ACL Tear With a Lateral Meniscal Root Tear and a Steep Posterior Tibial Slope

Both are failure multipliers. A lateral posterior root tear left unrepaired produces meniscal extrusion, loss of hoop tension, and rapid cartilage loss in a young patient; repair is best performed within roughly 4–6 weeks before the tear retracts and the meniscus becomes nonviable, and it requires protected weight bearing and limited flexion for 4–6 weeks afterward. That sequencing drives the ACL timing. I would do the root repair and ACL reconstruction together, but with a rehabilitation plan weighted toward meniscal protection, or stage them if the knee is still swollen and range of motion is not restored, since operating on a stiff, swollen knee risks arthrofibrosis. The 14° lateral posterior tibial slope is above the roughly 12° threshold associated with graft failure and meniscal re-tear. In a primary case with existing medial chondral change I would not routinely add a slope-reducing osteotomy, but I would counsel him that his slope is a risk factor, consider osteotomy strongly if this were a revision, and lean toward an anterolateral extra-articular tenodesis.

He is a 28-year-old, BMI 31 basketball player with a 2+ pivot shift and a previously reconstructed contralateral knee, which marks him as a high-risk, high-demand athlete whose opposite knee has already failed once. I would use a bone–patellar tendon–bone or quadrupled hamstring autograft; my preference here is hamstring autograft combined with an anterolateral extra-articular tenodesis, because the combination lowers rotational failure rates in high-risk patients and spares the extensor mechanism, which matters for jumping and for his BMI-related risk of anterior knee pain. Bone–patellar tendon–bone has a low re-rupture rate in some series but a higher rate of anterior knee pain and kneeling difficulty. I would avoid allograft in a 28-year-old. I would also address the root tear with a transtibial or suture-anchor repair and treat the grade 2 medial chondral lesion with debridement rather than cartilage restoration at this stage, deferring any larger cartilage procedure to a separate discussion.

Time alone is not a criterion. I would require at least 9 months, full symmetric range of motion, quadriceps limb symmetry index of at least 90%, hamstring symmetry of at least 90%, and passing single-leg hop, triple hop, and crossover hop tests at 90% or more of the uninjured side. Add a jump-landing assessment and the ACL-RSI psychological readiness score, since patients who return with low confidence have higher re-injury rates. Basketball-specific work with cutting, pivoting, and contested rebounding precedes clearance, and I would plan a gradual return with limited minutes. Counseling: with a prior contralateral reconstruction his risk of a second ACL injury is meaningfully elevated, on the order of 15–25% in young athletes returning to pivot sport, and the meniscal repair carries its own failure risk if he returns too early or abandons the protected-weight-bearing phase. His 14° slope is not modifiable without osteotomy, so strength, landing mechanics, and load management are his levers. Document that clearance is shared with the athletic trainer.