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Background: An increased posterior tibial slope (PTS) is a proven risk factor for both native anterior cruciate ligament (ACL) and ACL graft insufficiency. Anterior closing wedge high tibial osteotomy (ACW-HTO) for PTS correction is a validated procedure in revision ACL reconstruction (ACLR)., Purpose/hypothesis: The aim of this study was to evaluate the effect of combined ACW-HTO and at least a second revision ACLR procedure on knee stability, function, and sports performance in a large series of patients. The hypothesis was that patients would return to impact sports after ACW-HTO combined with a second or third revision ACLR procedure., Study Design: Case series; Level of evidence, 4., Methods: A total of 64 patients who underwent a second (or more) revision ACLR procedure and ACW-HTO between June 1, 2015, and June 1, 2019, and had a PTS >12° were included. The mean age was 29.60 ± 6.31 years, and the mean preoperative PTS was 13.79°± 1.50°. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 years (range, 2-5 years). At the last follow-up, the rate of patients returning to impact sports (based on the University of California, Los Angeles [UCLA], activity scale), ACL graft status (per magnetic resonance imaging), International Knee Documentation Committee (IKDC) scores, Lysholm scores, and laxity measurements using a knee arthrometer were recorded., Results: The total number of patients participating in impact sports and high-impact sports was as follows: 43 and 30, respectively, before the injury; 0 and 0, respectively, preoperatively; and 31 and 12, respectively, postoperatively. At the last follow-up, the UCLA score was ≥8 in 48.44% of the patients, and only 16 patients returned to their preinjury level of activity. At a minimum of 2 years of follow-up, there was clinical improvement in the IKDC score from 37.98 ± 12.48 preoperatively to 69.06 ± 12.30 postoperatively ( P < .0001), in the Lysholm score from 51.94 ± 14.03 preoperatively to 74.45 ± 11.44 postoperatively ( P < .001), and in the UCLA score. However, this clinical improvement did not equate to preinjury values for all outcome scores ( P < .001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71 and 89.26 ± 8.91, respectively. The mean change in anterior knee laxity using a knee arthrometer at 134 and 250 N was -4.03 ± 0.18 mm and -3.63 ± 0.16, respectively. There were 3 cases of a rerupture with a severe pivot shift on the clinical examination. None of these patients underwent revision per the patient's preference. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic., Conclusion: In the setting of chronic ACL-deficient knees, PTS reduction (ACW-HTO) with revision ACLR restored knee stability and improved function with an acceptable rate of specific complications. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Also, approximately half of the patients were able to return to impact sports., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.O. has received consulting fees from Newclip Technics, Arthrex, and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Return to sport after stabilization surgery using the open Latarjet procedure remains challenging. Additional knowledge is needed about postoperative shoulder functional deficits in order to better design return-to-sport programs., Purpose: To investigate the effects of the dominance status of the operated shoulder on the shoulder functional profile recovery at 4.5 months after open Latarjet procedure., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A retrospective analysis of prospectively collected data was performed. All patients who underwent the open Latarjet procedure between December 2017 and February 2021 were eligible for the study. Functional assessment at 4.5 months after the surgery was performed using the following tests: maximal voluntary isometric contractions in glenohumeral internal and external rotation, upper-quarter Y balance test, unilateral seated shot-put test, and modified closed kinetic chain upper extremity stability test, leading to 10 outcome measures. Patients whose dominant side had undergone surgery and those whose nondominant side had undergone surgery were compared with a group of 68 healthy control participants., Results: A total of 72 patients who underwent an open Latarjet procedure on the dominant side and 61 patients who underwent open Latarjet on the nondominant side were compared with 68 healthy control athletes. In patients whose dominant shoulder had undergone surgery, significant deficits for the dominant side ( P < .001) and for the nondominant side ( P < .001) were found in 9 of 10 functional outcome measures. Among patients whose operations were on the nondominant shoulder, significant deficits for the nondominant side ( P < .001) and for the dominant side ( P < .001) were found in 9 and 5 of the 10 functional outcome measures, respectively., Conclusion: Regardless of dominance of the stabilized shoulder, persistent deficits in strength, stability, mobility, power, and stroke frequency were observed at 4.5 months postoperatively. Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides. However, stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder., Registration: NCT05150379 (ClinicalTrials.gov identifier).

