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    Radiographic medial posterior tibial slope ≥16° predicts multiple revisions after anterior cruciate ligament reconstruction
    (Wiley, 2026) Kayaalp, Mahmut Enes; Inoue, Jumpei; Konstantinou, Efstathios; Kahraman, Hamit Çağlayan; Erden, Tunay; Musahl, Volker
    Purpose: An increased posterior tibial slope (PTS) has been implicated as a risk factor for anterior cruciate ligament (ACL) graft failure. This matched case–control study aimed to compare radiographic and magnetic reso nance imaging (MRI)‐based PTS measurements between patients under going multiple revision anterior cruciate ligament reconstruction (ACLR) and those with successful primary ACLR and to identify thresholds predictive of high revision risk. Methods: In this matched case–control study, 156 patients were analysed: 78 patients undergoing multiple revision ACLR and 78 patients with suc cessful primary ACLR. Medial PTS was measured on radiographs, while medial, lateral and PTS difference (PTS asymmetry) were measured on MRI. Group differences were assessed using independent t tests and χ2 tests. Receiver operating characteristic (ROC) analysis identified optimal thresholds, and logistic regression quantified odds ratios (ORs) for multiple revisions per 1° increase in radiographic medial PTS, adjusting for body mass index (BMI), sex, side, height and weight. Results: Radiographic medial PTS was significantly higher in the multiple‐ revision group (12.5 ± 3.5° vs. 11.2 ± 3.0°, p = 0.016). ROC analysis identi fied an optimal medial PTS cutoff of 13° (area under the curve = 0.58, sensitivity = 0.49, specificity = 0.65), but only a PTS ≥ 16° was significantly associated with increased multiple revision risk (OR = 3.10, 95% confidence interval [CI]: 1.14–8.40; p = 0.037; specificity = 0.91; positive predictive value [PPV] = 0.70). MRI‐based medial and lateral PTSs, as well as PTS asymmetry, did not differ significantly between groups. Univariate logistic regression demonstrated a 10% increase in odds per 1° increase in radio graphic PTS (OR = 1.10, 95% CI: 1.00–1.22, p = 0.049), remaining signifi cant after adjustment for BMI, sex, side, height and weight (adjusted OR = 1.11, 95% CI: 1.01–1.23, p = 0.034). Radiographic medial PTS cor related moderately with MRI‐based medial PTS (r = 0.49, p < 0.001), but not with lateral PTS (p: n.s.). Conclusion: Radiographic medial PTS showed the strongest differentiation between successful primary ACLR and multiple‐revision ACLR. A PTS ≥ 16° identifies patients at significantly higher risk of multiple revisions, whereas MRI‐based medial PTS, lateral PTS and PTS asymmetry provide no addi tional discriminatory value. Radiographic medial PTS appears practical for preoperative risk stratification, whereas MRI‐based measures do not show similar utility. Level of Evidence: Level III.