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Research Article
2026
:5;
100755
doi:
10.1016/j.jorep.2025.100755

Assessment of posterior tibial slope in adults: Insights from a prospective radiographic study

, , , , ,
a Department of Joint Surgery, 103 Military Hospital, Hanoi, Viet Nam
b Department of Orthopaedic and Trauma, Vietnam Military Medical University, Hanoi, Viet Nam
c Radiology Center, 103 Military Hospital, Hanoi, Viet Nam
d Graduate School of Medical Science, Kanazawa Medical University, Ishikawa, Japan

⁎Corresponding author: Anh Dung Vu. surgeonvuanhdung@gmail.com

Received: , Accepted: ,
The Authors
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The posterior tibial slope (PTS) plays a vital role in maintaining knee stability and biomechanics, influencing ligament loading, knee motion, and surgical outcomes. Despite its clinical importance, normative PTS values for the Vietnamese population remain poorly defined.

This study aims to establish population-specific reference values for the PTS in healthy adult Vietnamese individuals to support surgical planning and injury risk assessment.

A prospective study was conducted involving 120 healthy Vietnamese adults (60 males and 60 females) who underwent standardized lateral knee radiographs. Baseline demographic data (age, sex, height, weight, BMI) were collected. PTS was defined as the angle between a line perpendicular to the anterior tibial cortex and the line connecting the anterior and posterior margins of the tibial plateau, with measurements performed by two blinded orthopedic surgeons to ensure reliability.

Significant gender differences in the PTS were observed. Females exhibited higher mean PTS values than males on both the right (8.10±1.84° vs. 7.23±1.74°, p=0.002) and left (8.11±1.85° vs. 7.25±1.74°, p=0.003) knees. No significant differences in PTS were associated with BMI or height. The distribution of high and low PTS values also differed significantly by sex (p=0.003).

This study provided normative PTS data for the adult Vietnamese population, revealing notable sex-based variations. These findings underscore the importance of personalized surgical approaches and prosthetic design considerations tailored to specific demographic characteristics to optimize the clinical outcome of knee-related procedures.

Keywords

Posterior tibial slope
Vietnamese population
Lateral radiographs
Knee
Adults
1

1 Introduction

The posterior tibial slope (PTS) is the angle formed between a line perpendicular to the tibial anatomical axis and the line tangent to the tibial plateau, reflecting its tilt in the sagittal plane.1–6 The PTS is crucial for maintaining knee joint stability and function, as it influences the distribution of forces between the femur and tibia, ligament tension, and the mechanics of knee flexion and extension. Therefore, precise measurement of the PTS is essential for understanding normal joint dynamics and identifying the biomechanical factors contributing to ligament injuries and degenerative changes.

Changes in PTS are closely associated with cruciate ligament injuries. A steeper tibial slope is a significant factor in anterior cruciate ligament (ACL) ruptures, as it increases anterior tibial translation under axial and shear forces.7–11 However, a shallower slope is linked to a greater risk of posterior cruciate ligament (PCL) injury and posterior tibial displacement, likely due to reduced tibial restraint against the femur posteriorly.2,12 Additionally, biomechanical studies have shown that a more pronounced PTS decreases the quadriceps' extension moment required to transition the knee from flexion to extension, which may alter muscle loading and reduce joint stability.4,13–15

The biomechanical effects of the PTS play a critical role in surgical procedures such as total knee arthroplasty (TKA) and ACL reconstruction. Successfully restoring or purposefully altering the natural PTS during these operations is vital for maintaining normal knee movement and extending the lifespan of the implants.2,16,17 For instance, in TKA, a PTS that is overly steep heightens the stress on the rear portion of the tibial component, speeding up polyethylene wear and increasing the chances of early loosening without infection. Conversely, a slope that is too flat shifts pressure toward the front, raising the risk of the tibial component sinking into the bone.4,18,19 Similarly, in ACL reconstruction, the tibial slope significantly affects graft tension and knee motion after surgery, necessitating thorough preoperative planning and precise adjustments during the procedure to prevent the knee from being either too loose or overly restricted.

By skeletal maturity, healthy individuals typically present PTS values between 0° and 20°, with variability attributable to sex and ethnic background.20,21 However, substantial heterogeneity in reported normative ranges arises from divergent measurement techniques, imaging modalities, and study populations. These ethnic variations in tibial plateau morphology highlight the necessity for population-specific reference standards in surgical planning and implant design.

Despite the clinical significance of the PTS and its recognized variability among individuals, detailed normative data for the Vietnamese population remain insufficient. To fill this void, this study endeavors to calculate the average PTS in adult Vietnamese knees using uniform radiographic analysis. These tailored reference values will support more accurate surgical strategies, contribute to prosthetic development, and aid in assessing injury risks for Vietnamese patients.