Background: Recent imaging studies demonstrate that the anterolateral ligament (ALL) is frequently injured at the time of anterior cruciate ligament (ACL) rupture. The intrinsic healing potential of these injuries after ACL reconstruction (ACLR) has not been defined., Purpose/hypothesis: The primary objective was to evaluate the rate and duration of the healing process of injured ALLs after ACLR using serial 3-dimensional magnetic resonance imaging (3D-MRI). The secondary objective was to investigate whether any patient, injury, or surgical factors influenced the healing rate. The hypothesis was that serial imaging would demonstrate that the ALL has limited healing potential., Study Design: Case series; Level of evidence, 4., Methods: Patients enrolled in the study underwent 3D-MRI (slice thickness 0.5 mm) preoperatively and at 1, 6, 12, and 24 months after ACLR. Three observers determined the grade of ALL injury according to the Muramatsu classification. Inter- and intraobserver reliabilities were calculated. The rates of injury and time points for healing were determined. Full healing was defined as a change from a preoperative Muramatsu grade of B or C (indicating partial or complete injury) to grade A (normal). Multivariate analysis was used to investigate the association of aforementioned factors with the risk of incomplete healing., Results: A total of 44 patients were enrolled in the study. Of them, 71.2% had an ALL injury on preoperative imaging. Overall, full healing of ALL injuries occurred at a rate of 3.2%, 15.2%, and 30.3% at 1, 6, and 12 months, respectively. There were no changes in the Muramatsu grade in any patient beyond 12 months postoperatively. None of the complete lesions demonstrated full healing, but the proportion of patients with a grade C injury decreased from 13.6% preoperatively to 4.5% at 12 months due to an improvement to grade B in 4 of 6 patients (66%). Inter- and intraobserver reliabilities of the classification system were almost perfect at 0.81-0.94 and 0.95-1.00, respectively. None of the potential risk factors investigated were predictive of an increased risk of nonhealing., Conclusion: ALL injuries occurred in the majority of ACL-injured knees. They had limited intrinsic healing potential, with only 30.3% healing by 12 months after ACLR. The process of healing took >6 months in half of the patients in whom it occurred. No new cases of full healing occurred beyond 12 months postoperatively. No significant risk factors for failure of full healing to occur were identified, but it is likely that this aspect of the study was underpowered.

Purpose: To review a single-center experience with fenestrated and branched endovascular aneurysm repair (f/bEVAR) in patients with challenging iliac anatomies., Materials and Methods: A retrospective review of the department's database identified 398 consecutive patients who underwent complex endovascular repair f/bEVAR between January 2010 and June 2018; of these, 67 had challenging accesses. The strategies implemented to overcome access issues were reviewed, using a dedicated scoring system to evaluate the access (integrating diameter, tortuosity, calcification, and previous open or endovascular repair)., Results: In this subgroup of patients, the most common graft design was a 4-vessel fenestrated endograft (27, 40.3%). Hostile access was due to small diameter (<7 mm) in 25 patients (37.3%) and/or concentric calcifications in 19 patients (26.9%). Mean iliac diameter was 5.5±2.6 mm on the right side and 6.0±2.5 mm on the left side. Previous open or endovascular aortoiliac repair had been performed in 15 patients (22.4%), and 20 patients (29.9%) had a stent previously implanted in at least 1 iliac artery, resulting in the inability to perform standard fenestrated repair with access from both sides. Five patients (7.5%) had a single patent iliac access. Eight distinctive strategies were identified to overcome these access issues, including the use of preloaded renal catheters in the endograft delivery system, angioplasty, graft modification (branches instead of fenestrations or 4 preloaded fenestrations), a conduit via a retroperitoneal approach, iliac artery recanalization, and/or the multiple puncture technique. Technical success was achieved in 62 cases (92.5%). Four patients had access complications and 1 died in the early postoperative period of multiorgan failure. Median follow-up was 24.6 months (IQR 7.2, 41.3). Clinical success at the end of follow-up was achieved in 57 patients (85.1%). During follow-up, 14 patients died, including 4 from an aorta-related cause., Conclusion: Dedicated strategies can be implemented to overcome hostile iliac access in patients with complex aneurysms when f/bEVAR is required. Typically, these maneuvers are associated with favorable outcomes.

