{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T16:07:37Z","timestamp":1790698057439,"version":"4.1.0"},"reference-count":120,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T00:00:00Z","timestamp":1785715200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T00:00:00Z","timestamp":1785715200000},"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>Increased posterior tibial slope (PTS) is a known risk factor for anterior cruciate ligament (ACL) deficiency and graft failure after ACL reconstruction (ACLR). Although many studies investigated different aspects related to the PTS, there is still a lack of comprehensive recommendations and practical guidelines, especially with regard to radiographic analysis, surgical indication and surgical technique. The aim of this narrative review is to present such recommendations, based on the existing literature (evidence Level 3\u20134), supplemented by the expert opinions of the Osteotomy Committee of the German Knee Society. A review of the literature was conducted to summarize the current evidence concerning biomechanical background, radiological measurement, indication for surgical correction and surgical techniques. Results were presented to a panel of surgeons with recognized expertise in the treatment of ACL injuries and wide experience in surgical correction of the PTS, and consensus was formed by informal discussion. These recommendations were developed and included: (1) measuring the PTS should be performed on long lateral radiographs using the mechanical axis, with attention to a correct rotational alignment (exact superimposition of the posterior tibial condyles). (2) Indication for surgical correction does not depend on a single fixed cut\u2010off value of the PTS. It should be based on an individual risk assessment (e.g., degree of anterior tibial translation and instability, meniscal integrity, number and quality of previous ACLR, trauma mechanism: contact vs. non\u2010contact, contralateral injury). (3) For correction of pathologic PTS, different surgical techniques of anterior tibial closing wedge osteotomies have been reported without clear superiority of one technique. However, an infratuberositary approach is recommended, because it has been shown to be technically easier and safer.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>Level V, narrative review and expert opinion.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ksa.70549","type":"journal-article","created":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T15:15:32Z","timestamp":1785770132000},"page":"3586-3604","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Management of increased posterior tibial slope in ACL deficiency: A narrative review and recommendation of the Osteotomy Committee of the German Knee Society"],"prefix":"10.1002","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9319-7591","authenticated-orcid":false,"given":"Philipp","family":"Mayer","sequence":"first","affiliation":[{"name":"Orthopedic Hospital Markgroeningen Centre for Sports Orthopedics and Special Joint Surgery Markgroeningen Germany"},{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"F\u00fcrmetz","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Sports Traumatology and Arthroscopic Surgery BG Klinikum Murnau Murnau Germany"},{"name":"Department of Orthopedics and Trauma Surgery Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5788-6875","authenticated-orcid":false,"given":"Gerrit","family":"Bode","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Praxisklinik2000 Freiburg Germany"},{"name":"Department of Orthopedics and Trauma Surgery Freiburg University Hospital Freiburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Angele","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Clinic for Trauma and Reconstructive Surgery University Hospital Regensburg Regensburg Germany"},{"name":"Sporthopaedicum Regensburg Regensburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc\u2010Daniel","family":"Ahrend","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Traumatology and Reconstructive Surgery, BG Trauma Center T\u00fcbingen Eberhard Karls University T\u00fcbingen T\u00fcbingen Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7713-622X","authenticated-orcid":false,"given":"Sebastian","family":"Leutheuser","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopedic Surgery and Sports Traumatology, Sana Medical Centre Witten\/Herdecke University Cologne Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6349-7817","authenticated-orcid":false,"given":"Christoph","family":"Lutter","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopaedics Rostock University Medical Center Rostock Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6570-1308","authenticated-orcid":false,"given":"Svea","family":"Faber","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopedics and Trauma Surgery Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-6456-9518","authenticated-orcid":false,"given":"Maximilian Michael","family":"Mueller","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Trauma Surgery Orthopaedics and Sports Traumatology, BG Klinikum Hamburg Hamburg