2

2 Material and methods

2.1

2.1 Patient recruitment

This prospective study involved volunteers who were evaluated at the orthopedic outpatient clinic and subsequently underwent lateral radiographic imaging of the knee. The eligibility criteria were individuals over 18 years of age, without evidence of joint deformities or congenital malformations, and with no prior history of trauma, fractures, tumors, rheumatologic disorders, or inflammatory joint diseases. Only radiographs exhibiting true lateral positioning characterized by satisfactory superimposition of the medial and lateral femoral condyles were deemed acceptable. Radiographs were excluded if the posterior femoral condylar displacement exceeded 5 mm.22–24

Subjects were excluded based on the following criteria: non-Vietnamese ethnicity, presence of open growth plates, any signs of osteoarthritic changes or knee joint deformities, displaced periarticular fractures, or a history of knee surgery. Additional exclusion criteria included any condition potentially altering normal PTS morphology, such as congenital anomalies, neoplasms, or advanced osteoarthritis (as classified by the Kellgren-Lawrence grading system25). Cases lacking informed consent or with technically inadequate radiographs due to over-rotation, under-rotation, or detectable degenerative changes were also omitted.

2.2

2.2 Demographic data and radiographic imaging

Collected baseline demographic characteristics, including age, sex, height, weight and body mass index (BMI). PTS values were independently assessed for the right and left knees. The mean values for each side, along with overall combined measurements, were documented. Comparative evaluations were conducted between right and left sides, and between male and female subjects.

Standard lateral knee radiographs were acquired using the Delworks Medical X-ray system (2018, USA). Imaging parameters were consistently applied at 50–60 kV and 5–10 mAs. Each limb was imaged separately with the participant in a lateral decubitus position, the knee flexed at 30°, and the lower extremity fully externally rotated. The X-ray beam was directed perpendicularly to the table, centered precisely at the knee joint.

2.3

2.3 Radiographic measurements

All radiographs were stored within the hospital's PACS system, and PTS was measured using Radiant software. The anterior tibial cortex method was used to identify the tangent line along the anterior cortex of the tibia and the line connecting the anterior and posterior margins of the tibial plateau was identified. The posterior tibial slope angle (the larger, posteriorly directed angle) was defined as the angle formed between these two lines. The posterior tibial slope was then calculated by subtracting this angle from 90°, or equivalently, as the angle between a line perpendicular to the anterior tibial cortex and the line connecting the anterior and posterior borders of the tibial plateau.26

Two experienced orthopedic knee surgeons, blinded to participant data, independently performed all measurements. To mitigate observer bias, each surgeon repeated their assessments after a four-week interval, without access to their prior measurements or the other observer's results.

2.4

2.4 Statistical analysis

Statistical analysis was performed using SPSS version 26.0. The normality of data distribution was assessed using the Kolmogorov–Smirnov tests. Descriptive statistics included frequencies and percentages for categorical variables, whereas continuous variables were summarized using means and standard deviations. The Mann–Whitney U test was used to compare the differences in the mean values between the two knees. Fisher's exact test was used to compare categorical data. A p-value of less than 0.05 was considered statistically significant for all analyses.

3

3 Results

A total of 120 participants with an equal gender distribution (n=60 males, n=60 females) were enrolled in the study. Statistically significant gender-based differences were observed for several demographic and anthropometric parameters. Male participants exhibited a higher mean age (21.37±1.07) than their female counterparts (20.80±1.48), with this difference reaching statistical significance (p=0.003). In addition, males had significantly greater mean body weight (63.43±8.03 vs. 52.80±6.16, p<0.001), height (1.70±0.03 vs. 1.59±0.04, p<0.001), and BMI (21.68±2.46 vs. 20.53±2.14, p=0.013), as presented in Table 1.

Table 1 Participant characteristics.
Variables All participants Male Female P value†
Age (years) 21.08±1.31 21.37±1.07 20.80±1.48 0.003 ∗
Body weight (kg) 58.12±8.91 63.43±8.03 52.80±6.16 <0.001 ∗
Body height (m) 1.65±0.06 1.70±0.03 1.59±0.04 <0.001 ∗
BMI (kg/m2) 21.11±2.37 21.68±2.46 20.53±2.14 0.013 ∗

The assessment of the PTS revealed notable gender-related differences. On the right side, the mean PTS was significantly lower in males (7.23±1.74°) than in females (8.10±1.84°, p=0.002). A similar pattern was observed on the left side, where males had a mean PTS of 7.25±1.74° compared with 8.11±1.85° in females (p=0.003), as shown in Table 2. No significant differences in PTS values were identified when stratified by BMI or height (p>0.05).