Background: Cyclops syndrome is characterized by a symptomatic extension deficit attributed to impingement of a cyclops lesion within the intercondylar notch. The syndrome is an important cause of reoperation after anterior cruciate ligament reconstruction (ACLR). It has been suggested that remnant-preserving ACLR techniques may predispose to cyclops syndrome, but there is very limited evidence to support this. In general terms, risk factors for cyclops syndrome are not well-understood., Purpose: To determine the frequency of and risk factors for reoperation for cyclops syndrome in a large series of patients after ACLR., Study Design: Case-control study; Level of evidence, 3., Methods: A retrospective analysis of prospectively collected data was performed, including all patients who underwent primary ACLR between January 2011 to December 2017. Patients undergoing major concomitant procedures were excluded. Demographic data, intraoperative findings (including the size of preserved remnants), and postoperative outcomes were recorded. Those patients who underwent reoperation for cyclops syndrome were identified, and potential risk factors were evaluated in multivariate analysis., Results: A total of 3633 patients were included in the study, among whom 65 (1.8%) underwent reoperation for cyclops syndrome. Multivariate analysis demonstrated that preservation of large remnants did not predispose to cyclops lesions (odds ratio [OR], 1.11; 95% CI, 0.63-1.93). The most important risk factor was extension deficit in the early postoperative period. If present at 3 weeks postoperatively, it was associated with a >2-fold increased risk of cyclops syndrome (OR, 2.302; 95% CI, 1.268-4.239; P < .01), which was increased to 8-fold if present 6 weeks after ACLR (OR, 7.959; 95% CI, 4.442-14.405; P < .0001). None of the other potential risk factors evaluated were found to be significantly associated with an increased frequency of cyclops syndrome., Conclusion: Failure to regain full extension in the early postoperative period was the only significant risk factor for cyclops syndrome after ACLR in a large cohort of patients. Other previously hypothesized risk factors, such as preservation of a large anterior cruciate ligament remnant, did not predispose to the development of this debilitating postoperative complication.

Background: Professional athletes are reported to be at greater risk of septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) than the nonprofessional population. However, this finding has been controversial, and confusion has arisen in the literature owing to the underpowering of previous studies., Purpose/hypothesis: The purpose was to report the differences in the rate of SA after ACLR in a large series of patients and to perform pooled data analysis including previously published studies. The hypothesis was that professional athletes have a significantly higher risk of SA than nonprofessional athletes., Study Design: Case-control study; Level of evidence, 3., Methods: A retrospective analysis of prospectively collected data was performed. Patients who underwent ACLR between January 2009 and July 2017 (with a minimum follow-up of 12 months) were considered for study eligibility. The rate of SA was determined, and multivariate analysis was used to evaluate potentially important risk factors, including participation in professional sport. Furthermore, a literature search was performed, and data were extracted from all identified relevant studies. A pooled data analysis was performed to determine differences in the risk of SA between professional and nonprofessional populations., Results: The current series comprised 4421 anterior cruciate ligament surgical procedures with 265 professional athletes. There were 15 cases of SA diagnosed over the study period (0.34%; 95% CI, 0.19%-0.56%). Ten cases occurred in professional athletes (3.8%; 95% CI, 1.82%-6.83%). The percentage of SA was 0.12% (95% CI, 0.04%-0.28%) in the nonprofessional population. Being a professional athlete was associated with a significantly increased risk of SA after ACLR (odds ratio, 21.038; 95% CI, 6.585-75.789; P < .0001). This finding was confirmed in the pooled data analysis comprising 11,416 patients including 1118 professional athletes (odds ratio, 5.03; 95% CI, 1.17-21.61)., Conclusion: Professional athletes are at greater risk of SA after ACLR than nonprofessional athletes. The results of previous studies may have been conflicting owing to underpowering. The current study confirms the elevated risk by using a large clinical series and pooled data analysis to avoid the limitations of previous studies.

Background: Folfirinox (FFX) and gemcitabine/nab-paclitaxel (GN) are both standard first-line treatments in patients with metastatic pancreatic cancer (mPC). However, data comparing these two chemotherapeutic regimens and their sequential use remain scarce., Methods: Data from two independent cohorts enrolling patients treated with FFX ( n  = 107) or GN ( n  = 109) were retrospectively pooled. Primary endpoint was overall survival (OS). Progression-free survival (PFS) was the secondary endpoint. A propensity score based on age, gender, performance status (PS), and presence of liver metastases was used to make groups comparable., Results: In the whole study population, OS was significantly higher in FFX (14 months; 95% CI: 10-21) than in GN groups (9 months; 95% CI: 8-12) before ( p  = 0.008) and after ( p  = 0.021) adjusting for age, number of metastatic sites, liver metastases, peritoneal carcinomatosis and CA19.9 level at baseline. PFS tends to be higher in FFX (6 months) than GN groups (5 months; p  = 0.053). After matching ( n  = 49/group), patients were comparable for all baseline characteristics including PS. In the matched population, there was a trend toward greater OS in patients treated with FFX (HR = 0.67; p  = 0.097). However, survival in each group was not solely a result of the first-line regimen. The proportion of patients who were fit for GN after FFX failure (FFX-GN sequence) was higher (46.9%) than the reverse sequence (20.4%; p  = 0.01), which suggests a higher feasibility for the FFX-GN sequence. Corresponding median OS were 19 months versus 9.5 months, respectively ( p  = 0.094)., Conclusion: This study shows greater OS with FFX than with GN in patients with mPC. GN after FFX failure appears more feasible than the reverse sequence., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2019.)

