Assessment of the tibial slope is highly dependent on the type and accuracy of the preceding acquisition

Background Precise measurement of the tibial slope (TS) is crucial for realignment surgery, ligament reconstruction, and arthroplasty. However, there is little consensus on the ideal assessment. It was hypothesized that the tibial slope changes according to the acquisition technique and both tibial length as well as femoral rotation serve as potential confounders. Methods 104 patients (37 women, 67 men; range 12-66 years) were retrospectively selected, of which all patients underwent a 1.5-Tesla MRI and either additional standard lateral radiographs (SLR, n = 52) or posterior stress radiographs (PSR, n = 52) of the index knee. Two blinded observers evaluated the medial tibial slope as the medial TS is primarily used in clinical practice. Additionally, the length of the diaphyseal axis and the extent of radiographic malrotation were measured. Results Mean TS on MRI was significantly lower compared to radiographs (4.2 degrees +/- 2.9 degrees vs. 9.1 degrees +/- 3.6 degrees; p < 0.0001). There was a significant correlation between MRI and PSR (p < 0.0001 with r = 0.7), but not with SLR (p = 0.93 with r = 0.24). Tibial length was a significant predictor for the difference between MRI and SLR (regression coefficient ss = - 0.03; p = 0.035), yet not between MRI and PSR (ss = - 0.003; p = 0.9). Femoral rotation proved to be a significant predictor for the agreement between both observers (PSR: ss = 0.14; p = 0.001 and SLR: ss = 0.08; p = 0.04). ICC indicated a high interrater agreement for the radiographic assessment (ICC >= 0.72). Conclusions There is a substantial variance between MRI and radiographic measurement of the tibial slope. However, as MRI assessment is time-consuming and requires specialized software, instrumented radiographs might be an alternative. Due care has to be taken to ensure that radiographs contain a sufficient tibial length, and femoral rotation is avoided. Study design Case series (diagnosis); Level of evidence, 4.