Table 2 Comparison of PTS by gender, BMI and height.
Variables Right side P value Left side P value
Gender
Male 7.23±1.74° 0.002 ∗ 7.25±1.74° 0.003 ∗
Female 8.10±1.84° 8.11±1.85°
BMI
Normal group 7.67±1.84° 0.891 7.68±1.84° 0.869
Abnormal group 7.62±1.85° 7.64±1.87°
Body Height
Above Average Height Group 7.61±1.78° 0.671 7.62±1.79° 0.678
Below Average Height Group 7.91±2.09° 7.93±2.09°

A comparative analysis of PTS classification into high and low groups, based on the median cut-off value, revealed a notable difference in gender distribution. The high PTS group included 39 males (63.9%) and 22 females (36.1%), whereas the low PTS group included 21 males (35.6%) and 38 females (64.4%). This gender disparity was statistically significant (p=0.003), as shown in Table 3. However, no significant relationships were identified between PTS classification and either BMI or height categories (p>0.05).

Table 3 Distribution of gender, BMI and height according to high and low PTS.
Variables All participants P value
High PTS Low PTS
Gender
Male 39 (63.9%) 21 (35.6%) 0.003 ∗
Female 22 (36.1%) 38 (64.4%)
BMI
Normal group 48 (78.7%) 53 (89.8%) 0.133
Abnormal group 13 (21.3%) 6 (10.2%)
Height
Above Average Height Group 51 (83.6%) 48 (81.4%) 0.813
Below Average Height Group 10 (16.4%) 11 (18.6%)
4

4 Discussion

This study aimed to establish normative PTS values for healthy Vietnamese adults, thereby offering a valuable reference for surgical planning in this population. These findings highlight notable differences in PTS based on both sex and age, underscoring the importance of individualized approaches to knee surgery. In particular, males showed significantly lower average PTS than females on both the right side (7.23±1.74° vs. 8.10±1.84°; p=0.002) and the left side (7.25±1.74° vs. 8.11±1.85°; p=0.003). Additionally, older individuals exhibited changes in slope, which may be attributed to age-related bone remodeling and early degenerative processes.

Knee stability relies on both dynamic elements provided by the periarticular musculature and static structures, including osseous geometry, the joint capsule, and ligaments.22,27 Variations in PTS alter the sagittal mechanical axis of the lower limb, thereby modulating cruciate ligament loading, which predisposes the ACL to greater tensile forces under axial load, increasing anterior tibial translation,28–30 whereas a decreased slope shifts the load toward the PCL.31

Precise evaluation of the PTS plays a crucial role in surgeries such as TKA and ACL reconstruction.28,32 Although imaging techniques such as CT and MRI provide detailed assessment of the tibial plateau anatomy and allow for distinct visualization of the medial and lateral sides, their widespread application is hindered by factors such as high cost, extended scanning time, limited accessibility, and difficulties in achieving proper alignment with the tibial anatomical axis.23,33 In contrast, lateral radiographs offer broad accessibility, rapid imaging, and lower radiation exposure than CT,23 and are widely used for both preoperative templating and postoperative assessment.34 However, the overlap of the medial and lateral plateaus can introduce measurement variability. Among radiographic techniques, the anterior tibial cortex (ATC) and tibial proximal anatomical axis (TPAA) methods are the most commonly employed, with the extramedullary alignment rod placed parallel to the ATC during surgical guidance.35–37 To ensure clinical relevance, the ATC method was used in this study.

Measurement reliability also depends on the length of the tibial shaft referenced when determining the anatomical axis; longer segments correlate with improved precision.38 In individuals with a pronounced PTS, identifying joint-line landmarks such as the medial proximal tibial angle (MPTA) and joint line convergence angle (JLCA) can be challenging, underscoring the value of repeated measurements to minimize error.39

When compared with international cohorts, our Vietnamese data align with recognized ethnic and regional differences. Chinese populations report a mean PTS of 7.68°,26 Indian adults average approximately 12.6°,40 Turkish subjects measure approximately 11.0–11.1°,41 and Japanese cohorts exhibit a mean of 9.7°42 (Table 4). These disparities likely arise from genetic, developmental, and methodological sources, including variations in sample composition.

