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Chapter 5106to compensate for rotatory laxity in the long run. Taking these factors into account, caution should be exercised with highly invasive procedures such as an anterior closing-wedge osteotomy of the tibia. Theoretically, a tibial osteotomy will influence the biomechanical interaction between passive ATT and PTS but neglects the (powerful) influence of muscle activation. Ultimately, the correlation between PTS and ATT may be corrected by muscle activation, but this may not be the case for the correlation between PTS and rTR. Hence the possibilities of an alternative osteotomy technique to correct for tibial rotation, for instance an anteromedial opening wedge, may be explored. Limitations and future researchThis study has several limitations. The narrow inclusion and exclusion criteria were mainly responsible for the small sample size - for instance, subjects with concomitant injury were excluded. Injury to the menisci and anterolateral structures of the knee are known to influence the amount of tibial rotation.20 By including subjects with concomitant injury, the results could have been biased. Although concomitant injury is a common feature in the general population, we regard our results as an accurate representation of the biomechanics involved in solitary ACL deficiency. The limited sample size is mainly responsible for the non-significant result of the correlation tests. However correlation coefficients are more relevant when interpreting Spearman’s test as opposed to significance levels. Nonetheless the results our study urge the need for future studies with more subjects to confirm the correlations found. Our study did not include electromyography (EMG) measurements to support our theory. In future research it would be interesting to incorporate the use of EMG to evaluate muscle activation patterns during SLHD in ACL deficiency and after ACLR. The average medial PTS in our population was ‑6.7° (95% CI ‑4.9; ‑8.5), and in the lateral compartment ‑5.7° (95% CI ‑4.3; ‑7.1). It must be noted that interobserver and intraobserver agreement was poorer for lateral PTS compared to medial PTS. Still, our observed PTS values are comparable to previous studies. In a systematic review and meta-analysis by Wordeman et al., average lateral PTS in ACL-injured subjects was between ‑1.8 (±3.2) Mark Zee.indd 106 03-01-2024 08:56