High tibial osteotomy with virtual planning and patient specific instrumentation: a narrative review

Introduction

High tibial osteotomy (HTO) is a common orthopedic procedure that corrects angular or multiplanar deformities of the knee. It is usually performed in younger patient populations to correct mechanical axis malalignment, causing damage in a single compartment (1-3). The development of patient-specific instrumentation (PSI) originated from the need to improve the accuracy of this technically challenging procedure. The traditional HTO surgical technique requires repeat intraoperative fluoroscopy to ensure correct alignment and positioning of the bone cuts. The intraoperative tools to assess alignment, including rulers, bovie cords and protractors, are rudimentary and can be fraught with malcorrection based on limb position or rotation. Virtual planning allows the surgeon to precisely map out the degree of correction needed for a patient’s specific deformity (Figure 1). PSI then utilizes a preoperative computed tomography (CT) scan to develop a customized cutting guide specific to the patient’s anatomy (Figure 2). Not only do the customized cutting guides provide greater accuracy, but they also decrease the need for intraoperative measurements and adjustments of bone cuts, which reduces fluoroscopy use (4-6). Early data has supported the use of patient-specific instrumentation, and this technology will likely continue to improve.

Figure 1 Example of a virtual planning page to correct a patient’s varus alignment with a medial opening wedge high tibial osteotomy.

Figure 2 Example of a customized cutting guide for a medial opening wedge high tibial osteotomy.

The objective of this article is to provide a narrative review of the inception and current data surrounding patient-specific instrumentation and virtual planning for HTO, specifically in regard to radiation, cost effectiveness, hinge fractures, surgical accuracy, and multiplanar osteotomies. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-44/rc).

Methods

A thorough review of the literature was conducted (Table 1). The PubMed database was searched using the keywords “high tibial osteotomy, virtual planning, patient-specific instrumentation, and 3D planning”. All studies published up until the search date (March 1^st, 2025) were considered for inclusion. The most relevant English-language articles were chosen for review.

Inception

The inception of PSI in HTO has been driven by the need for greater precision in these surgical procedures. PSI leverages advanced imaging techniques, such as CT and magnetic resonance imaging (MRI), combined with three-dimensional (3D) printing to create customized surgical guides tailored to the patient’s unique anatomy.

The first use of 3D printing in medicine can be traced back to the late 1980s (7). It was initially applied to create anatomical models from imaging data, such as CT scans, for surgical planning and the design of customized implants. One of the earliest documented uses involved the creation of models for craniofacial surgery, as noted by the Radiological Society of North America (7).

3D printing technology soon expanded to orthopedic surgery. According to Berry et al., selective laser sintering (SLS) was used in 1997 to make anatomical models of femurs for testing hip implants (8). This preliminary experience demonstrated the potential applications of 3D printing in the orthopedic field, particularly for complex reconstructive procedures and surgical planning.

The use of virtual planning and customized implants continued to permeate throughout the orthopedic surgery field. The use of PSI in HTO has been reported as early as 2013. In a feasibility and proof-of-concept study, Victor et al. investigated the benefits of patient-specific guides for osteotomies around the knee (9). The authors developed preoperative plans based on full-leg standing radiographs and CT scans to develop patient-specific guides for the surgery. The patients underwent single, dual, or triplanar opening wedge osteotomies in either the femur or tibia. After performing the surgeries and comparing mean deviations between planned and performed osteotomies, the authors concluded that CT data could be used to plan the correction of angular deformity around the knee, it is possible to fit patient specific guides to the femur and tibia using a conventional surgical exposure, and that there is high accuracy of a performed osteotomy in relation to the pre-operative plan. This proof-of-concept study demonstrated the feasibility and accuracy of these custom-made guides in achieving the planned osteotomy corrections. This early work laid the foundation for subsequent studies that further refined and validated the use of PSI in HTO.

Radiation

Radiation exposure remains a critical consideration in HTO, particularly given the cumulative risks associated with intraoperative fluoroscopy. The advent of PSI has introduced a promising alternative to conventional freehand techniques, with potential advantages in radiation safety and efficiency. Multiple recent studies have evaluated the impact of PSI on intraoperative fluoroscopy.

In a prospective comparative study, Mao et al. reported a threefold decrease in radiation use in the PSI group for medial opening-wedge technique [medial opening-wedge high tibial osteotomy (MOWHTO)] (P<0.00001), alongside significantly shorter operative times (10). Similarly, Pérez-Mañanes et al. found that PSI-assisted MOWHTO procedures reduced fluoroscopy usage nearly sevenfold and operative time by 31 minutes, without compromising correction accuracy (4). Predescu et al. observed consistent alignment within 2° of the planned values in all 25 patients who underwent a MOWHTO, with an average of only 10 fluoroscopic images (5).