Germany"},{"name":"Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork\u2010Presbyterian Weill Medical College of Cornell University New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5808-8824","authenticated-orcid":false,"given":"J\u00f6rg","family":"Harrer","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopedics and Traumatology Sana Klinikum Lichtenfels Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4641-9224","authenticated-orcid":false,"given":"Felix","family":"Ferner","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopaedics Rostock University Medical Center Rostock Germany"},{"name":"Department of Orthopedics and Traumatology Sana Klinikum Lichtenfels Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8781-2751","authenticated-orcid":false,"given":"Bj\u00f6rn","family":"Vogt","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Pediatric Orthopedics, Deformity Reconstruction and Foot Surgery Muenster University Hospital Muenster Germany"},{"name":"General Orthopedics and Tumor Orthopedics Muenster University Hospital Muenster Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2159-2071","authenticated-orcid":false,"given":"Florian B.","family":"Imhoff","sequence":"additional","affiliation":[{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopaedics and Traumatology University Hospital of Basel Basel Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2418-6642","authenticated-orcid":false,"given":"Philipp","family":"Schuster","sequence":"additional","affiliation":[{"name":"Orthopedic Hospital Markgroeningen Centre for Sports Orthopedics and Special Joint Surgery Markgroeningen Germany"},{"name":"Osteotomy Committee of the German Knee Society (Deutsche Kniegesellschaft) Schwarzenbeck Germany"},{"name":"Department of Orthopedics and Traumatology, Clinic Nuremberg Paracelsus Medical University Nuremberg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,3]]},"reference":[{"issue":"9","key":"e_1_2_11_2_1","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1007\/s00402-004-0728-8","article-title":"Effect of high tibial flexion osteotomy on cartilage pressure and joint kinematics: a biomechanical study in human cadaveric knees. 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slope?","volume":"18","author":"Bisicchia S","year":"2017","journal-title":"J Orthop Traumatol"},{"issue":"6","key":"e_1_2_11_8_1","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1016\/j.clinbiomech.2009.03.008","article-title":"In vitro study of inter\u2010individual variation in posterior slope in the knee joint","volume":"24","author":"de Boer JJ","year":"2009","journal-title":"Clin Biomech"},{"issue":"6","key":"e_1_2_11_9_1","doi-asserted-by":"crossref","DOI":"10.1177\/23259671231179757","article-title":"Bone morphological characteristics as risk factors for anterior cruciate ligament injury: comparison between contact and noncontact injury","volume":"11","author":"Choi N\u2010H","year":"2023","journal-title":"Orthop J Sports Med"},{"issue":"3","key":"e_1_2_11_10_1","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1007\/s00590-014-1549-2","article-title":"Revision of failed anterior cruciate ligament reconstruction with quadrupled semitendinosus allograft: intermediate\u2010term outcome","volume":"25","author":"Chougule S","year":"2015","journal-title":"Eur J Orthop Surg Traumatol"},{"issue":"11","key":"e_1_2_11_11_1","doi-asserted-by":"crossref","first-page":"4652","DOI":"10.1007\/s00167-023-07550-5","article-title":"Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II\u2010surgical strategy","volume":"31","author":"Condello V","year":"2023","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"7","key":"e_1_2_11_12_1","doi-asserted-by":"crossref","first-page":"1419","DOI":"10.1007\/s40279-020-01424-3","article-title":"Risk factors for contra\u2010lateral secondary anterior cruciate ligament injury: a systematic review with meta\u2010analysis","volume":"51","author":"Cronstr\u00f6m A","year":"2021","journal-title":"Sports Med"},{"issue":"3","key":"e_1_2_11_13_1","doi-asserted-by":"crossref","first-page":"846","DOI":"10.1016\/j.arthro.2023.07.007","article-title":"Four to 6\u00b0 is 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ant\u00e9rieure \u00e0 propos de 22 cas","volume":"84","author":"Dejour D","year":"1998","journal-title":"Rev Chir Orthop"},{"issue":"8","key":"e_1_2_11_17_1","doi-asserted-by":"crossref","first-page":"736","DOI":"10.1055\/s-0037-1603637","article-title":"Sagittal plane corrections around the knee","volume":"30","author":"Dejour D","year":"2017","journal-title":"J Knee Surg"},{"issue":"2","key":"e_1_2_11_18_1","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1007\/s00167-018-5180-3","article-title":"Preoperative laxity in ACL\u2010deficient knees increases with posterior tibial slope and medial meniscal tears","volume":"27","author":"Dejour D","year":"2019","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"10","key":"e_1_2_11_19_1","doi-asserted-by":"crossref","first-page":"4467","DOI":"10.1007\/s00167-023-07493-x","article-title":"First revision ACL reconstruction combined with tibial deflexion osteotomy improves clinical scores at 2 to 7 years 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