Does Posterior Tibial Slope Affect Graft Rupture

Following ACL Reconstruction?

Chae Chil Lee, M.D., Yoon Seok Youm, M.D., Sung Do Cho, M.D., Seung Hyun Jung, M.D.,
Mun Hee Bae, M.D., Seon Jae Park, M.D., and Han Wook Kim, M.D.

Purpose: The purpose of this study was to evaluate the association between posterior tibial slope (PTS) and anterior
cruciate ligament (ACL) graft rupture in patients who have undergone ACL reconstruction by comparing results in
patients who experienced graft rupture and a matched control group. Methods: The study included 64 knees of 64
patients (58 men and 6 women), of mean age 31 years (range, 18-60 years) who underwent revision ACL reconstruction
for ACL graft rupture, as well as a control group without ACL graft rupture matched for age, sex, body mass index (BMI),
and left or right side. The mean time to failure in study group was 48.5 months, and after revision surgeries, the mean
follow-up period was 37.7 months. The graft used for the primary surgery was autograft in 3 patients (4.7%) and allograft
in 49 patients (76.6%). The type of graft could not be confirmed in the remaining 12 patients (18.7%). PTS was measured
on plain radiographs and compared in the 2 groups. Results: Mean PTS was significantly higher in patients with
(13.2
 2.5
; range, 8.5
-18.2
) than without (10.9
 3.1
; range, 4.9
-13.6
) rerupture (P < .01). When mean PTS was
compared in the 37 patients who underwent primary surgery by the same surgeon, it was significantly higher in patients
with (13.5
 2.5
; range, 8.5
-18.2
) than without (11.1
 2.9
; range, 5.1
-13.6
) rerupture (P < .01). PTS in patients
with rerupture was not significantly associated with age, gender, BMI, and right or left side. The odds ratio of ACL graft
rupture in knees with PTS 12
was 4.52 (P < .001). Conclusions: This study showed that mean PTS was significantly
greater in patients with than without noncontact ACL graft rerupture (13.2
vs 10.9
, P < .01). The failure of ACL
reconstruction appears to be associated with increased PTS, with PTS 12
a risk factor for the failure of ACL
reconstruction. Level of Evidence: Level III, retrospective comparative study.

A natomic characteristics of a knee joint have been

associated with injury to the anterior cruciate
ligament (ACL).1 These include a narrow intercondylar
notch, steep posterior tibial slope (PTS), generalized
joint laxity, and increased Q-angle.1-5 Among those,
increased PTS can cause anterior displacement of the
tibia, affecting the biomechanics of the ACL.6-8 Even-
tually, this may increase the risk of ACL rupture.
From the Department of Orthopedic Surgery, Ulsan University Hospital,
University of Ulsan College of Medicine (C.C.L., Y.S.Y., S.H.J., M.H.B., S.J.P.,
H.W.K.); and Department of Orthopedic Surgery, Dongcheondongkang Hos-
pital (S.D.C.), Ulsan, Korea.
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Full ICMJE author disclosure forms are
available for this article online, as supplementary material.
Received August 8, 2017; accepted January 30, 2018.
Address correspondence to Yoon Seok Youm, M.D., Associate Professor,
Department of Orthopedic Surgery, Ulsan University Hospital, 877
Bangeojinsunhwan-doro Dong-gu, Ulsan 44033, Korea. E-mail: tkra@naver.
com
Ó 2018 by the Arthroscopy Association of North America
0749-8063/17961/$36.00
https://doi.org/10.1016/j.arthro.2018.01.058
Moreover, increased PTS may predispose to ACL
injuries.2,9-14
Increases in the numbers of persons participating in
sports activities have increased the risks of ACL injury, as
well as rupture of an ACL graft. Salmon et al.15 reported
that after reconstruction, repeat ACL injury occurred in
6% of patients over 5 years. The revision rate in a
Swedish registry was 3.3%, and in a Danish registry it
was 4.1%.16,17 However, the relationship between the
risk of ACL graft rupture and PTS remains unclear.18-20
The purpose of this study was to evaluate the associa-
tion between PTS and ACL graft rupture in patients who
had undergone ACL reconstruction by comparing results
in patients who experienced graft rupture and a matched
control group. We hypothesized that PTS would be
greater in patients with ACL graft rupture.
Methods
The study included 64 knees of 64 patients who un-
derwent revision ACL reconstruction for ACL graft
rupture by a noncontact mechanism from April 2005 to
October 2014. Noncontact ACL injury occurs without
direct physical contact with other people or objects at

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2018: pp 1-4 1
2 C. C. LEE ET AL.

