The role of slope-increasing tibial osteotomy in posterior cruciate Ligament Insufficiency and Reconstruction: A Scoping Review of techniques, biomechanics, and clinical outcomes

To map existing evidence on slope-increasing osteotomy for posterior knee instability related to posterior cruciate ligament (PCL) insufficiency or PCL reconstruction, focusing on surgical techniques, biomechanical effects, and clinical outcomes. A scoping review was conducted according to PRISMA-ScR guidelines, with PubMed, MEDLINE, and EMBASE searched on January 31 2026 for studies discussing PCL insufficiency or reconstruction with a slope-increasing osteotomy. Eligible studies included clinical studies, biomechanical analyses, and surgical technique reports. A total of 17 studies met the inclusion criteria (8 technique papers, 7 biomechanical studies, 2 clinical case series). Technique reports often described a slope-increasing anterior opening-wedge osteotomy ( n = 5), with some describing a biplanar high tibial osteotomy ( n = 3). Fixation was often performed with plates and bone grafting was universally reported. Target correction was inconsistently specified, with reported goals generally targeting a final slope of 5–10 degrees. Biomechanical investigations included 51 cadaveric knees and 15 computational models. Studies consistently demonstrated that increasing PTS shifted the tibial resting position anteriorly, reduced posterior tibial sag, and decreased PCL or graft loading. Clinical evidence was limited to two case series ( n = 16), with heterogeneous indications and techniques. One study comprising six patients reported that one patient required re-fixation for delayed union at 4 months and two other patients required hardware removal and subsequent ligament reconstruction after 12 months (reoperation 3/6; 50%). The other study of 10 patients reported improvement in functional outcomes after slope-increasing osteotomy with no complications or reoperations. Slope-increasing osteotomy for PCL deficiency is supported by technical descriptions and biomechanical rationales, yet clinical outcomes data remain sparse and require further investigation. Slope increases can reduce posterior sag and decrease graft loads. There are significant knowledge gaps in optimal indications, slope thresholds, correction targets, and comparative effectiveness with and without PCL reconstruction.