Table 4 Comparison with previous publications.
Author Year Country Sample Age Gender Measurement method PTS
Chen et al.24 2022 China Healthy adults 25–59 Male and Female ATC/Xray 7.68±3.84°
Singh et al.38 2023 India Healthy adults >18 Male and Female ATC/Xray Right: 12.76±2.35°
Left: 12.55±2.46°
Kavak et al.39 2024 Turkey Healthy adults 25–65 Male and Female ATC, PTAA, PTC/Xray ATC right: 11.08±2.4°
ATC left: 10.99±2.26°
PTAA right: 8.73±2.25°
PTAA left: 8.64±2.08°
PTC right: 6.31±2.33°
PTC left: 6.19±2.13°
Kawada et al.40 2025 Japan MMPRTs 65.5±8.9 Male and Female PTAA/Xray 9.7±2.8°
The present research 2025 Vietnam Healthy adults 19–25 Male and Female ATC/Xray 7.67±1.84°

The sex-related slope differences observed here may reflect distinct patterns of skeletal maturation and degeneration: males typically achieve peak bone mass later, whereas postmenopausal women undergo accelerated subchondral changes that can modify slope geometry. Likewise, age-dependent alterations in PTS may correspond to cumulative remodeling and the inception of osteoarthritic processes.

Hiyama et al. found notable ethnic differences in PTS, with Indian patients having the steepest angles, followed by Chinese and then Japanese patients. Significant sex-related differences were observed only in the Chinese group, while age had no impact on PTS.43

The angle of the slope affects parameters such as flexion gap alignment in TKA, tension on the PCL, patellofemoral joint loading, and overall kinematic behavior of the knee joint.44 In the context of unicompartmental knee arthroplasty (UKA), an excessively steep medial PTS has been linked to abnormal elongation of the ACL, indicating that avoiding overly steep slopes is important for maintaining ligament integrity.45 Biomechanical studies also showed that a higher PTS increases ACL loading under compressive forces, raising the risk for non-contact injuries, while a flatter slope may increase stress on the PCL.31 Moreover, patients with ACL injuries tend to show steeper PTS than uninjured individuals.46,47

In TKA, an exaggerated slope can also lead to premature wear of the polyethylene insert and potential loosening of the implant. Selznick et al. reported that a reduction in posterior tibial slope compared to the native anatomy after TKA produced only a modest, non-clinically significant improvement in Knee Society Scores at six weeks. They also found no notable differences in outcomes at six months, Oxford Knee Scores, or maximum knee flexion among the groups, and increasing the tibial slope did not appear to enhance flexion, potentially due to differences in implant designs used.48 Morrisey et al. developed the CS-PAK classification by integrating PTS into the existing CPAK system, categorizing knees as Type A (PTS≤8°) or Type B (PTS>8°). Although Type B knees demonstrated higher flexion both before and after surgery, Type A knees experienced a greater increase in flexion and showed more ligamentous laxity and gap variation, indicating a greater need for soft tissue balancing during robotic kinematically aligned TKA.49

Standard prosthetic designs typically recommend a slope between 3° and 7°. However, our findings suggest that these norms may require revision to better match the average values observed in the Vietnamese population.

It is important to note that the cross-sectional nature of this study, along with its sole reliance on radiographic methods, may restrict the ability to assess changes over time and may be subject to observer-related variability. Future research should consider incorporating 3D imaging technologies and prospective designs to better clarify the role of PTS in knee degeneration.

5

5 Conclusion

In conclusion, this study provided normative PTS values for Vietnamese adults, highlighting significant variations by age and sex. These results support the need for individualized surgical planning and prosthesis customization in the Vietnamese population to enhance biomechanical performance and clinical outcomes.

CRediT authorship contribution statement

Nhat Dinh Vu: Investigation, Methodology, Writing – original draft, Writing – review, Supervision. Tuan Anh Phung: Data curation, Writing – review, Supervision. Tien Thanh Pham: Writing – original draft, Conceptualization, Methodology. Ngoc Binh Thai: Data curation, Writing – original draft. Duy Chi Le: Data curation, Writing – original draft. Anh Dung Vu: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing.

Ethics approval and consent to participate

The study was approved by the Institutional Ethics Committee (approval number: 71/CNChT-HDDD) and complied with the World Medical Association Declaration of Helsinki. All patients were provided with detailed explanations of the procedures and tests in their native language, and informed consent was obtained accordingly.

Data availability

The data sets produced and examined in this study can be accessed from the corresponding author upon a reasonable request.

Ethics statement and consent to participate

The Institutional Ethics Committee approved the study (approval number: 71/CNChT-HDDD) and the study adhered to the principles of the Declaration of Helsinki. All patients were provided with detailed explanations of the procedures and tests in their native language, and informed consent was obtained accordingly.

Consent

Informed consent for the use of identifying information and/or images in this open-access publication was obtained from all participants and/or their legal guardians. The manuscript is not submitted elsewhere for publication consideration.

Funding

No funding to declare.

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