Table 1. Preoperative Demographics line was defined as the PTS (Fig 1). All parameters on
radiographs were measured with a picture archiving
Study Group Control Group
communication system (Pi view STAR software;
Patients (knees) 64 (64) 64 (64)
Age, mean 31 31 Infinitt, Seoul, South Korea). All measurements were
Gender, male:female 58:6 58:6 performed 2 times by 2 individuals who were blinded to
BMI, kg/m2, mean 25.2 25.5 patient grouping, and mean values were used. The
Time to failure, mos, mean 48.5 interobserver and intraobserver reliability (intraclass
Follow-up period, mos, mean 59.7
correlation coefficient) was calculated, and it was strong
NOTE. There were no significant differences between comparisons. for both (0.901-0.984 and 0.919-0.995).

the time of injury. The study population consisted of 58 Statistical Analysis

men and 6 women, of mean age 31 years (range, 18- Differences in PTS between groups with and without
60 years; Table 1). Of the 64 patients, 31 underwent ACL graft rerupture were analyzed by paired t-tests. The
operation on the right knee and 33 on the left knee; 37 associations between PTS and age, sex, BMI, and left or
underwent index surgery by one surgeon at our right side in the rerupture group were analyzed by inde-
hospital and 27 by 11 surgeons at other hospitals. The pendent t-tests and Pearson correlation tests. A logistic
mean time to failure in the study group was regression model was used to determine the probability of
48.5 months (range, 10-139 months), and after revision an ACL injury (odds ratio [OR]). All statistical analyses
surgeries, the mean follow-up period was 37.7 months were performed using commercially available software
(range, 12-126 months). The graft used for the primary (SPSS, Chicago, IL), with P values <.05 considered
surgery was autograft in 3 patients (4.7%) and allograft statistically significant. Post hoc power analysis showed
in 49 patients (76.6%). The type of graft could not be that a sample size of 64 patients in each group provided
confirmed in the remaining 12 patients (18.7%). The sufficient power for statics validation (effect size
transtibial technique was used for the index d ¼ 0.778, alpha ¼ 0.05, power[1-beta] ¼ 0.9969).
reconstructions at our institution. This study was
approved by our institutional review board.
Among 81 patients who underwent revision ACL
reconstruction for ACL graft rupture during same
period, the study excluded 17 patients who had a
history of contact ACL injuries (9 patients), had
undergone rerevision ACL surgery (3 patients), had
undergone index surgeries using synthetic ligaments (2
patients), had multiple ligament injuries (2 patients), or
had combined fractures (one patient).
The control group included 64 patients who had
undergone ACL reconstruction at our hospital by a
single surgeon without ACL graft rupture and were
matched with the rerupture group by age, sex, body
mass index (BMI), and left or right side (Table 1). The
mean follow-up period was 59.7 months.
Among 64 patients of the study group, the 37 patients
who underwent primary surgery at our hospital by a
single surgeon and experienced ACL graft rupture were
matched with a control group of patients who underwent
primary surgery at our hospital without rerupture for
subgroup analysis.
PTS was measured on plain lateral radiographs. To
measure the PTS, the diaphyseal axis of the tibia was
drawn between 2 points equidistant from the anterior
and posterior borders of the tibia: one just below the
tibial tubercle and the other a further 10 cm below. A
reference line was drawn perpendicular to that axis at
the level of the tibiofemoral joint. The inclination of the
tibia was drawn from the most superior points at the
anterior and posterior edges of the medial tibial plateau Fig 1. Measurement of posterior tibial slope on a plain lateral
(dished surface). The angle of this line to the reference radiograph (right side).
 POSTERIOR TIBIAL SLOPE AND GRAFT RUPTURE
Table 2. Analysis of Posterior Tibial Slope Between the 2
Groups
Study Group Control Group
Mean posterior tibial 13.2
 2.5
10.9
 3.1

