The tibial slope represents an important risk factor for both primary anterior cruciate ligament (ACL) injury and subsequent reconstruction failure. A high tibial slope has been associated with increased anterior tibial translation, increased strain on the ACL, and increased posteromedial compartment contact pressure. Patients with ACL-deficient knees who also have coronal tibiofemoral malalignment may potentially benefit from concomitant high tibial osteotomy and ACL reconstruction. Understanding the impact of the tibial slope on ACL reconstruction outcomes and the treatment options with regard to coronal tibiofemoral alignment allows for the appropriate care of patients with both morbidities.