In the presence of markedly increased posterior tibial slope (PTS) — recognised as a risk factor for anterior cruciate ligament (ACL) graft failure — conventional anterior closing wedge osteotomies may not achieve the desired correction, especially when the required slope change exceeds ~20° or when patellofemoral mechanics and fixation risks are significant. This paper introduces the concept of a tibial plateau-leveling osteotomy (TPLO-style in humans) as an alternative — a curved osteotomy around the proximal tibia that enables larger slope correction while preserving soft tissue tension and patellofemoral mechanics.
Scope & technique overview
Authored by Matthieu Ollivier et al., the paper is published in Arthroscopy Techniques (2024) with PMID 40207317. The authors describe a human adaptation of the TPLO (commonly used in canine knees), applied to knees with massive sagittal tibial deformity and ACL-deficient or revision settings. The technique involves:
- Planning the osteotomy radius of rotation just above the proximal tibio-fibular joint, centred on the proximal tibia.
- Drilling a curved osteotomy from anterior to posterior across the tibial plateau, then rotating the proximal segment to reduce the slope.
- Fixing the osteotomy with locking plates allowing early mobilisation.
- Benefits cited include improved soft-tissue tension maintenance, avoidance of patella alta/baja, and control of large slope corrections.
Clinical implications & take-home messages
- Surgeons should recognise that very high posterior tibial slopes (>15°–20°) may be inadequately addressed by standard closing wedge osteotomies; the TPLO-style approach offers a robust alternative.
- Pre-operative planning must include full sagittal imaging, measurement of PTS, and planning of the radius of rotation for the curved osteotomy to achieve exact correction.
- Preservation of the extensor mechanism and patellar tracking remains key; this approach may reduce the risk of patellofemoral complications which can occur with large wedge osteotomies.
- While this is a technique description (rather than a large outcomes series), surgeons managing complex ACL revision cases with massive slope should consider this advanced option.
