Abstract

Patient‐specific cutting guides are widely used in medial opening wedge high tibial osteotomy to improve alignment accuracy, yet their multiplanar sensitivity to intraoperative malpositioning remains poorly quantified.

This study investigated how translational and rotational malpositioning of patient‐specific cutting guides affect postoperative multiplanar alignment using virtual surgical simulation. Virtual osteotomy procedures were performed on twenty tibial models reconstructed from preoperative computed tomography scans, targeting a 62.5% weight‐bearing line. Guides were systematically malpositioned vertically, rotationally, and horizontally along the anteromedial tibial cortex.

Postoperative medial proximal tibial angle, posterior proximal tibial angle, and tibial torsion were compared with the ideal plan, and clinically acceptable alignment error was defined as within 1°. Vertical malpositioning predominantly affected coronal alignment, with distal displacement greater than 8 mm producing medial proximal tibial angle overcorrection beyond acceptable limits, while posterior proximal tibial angle and tibial torsion were relatively insensitive within 10 mm. Rotational malpositioning affected all alignment parameters, with tibial torsion being the most sensitive, and acceptable alignment was maintained only between −10° and +8°. Horizontal malpositioning produced variable effects, particularly on posterior proximal tibial angle, with acceptable alignment maintained between −4 mm and +3 mm, while tibial torsion was minimally affected.

Clinical Significance:

This study defines clinically acceptable ranges of patient‐specific cutting guide malpositioning in medial opening wedge high tibial osteotomy and identifies which displacement modes most strongly affect coronal, sagittal, and axial alignment. These findings provide practical thresholds to guide PSI design, fixation, and intraoperative placement, helping to reduce alignment errors arising from subtle guide mispositioning.

What are the new findings?

• Guide malpositioning produced predictable alignment errors across all three anatomical planes in MOWHTO.

• Vertical displacement primarily affected coronal correction, with distal movement beyond 8 mm increasing the risk of overcorrection.

• Rotational malpositioning had the broadest effect, influencing coronal, sagittal and axial alignment.

• Tibial torsion was most sensitive to rotation, with acceptable alignment maintained between −10° and +8°.

• Horizontal displacement had the greatest effect on posterior tibial slope, with acceptable positioning limited to −4 mm to +3 mm.

• The findings provide practical tolerances to support stable guide design and precise intraoperative placement.

*Corresponding author.

Sydney Orthopaedic Research Institute
Level 2, 500 Pacific Highway
St Leonards, Sydney, 2065
Australia
Tel: +61 2 9904 7182
E-mail address: koumei.01.13@gmail.com (T. Hiranaka).

https://doi.org/10.1002/jor.70199

Received: 27 January 2026 | Revised: 27 January 2026 | Accepted: 24 March 2026

Available online 24 March 2026

2059-7754/© 2026 The Author(s). Published by Elsevier Inc. on behalf of International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).