slope (range) (8.5
-18.2
) (4.9
-13.6
)
Results
Mean PTS was significantly higher in patients with
(13.2
 2.5
; range, 8.5
-18.2
) than without
(10.9
 3.1
; range, 4.9
-13.6
) rerupture (P < .01;
Table 2). When mean PTS was compared in the 37
patients who underwent primary surgery by the same
surgeon, it was significantly higher in patients with
(13.5
 2.5
; range, 8.5
-18.2
) than without
(11.1
 2.9
; range, 5.1
-13.6
) rerupture (P < .01).
Subgroup analysis of patients with rerupture showed
that the mean PTS did not differ significantly between
men (13.3
 2.4
; range, 8.5
-18.2
) and women
(12.2
 3.2
; range, 9.1
-17.9
; P ¼ .136) and did not
differ significantly between right (13.0
 2.6
; range,
8.5
-18.2
) and left (13.2
 2.4
; range, 8.5
-18.1
)
knees (P ¼ .840). In addition, PTS did not correlate with
age (P ¼ .241) or BMI (P ¼ .613).
A linear regression model showed that PTS was an
important risk factor for ACL graft rupture, with an OR
of 1.37 per 1
increase in PTS (P < .001). The OR of
ACL graft rupture in knees with PTS  11
was 3.48,
and with PTS  12
it was 4.52 (P < .001). In addition,
for determining a cutoff point, receiver operating
characteristic curves were calculated. At the optimal
cutoff point 12
, sensitivity was 0.703 and
1-specificity was 0.344.
Discussion
This study showed that mean PTS was significantly
greater in patients who experienced ACL graft rupture
than in matched control patients. However, PTS in
patients with ACL graft rupture was not associated with
age, gender, BMI, or right or left side injury.
The anatomical factors of a distal femur and a prox-
imal tibia may affect ACL injury.1-5 Although no
consensus has been reached to date, the relationship
between PTS and ACL injury has received considerable
attention.21-24 An increased PTS results in an anterior
translation of the tibia during weight-bearing activities,
potentially placing more strain on the ACL and
increasing the risk of ACL injury.6-8,14 To date,
however, few studies have assessed the relationship
between PTS and the risk of ACL graft rupture.6,18,19 A
prospective longitudinal (>15 years) case-control study
of 200 patients with isolated ACL ruptures found that
an increased PTS was associated with an increased
likelihood of further ACL injury after ACL reconstruc-
tion, with the increase most pronounced when PTS was
3
12
on radiographs.19 A case-control study of 20
patients who failed ACL reconstruction and 20
P Value
randomly selected controls found that both medial and
<.01
lateral PTSs were significantly steeper in those who
failed ACL reconstruction, with medial or lateral PTS 
5
, as determined by magnetic resonance imaging, be-
ing a new risk factor for ACL graft failure.18 Christensen
et al.20 suggested that an increased lateral PTS as
measured on magnetic resonance imaging was
associated with an increased risk for early ACL graft
failure. Our matched control study showed similar
findings, in that increased PTS on radiography was
significantly associated with ACL graft rupture.
In general, the etiology of ACL graft failure can be
divided into 3 categories: (1) surgical technique, (2)
trauma, and (3) biological causes.25 Except for direct
contact injuries, the most common causes of ACL graft
failure are technical problems during surgery, such as
malposition of the femoral and tibial tunnels or
inappropriate fixation of the grafts. A systematic review
reported that causes of previous graft failure included
technical error in 45.8% of knees, traumatic reinjury in
49.3%, and biological factors in 4.9%.26 However, the
relationship between PTS and ACL graft rupture was
rarely evaluated. Our study excluded patients with
contact ACL injuries. Moreover, to minimize the effects
of technical error, we evaluated the subgroup of patients
who underwent primary surgery by a single surgeon.
Our results showed that patients with a steeper PTS were
at higher risk of rupture of a reconstructed ACL graft.
Limitations
The limitations of this study included the relatively
small number of patients and possible selection bias for
selecting the control group. However, the number of
revision ACL reconstruction procedures is much smaller
than that of primary ACL reconstruction. Other limita-
tions include the retrospective design of this study and
the multifactorial causes of ACL reconstruction failure.
In addition, type and intensity of sports activity were not
considered in selection of the matched controls, even
though participation in high-risk sport activity appar-
ently is a risk factor for graft reruptures. In addition, the
effects of other potential risk factors such as reconstruc-
tive procedure on the graft rupture rate were not
subjected to the analysis. The use of plain radiographs for
measurement of PTS may be listed as a study limitation
because separate analysis of medial/lateral PTS may not
be feasible in this method. Lastly, this study does not
describe any changes in therapy, bracing, activity, graft
type, or injury associated with rerupture.
Conclusions
This study showed that mean PTS was significantly
greater in patients with than without noncontact ACL
graft rerupture (13.2
vs 10.9
, P < .01). The failure of
4 C. C. LEE ET AL.
ACL reconstruction appears to be associated with
increased PTS, with PTS  12
a risk factor for the
failure of ACL reconstruction.
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