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September 10, 2025Open Access

Steeper medial posterior tibial slope is associated with bilateral ACL injuries: A radiographic comparison with unilateral cases

JDJulien DruelCentre National de la Recherche Scientifique PLPaul LaidetCentre National de la Recherche Scientifique AKApoorva KhajuriaRoyal London Hospital

Key Points

A steeper medial posterior tibial slope is significantly associated with the need for bilateral ACL reconstruction.
Patients in the biACLR group had a higher mean MPTS of 12.39° compared to 8.16° in the uniACLR group, indicating a notable difference.
Retrospective comparative cohort study involving 114 patients matched for age, gender, and BMI was conducted to assess MPTS.
These findings suggest that systematic assessment of MPTS could identify patients at risk for contralateral ACL injuries, aiding surgical planning.

Abstract

The posterior tibial slope (PTS) plays a key role in knee biomechanics and may influence the risk of anterior cruciate ligament (ACL) rupture as well as the outcomes of its reconstruction. We hypothesised that a steeper medial posterior tibial slope (MPTS) would be associated with an increased risk of bilateral ACL reconstruction compared to unilateral reconstruction. This study aimed to test this hypothesis by comparing the MPTS between patients undergoing unilateral ACL reconstruction (uniACLR) and those requiring non-simultaneous bilateral ACL reconstruction (biACLR), using radiographic imaging. This single-centre retrospective study included 114 patients (57 uniACLR, 57 biACLR), matched by age, gender, body mass index (BMI), and presence of meniscal injury. The MPTS was measured on standardised lateral radiographs. Meniscal, cartilage, and ligamentous injuries were evaluated arthroscopically. Statistical analyses included univariate and multivariate models, with a significance threshold of p < 0.05. Patients in the biACLR group demonstrated a significantly higher MPTS compared to the uniACLR group (mean ± SD: 12.39° ± 2.74° vs. 8.16° ± 1.67°; mean difference 4.23°, 95% confidence interval: 3.35°-5.11°; p < 0.0001). No significant differences were observed between groups in meniscal, cartilaginous lesions, graft selection, use of lateral extra-articular tenodesis, or reoperation rates. Subgroup analysis indicated that higher MPTS was particularly associated with meniscal root tears. A steeper MPTS is significantly associated with bilateral ACL reconstruction, suggesting it may represent an anatomical risk factor for repeated ACL injuries. Systematic assessment of MPTS may help identify patients at higher risk of contralateral ACL injury, aiding in surgical planning and postoperative monitoring. Level III, retrospective comparative cohort study.

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