Background: Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of anterior cruciate ligament reconstruction (ACLR) has been shown to improve knee biomechanics., Purpose: The primary objectives of this study were to evaluate the incidence of and risk factors for ramp lesions among a large series of patients undergoing ACLR. Secondary objectives were to determine the reoperation rate for failure of ramp repair, defined by subsequent reoperations for partial medial meniscectomy., Study Design: Case-control study; Level of evidence, 3. Case series; Level of evidence, 4., Methods: All patients underwent transnotch posteromedial compartment evaluation of the knee during ACLR. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of 2 years was undertaken to determine the secondary partial meniscectomy rate for failed ramp repair., Results: The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions among 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male sex, patients aged <30 years, revision ACLR, chronic injuries, preoperative side-to-side laxity >6 mm, and concomitant lateral meniscal tears. The secondary meniscectomy rate was 10.8% at a mean follow-up of 45.6 months (range, 24.2-66.2 months). Patients who underwent ACLR + anterolateral ligament reconstruction had a >2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95% CI, 0.226-0.864; P = .021)., Conclusion: There is a high incidence of ramp lesions among patients undergoing ACLR. The identification of important risk factors for ramp lesions should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates.

Background: The prevalence of osteoarthritis after successful meniscal repair is significantly less than that after failed meniscal repair., Purpose: To determine whether the addition of anterolateral ligament reconstruction (ALLR) confers a protective effect on medial meniscal repair performed at the time of anterior cruciate ligament reconstruction (ACLR)., Study Design: Cohort study; Level of evidence, 3., Methods: Retrospective analysis of prospectively collected data was performed to include all patients who had undergone primary ACLR with concomitant posterior horn medial meniscal repair through a posteromedial portal between January 2013 and August 2015. ACLR autograft choice was bone-patellar tendon-bone, hamstring tendons (or quadrupled hamstring tendons), or quadrupled semitendinosus tendon graft with or without ALLR. At the end of the study period, all patients were contacted to determine if they had undergone reoperation. A Kaplan-Meier survival curve was plotted, and a Cox proportional hazards regression model was used to perform multivariate analysis., Results: A total of 383 patients (mean ± SD age, 27.4 ± 9.2 years) were included with a mean follow-up of 37.4 months (range, 24-54.9 months): 194 patients underwent an isolated ACLR, and 189 underwent a combined ACLR + ALLR. At final follow-up, there was no significant difference between groups in postoperative side-to-side laxity (isolated ACLR group, 0.9 ± 0.9 mm [min to max, -1 to 3]; ACLR + ALLR group, 0.8 ± 1.0 mm [min to max, -2 to 3]; P = .2120) or Lysholm score (isolated ACLR group, 93.0 [95% CI, 91.3-94.7]; ACLR + ALLR group, 93.7 [95% CI, 92.3-95.1]; P = .556). Forty-three patients (11.2%) underwent reoperation for failure of the medial meniscal repair or a new tear. The survival rates of meniscal repair at 36 months were 91.2% (95% CI, 85.4%-94.8) in the ACLR + ALLR group and 83.8% (95% CI, 77.1%-88.7%; P = .033) in the ACLR group. The probability of failure of medial meniscal repair was >2 times lower in patients with ACLR + ALLR as compared with patients with isolated ACLR (hazard ratio, 0.443; 95% CI, 0.218-0.866). No other prognosticators of meniscal repair failure were identified., Conclusion: Combined ACLR and ALLR is associated with a significantly lower rate of failure of medial meniscal repairs when compared with those performed at the time of isolated ACLR.

