tibial slope (PTS) is a well\u2010established biomechanical contributor. Each degree of increased PTS leads to greater anterior tibial translation (ATT) and higher ACL graft strain. Nevertheless, current decision\u2010making frameworks often consider PTS in isolation and may underappreciate important patient\u2010specific risk factors. To address this gap, the A\u2009+\u2009STRA score (ACL\u2009+\u2009slope tracing risk\u2010factor algorithm), a pragmatic, stratified system is proposed. The A\u2009+\u2009STRA score integrates medial posterior tibial slope (MPTS) measured on long\u2010leg lateral radiographs with individual clinical risk and limiting factors to guide the use of slope\u2010correcting osteotomy (SCO) in ACL reconstruction. The algorithm is structured around four key elements: (1) degree of posterior tibial slope, (2) surgical context (primary vs. revision), (3) cumulative risk factors for graft failure and (4) potential limiting factors that may contraindicate SCO. PTS thresholds are dynamically adjusted according to revision burden and further modified by additive or subtractive scores for risk and limiting variables. A threshold of &gt;13\u00b0 on long\u2010leg radiographs was selected, accounting for the approximately 2\u00b0 overestimation reported with this modality compared to standard short\u2010leg radiographs. The A\u2009+\u2009STRA Score assigns weighted values to risk factors (e.g., medial meniscus integrity, static anterior tibial translation [sATT]\u2009&gt;\u200910\u2009mm, contralateral ACL injury, revision status) and limiting factors (e.g., tunnel malposition, recurvatum, prior infection and professional athletic status). The summed score is plotted against PTS to yield individualised surgical recommendations, ranging from isolated ACL reconstruction to combined SCO and lateral extra\u2010articular tenodesis. High scores (\u226510) indicate slope correction regardless of the PTS value. To demonstrate the clinical applicability and enhance understanding of the algorithm's utility, a series of case scenarios is presented, reflecting a wide spectrum of anatomical and clinical profiles. These cases illustrate how the A\u2009+\u2009STRA Score can guide real\u2010world surgical decision\u2010making in complex ACL reconstructions.<\/jats:p>","DOI":"10.1002\/ksa.70162","type":"journal-article","created":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T19:49:35Z","timestamp":1761680975000},"page":"804-814","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Beyond the posterior tibial slope: Rethinking anterior cruciate ligament (ACL) re\u2010rupture risk through integrated scoring"],"prefix":"10.1002","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6910-0873","authenticated-orcid":false,"given":"Matthieu","family":"Ollivier","sequence":"first","affiliation":[{"name":"Aix Marseille Univ, APHM, CNRS, ISM, Inst Movement Sci Sainte\u2010Marguerite Hospital Marseille France"},{"name":"Department of Orthopaedics and Traumatology, Aix Marseille Univ, APHM, CNRS, ISM, Sainte\u2010Marguerite Hospital Institute for Locomotion Marseille France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2547-3176","authenticated-orcid":false,"given":"Ahmed","family":"Mabrouk","sequence":"additional","affiliation":[{"name":"Trauma and Orthopaedics Department Basingstoke and North Hampshire Hospitals Basingstoke UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastien","family":"Parratte","sequence":"additional","affiliation":[{"name":"International Knee and Joint Centre Hazza Bin Zayed St. Abu Dhabi UAE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristian","family":"Kley","sequence":"additional","affiliation":[{"name":"London Knee Osteotomy Centre, Orthopaedic Specialists Harley Street Specialist Hospital London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael T.","family":"Hirschmann","sequence":"additional","affiliation":[{"name":"University Department of Orthopedic Surgery and Traumatology Kantonsspital Baselland Bruderholz Switzerland"},{"name":"Department of Clinical Research, Research Group Michael T. Hirschmann, Regenerative Medicine &amp; Biomechanics University of Basel Basel Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2025,10,28]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-021-06765-8"},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.OA.20.00106"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.arthro.2023.07.007"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.1177\/23259671221079380"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1302\/0301-620X.76B5.8083263"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-020-06012-6"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.1177\/0363546503258880"},{"key":"e_1_2_6_9_1","doi-asserted-by":"publisher","DOI":"10.1177\/0363546515617742"},{"key":"e_1_2_6_10_1","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.G.01358"},{"key":"e_1_2_6_11_1","doi-asserted-by":"publisher","DOI":"10.1002\/ksa.12719"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.23.01352"},{"key":"e_1_2_6_13_1","doi-asserted-by":"publisher","DOI":"10.1002\/ksa.70003"},{"key":"e_1_2_6_14_1","doi-asserted-by":"publisher","DOI":"10.1002\/ksa.12575"},{"key":"e_1_2_6_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.arthro.2016.04.017"},{"key":"e_1_2_6_16_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-022-06888-6"},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1002\/jeo2.70120"},{"key":"e_1_2_6_18_1","doi-asserted-by":"publisher","DOI":"10.1177\/03635465251350397"},{"key":"e_1_2_6_19_1","doi-asserted-by":"publisher","DOI":"10.1002\/ksa.12176"},{"key":"e_1_2_6_20_1","doi-asserted-by":"publisher","DOI":"10.1177\/03635465231177465"},{"key":"e_1_2_6_21_1","doi-asserted-by":"publisher","DOI":"10.1002\/ksa.12797"},{"key":"e_1_2_6_22_1","doi-asserted-by":"publisher","DOI":"10.1002\/ksa.12174"},{"key":"e_1_2_6_23_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jisako.2025.100900"},{"key":"e_1_2_6_24_1","doi-asserted-by":"publisher","DOI":"10.1177\/0363546513503288"},{"key":"e_1_2_6_25_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-021-06460-8"},{"key":"e_1_2_6_26_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00167-022-06923-6"},{"key":"e_1_2_6_27_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.arthro.2020.08.031"}],"container-title":["Knee Surgery, Sports Traumatology, Arthroscopy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/ksa.70162","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/ksa.70162","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/ksa.70162","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T12:17:39Z","timestamp":1773836259000},"score":1,"resource":{"primary":{"URL":"https:\/\/esskajournals.onlinelibrary.wiley.com\/doi\/10.1002\/ksa.70162"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,28]]},"references-count":26,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,3]]}},"alternative-id":["10.1002\/ksa.70162"],"URL":"https:\/\/doi.org\/10.1002\/ksa.70162","archive":["Portico"],"relation":{},"ISSN":["0942-2056","1433-7347"],"issn-type":[{"value":"0942-2056","type":"print"},{"value":"1433-7347","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,28]]},"assertion":[{"value":"2025-08-20","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-11","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-28","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}