Association of Slope-Reducing Osteotomy With Return to Preinjury Level of Sport After Failed Anterior Cruciate Ligament Reconstruction in Elite Athletes

Background: Increased posterior tibial slope (PTS) has been identified as a major risk factor for failure after anterior cruciate ligament reconstruction (ACLR). In athletes with high PTS undergoing revision ACLR, slope-reducing osteotomy (SRO) has been proposed to reduce anterior cruciate ligament graft forces and improve outcomes, but data regarding return to sport in elite athletes remain limited. Purpose: To evaluate whether combining SRO with revision ACLR would allow elite athletes with increased PTS to return to their preinjury level of sport and, further, to assess clinical, functional, and radiographic outcomes. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study included elite athletes with failed ACLR and PTS ≥10° who underwent revision ACLR combined with supratuberosity SRO between 2011 and 2023 at 2 centers. Return-to-sport (RTS) rate and time, clinical and functional outcomes (International Knee Documentation Committee [IKDC], Lysholm, Tegner, Anterior Cruciate Ligament–Return to Sport After Injury scale [ACL-RSI]), and radiographic parameters (PTS, hip-knee-ankle angle, and Caton Deschamps index) were evaluated. Results: Of the 22 ACLRs with SRO performed, 19 patients met the inclusion criteria. All athletes returned to competition at their preinjury level after a mean of 12.1 ± 2.3 months (range, 10-20 months), with a mean ACL-RSI score of 87.2 ± 6.7. Final scores, obtained at a mean follow-up of 58.8 ± 38.7 months (range, 24-169 months), showed excellent outcomes: IKDC score improved from 44.2 ± 10.7 preoperatively to 92.3 ± 6.7 postoperatively ( P < .001; 95% CI, 42-54), and Lysholm score improved from 46.8 ± 14.2 to 96.9 ± 3.1 ( P < .001; 95% CI, 35.2-65). Postoperative Tegner score corresponded to elite participation (mean, 9.7). Mean PTS decreased from 14.9°± 3° to 4.5°± 2.8°, with no significant changes in coronal alignment or patellar height. No graft failure or major complications occurred; reoperations were limited to staple removal for local discomfort. Conclusion: In elite athletes with high PTS and failed ACLR, combining SRO with revision ACLR was safe and effective, enabling RTS with excellent clinical and functional outcomes.