Background: Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known., Purpose: To determine the rate of reoperation after combined ACL and ALL reconstruction., Study Design: Case series; Level of evidence, 4., Methods: A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort., Results: The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non-graft rupture-related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002)., Conclusion: The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

Background: Graft failure and low rates of return to sport are major concerns after anterior cruciate ligament (ACL) reconstruction, particularly in a population at risk., Purpose: To evaluate the association between reconstruction techniques and subsequent graft rupture and return-to-sport rates in patients aged 16 to 30 years participating in pivoting sports., Study Design: Cohort study; Level of evidence, 2., Methods: A prospective study of patients undergoing primary ACL reconstruction with a bone-patellar tendon-bone (B-PT-B) graft, quadrupled hamstring tendon (4HT) graft, or hamstring tendon graft combined with anterolateral ligament reconstruction (HT+ALL) was conducted by the Scientific ACL NeTwork International (SANTI) Study Group. Survivorship data from Kaplan-Meier analysis were analyzed in multivariate Cox regression models to identify the prognosticators of graft ruptures and return to sport., Results: Five hundred two patients (mean age, 22.4 ± 4.0 years) with a mean follow-up of 38.4 ± 8.5 months (range, 24-54 months) were included. There were 105 B-PT-B, 176 4HT, and 221 HT+ALL grafts. The mean postoperative scores at latest follow-up were the following: Lysholm: 92.4 ± 8.6, Tegner: 7.4 ± 2.1, and subjective International Knee Documentation Committee (IKDC): 86.8 ± 10.5 for B-PT-B grafts; Lysholm: 91.3 ± 9.9, Tegner: 6.6 ± 1.8, and subjective IKDC: 85.4 ± 10.4 for 4HT grafts; and Lysholm: 91.9 ± 10.2, Tegner: 7.0 ± 2.0, and subjective IKDC: 81.8 ± 13.1 for HT+ALL grafts. The mean side-to-side laxity was 0.6 ± 0.9 mm for B-PT-B grafts, 0.6 ± 1.0 mm for 4HT grafts, and 0.5 ± 0.8 mm for HT+ALL grafts. At a mean follow-up of 38.4 months, the graft rupture rates were 10.77% (range, 6.60%-17.32%) for 4HT grafts, 16.77% (range, 9.99%-27.40%) for B-PT-B grafts, and 4.13% (range, 2.17%-7.80%) for HT+ALL grafts. The rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts (hazard ratio [HR], 0.393; 95% CI, 0.153-0.953) and 3.1 times less than with 4HT grafts (HR, 0.327; 95% CI, 0.130-0.758). There was no significant difference in the graft failure rate between 4HT and B-PT-B grafts (HR, 1.204; 95% CI, 0.555-2.663). Other prognosticators of graft failure included age ≤25 years ( P = .012) and a preoperative side-to-side laxity >7 mm ( P = .018). The HT+ALL graft was associated with higher odds of returning to preinjury levels of sport than the 4HT graft (odds ratio [OR], 1.938; 95% CI, 1.174-3.224) but not compared with the B-PT-B graft (OR, 1.460; 95% CI, 0.813-2.613)., Conclusion: In a high-risk population of young patients participating in pivoting sports, the rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts and 3.1 times less than with 4HT grafts. The HT+ALL graft is also associated with greater odds of returning to preinjury levels of sport when compared with the 4HT graft.

Background: Physicians should consider an increased posterior tibial slope (PTS) as a risk factor for graft failure when proposing anterior cruciate ligament (ACL) re-revision., Purpose: To describe the surgical technique of combined ACL revision and proximal tibial anterior closing wedge osteotomy and to evaluate its clinical outcome in cases of recurrent graft failure with associated increased tibial slope., Study Design: Case series; Level of evidence, 4., Methods: Between 2008 and 2010, 5 combined ACL re-revisions with proximal tibial anterior closing wedge osteotomy were retrospectively evaluated after a mean 31.6 months' follow-up (range, 23-45 months). All patients reported subjective knee instability preoperatively and demonstrated increased laxity on physical examination. Intrinsic risk factors for graft failure (excessive tibial slope) were identified in all cases. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale., Results: The mean Lysholm score was 46.2 preoperatively (range, 26-69) and 87.8 (range, 60-100) postoperatively. The mean IKDC subjective score was 39.5 (range, 21.8-64.4) before surgery and 79.1 (range, 48.3-98.9) at the last follow-up. The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last follow-up. The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The mean differential anterior laxity was 10.4 mm (range, 8-14 mm), and this significantly decreased to 2.8 mm (range, 2-4 mm) at the last follow-up. Using the Kellgren-Lawrence classification to evaluate the presence of arthritis, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3., Conclusion: Combined ACL re-revision with proximal tibial anterior closing wedge osteotomy restores knee stability and function with satisfactory clinical outcomes in patients who experience recurrent ACL ruptures with an associated increased PTS., (© 2014 The Author(s).)