<i>Editorial Commentary</i> : Managing Posterior Tibial Slope in Knee Ligament Surgery: What Is All the Fuss?

Graft failure after knee ligament reconstruction persists despite decades of technical refinement in anterior cruciate ligament and posterior cruciate ligament surgery. Recently, attention has shifted towards posterior tibial slope (PTS) as a key, modifiable driver of graft biomechanics and clinical outcomes. Importantly, multiple authors have reported that increased PTS promotes anterior tibial translation, thus elevating the stress placed upon the anterior cruciate ligament graft while decreased slope may overload posterior cruciate ligament reconstructions. Although multiple imaging modalities exist to measure PTS, recent work has emphasized the importance of using the medial tibial slope rather than the lateral slope, and to ideally perform the slope measurement on a full-length, standing mono-pedal lateral tibial radiograph with at least 15 cm of tibial bone length. Currently, there is no standard "cut off" values for PTS, in particular for bicruciate ligament reconstructions. Optimization of PTS and its downstream effects on both anterior and posterior tibial translation may represent one of the most impactful opportunities to improve patient outcomes and reduce graft failure rates in complex knee ligament surgery.