{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T16:06:55Z","timestamp":1790698015569,"version":"4.1.0"},"reference-count":25,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:00:00Z","timestamp":1784678400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:00:00Z","timestamp":1784678400000},"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":[[2026,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:label\/>\n                    <jats:p>Sagittal plane tibial geometry is a critical and modifiable determinant of outcomes in posterior cruciate ligament (PCL) insufficiency and genu recurvatum. The posterior tibial slope normally ranges from 7\u00b0 to 10\u00b0, and pathological mechanics arise when it falls below 5\u00b0 or becomes reversed. In PCL insufficiency, a flattened slope substantially increases graft failure risk, with long\u2010term data demonstrating markedly reduced 10\u2010year survival for patients with severely flattened medial and lateral slopes. Biomechanically, tibial slope exerts a linear, independently significant effect on PCL graft force in loaded states, and flattened slopes further worsen multiplanar instability following combined ligament reconstruction. In genu recurvatum, a flat or negative slope amplifies a chronic hyperextension moment that overstresses the posterior capsule and posterolateral ligamentous complexes, producing pain, weakness, instability and functional impairment. Both conditions share a common biomechanical root and benefit from surgical correction through anterior opening\u2010wedge high tibial osteotomy (AOW\u2010HTO), which restores physiologic slope by shifting the tibial resting position anteriorly and reducing posterior sag. Surgical planning relies on calibrated radiographs, with each millimetre of opening corresponding to approximately 2\u00b0 of correction; three\u2010dimensional computed tomography planning with patient\u2010specific cutting guides adds accuracy for complex or biplanar deformities. Three operative approaches are described, supratuberosity, trans\u2010tuberosity and infratuberosity, each with distinct implications for patellar height, healing potential and concurrent ligamentous procedures. Published data report mean slope increases of 9\u00b0\u201324\u00b0 with 70%\u201390% good\u2010to\u2010excellent functional outcomes, and modern tuberosity\u2010sparing techniques have expanded indications while preserving patellofemoral mechanics. Principal complications include hinge fractures, patella baja, implant irritation and iatrogenic extension loss, mitigated by meticulous technique and mandatory intraoperative extension testing. Four illustrative cases, spanning recurrent PCL insufficiency, growth\u2010arrest\u2010related recurvatum treated with acute and gradual correction and a biplanar osteotomy combined with revision PCL reconstruction in a professional athlete, demonstrate the breadth of application. The evidence base remains predominantly Level III\u2013IV and prospective comparative studies are needed; nevertheless, AOW\u2010HTO is an effective, joint\u2010preserving procedure and a valuable adjunct to ligamentous reconstruction in patients with pathological sagittal malalignment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>Level V.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ksa.70538","type":"journal-article","created":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T15:25:45Z","timestamp":1784733945000},"page":"3719-3731","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Anterior opening\u2010wedge high tibial osteotomy for restoring posterior tibial slope in PCL insufficiency and genu recurvatum: A narrative review"],"prefix":"10.1002","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1702-9569","authenticated-orcid":false,"given":"Dan","family":"Cohen","sequence":"first","affiliation":[{"name":"Department of Orthopedic Surgery and Sports Medicine University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2811-6817","authenticated-orcid":false,"given":"Luca","family":"Ambrosini","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery and Sports Medicine University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00f6rg","family":"Dickschas","sequence":"additional","affiliation":[{"name":"Department of Trauma and Orthopedic Surgery University Hospital Erlangen, Friedrich\u2010Alexander University Erlangen Germany"},{"name":"Klinik f\u00fcr Orthop\u00e4die und Unfallchirurgie Sozialstiftung Bamberg Bamberg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronald","family":"van Heerwaarden","sequence":"additional","affiliation":[{"name":"Centre for Deformity Correction and Joint Preserving Surgery Kliniek ViaSana Mill the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthieu","family":"Ollivier","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Traumatology, APHM, CNRS, ISM, Institute of Movement Sciences, Sainte\u2010Marguerite Hospital Aix Marseille University Marseille France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Volker","family":"Musahl","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery and Sports Medicine University of Pittsburgh Medical Center Pittsburgh Pennsylvania 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