Posterior tibial slope in anterior cruciate ligament surgery: The pitfalls of simplifying a complex risk factor

Anterior cruciate ligament (ACL) injury and graft failure remain multifactorial problems, yet few anatomical parameters have received as much attention in recent years as the posterior tibial slope (PTS) [1,2]. A growing body of biomechanical and clinical evidence has established increased PTS as a relevant risk factor for both primary ACL injury and graft failure after anterior cruciate ligament reconstruction (ACL-R) [3,4]. By promoting anterior tibial translation and increasing strain on the ACL or ACL graft, a steeper PTS contributes to a biomechanical environment that might challenge ligament integrity [4].