Similarly, Grillo et al. reported significantly lower radiation exposure in the PSI group (8 vs. 23.5 seconds; P<0.05) in an outpatient setting of MOWHTO patients (11). Carey et al. also showed reduced radiation dose with PSI (0.85 vs. 2.04 mGy; P<0.01), while maintaining equivalent operative times in a cadaveric model of MOWHTO (12). These findings are consistently supported by additional studies, which report significant reductions in intraoperative radiation exposure and operative time, underscoring improvements in surgical efficiency and patient safety (6,13).

The collective evidence supports a substantial reduction in intraoperative radiation exposure with the use of PSI in HTO. Across a range of clinical settings and study designs, PSI repeatedly demonstrates improved fluoroscopy efficiency, often accompanied by shorter operative times. These findings highlight the potential of PSI to enhance both surgeon performance and patient safety. As radiation safety remains a priority in orthopedic practice, PSI represents a valuable advancement in the evolution of precise, efficient, and safer HTO procedures.

Cost effectiveness

The use of PSI introduces additional costs related to preoperative CT or MRI imaging, 3D planning, and the manufacturing of custom guides and implants. These upfront costs may be partially offset by reductions in operative time, intraoperative radiation, and potentially lower complication rates, but the magnitude of these savings is not well quantified. There is limited data on direct comparisons between the cost of HTO with and without PSI.

However, one study in the literature does directly compare the costs of the procedures. Savage-Elliott et al. used a time-driven activity-based costing analysis to compare the costs of HTO with and without PSI in 22 patients (14). They found that the total cost of standard HTO was $27,100 and HTO with PSI was $27,530. This demonstrates that the costs with and without PSI are essentially the same, with the PSI group only being marginally more expensive by 1.6%.

Although this study demonstrates near identical costs between the two groups, the absence of long-term data on revision rates, survivorship, and downstream healthcare utilization limits economic evaluation. Thus, while PSI offers technical advantages, its cost-effectiveness relative to conventional HTO requires further research.

Hinge fractures

Hinge fractures are a common but potentially serious complication following high tibial osteotomies. The incidence varies depending on the detection method with ranges from 8.5–32% based on postoperative radiographs and some studies reporting up to 24.3–50% based on CT scans (15-18). The prevention of hinge fractures is critical given the negative sequelae—including delayed bone healing or nonunion, loss of correction, malunion, implant failure, and changes in posterior tibial slope (PTS) (19-22). The use of patient-specific instrumentation could be a potential solution for the high rates of hinge fractures. Because the guides are individually designed for each patient, their cutting slots are tailored to the patient’s unique anatomy, with the osteotomy cut ending in the safe zone for MOWHTO, close to the fibular head. Many of them are also designed with mechanical blocks that only allow for the intended depth of osteotomy cut, or the option to add a “hinge pin” which prevents deep cut penetration and helps shield the lateral cortex when opening the hinge (23).

Current data surrounding patient-specific instrumentation shows promising results in regard to hinge fractures (24). Multiple studies demonstrate no significant difference in incidence of hinge fractures in high tibial osteotomies with and without patient-specific instrumentation (11,25). However, most of the studies have small patient cohorts and there is currently a paucity of high-quality literature specifically quantifying the incidence of hinge fractures in HTO performed with patient-specific instrumentation. While the theoretical advantages of using PSI in regards to hinge fractures are well-established, larger cohort-based and comparative studies are necessary to validate these benefits in practice.

Surgical accuracy

Achieving precise alignment is vital to the long-term success of HTO with surgical accuracy directly impacting both biomechanical correction and clinical outcomes (26). Recent comparative and prospective studies have demonstrated that PSI consistently outperforms conventional and navigation-assisted techniques in minimizing deviation from planned corrections.

Zhu et al. conducted a prospective, randomized trial of MOWHTO that reported significantly lower hip-knee-ankle (HKA) deviation in the PSI group (0.6°) versus conventional (2.6°) and navigation methods (2.3°) (27). A systematic review by Zaffagnini et al. found that 3D-printed cutting guides typically achieved deviations ≤3° (28) . In a subsequent prospective series, the same authors observed mean differences of 2.1° (HKA) and 0.2° (PTS) between planned and achieved corrections in MOWHTO, alongside significant improvements in patient-reported outcomes (29).

Munier et al. reported that 19 of 20 postoperative measurements in 10 MOWHTO cases were within 2° of the surgical plan, with no complications except one self-resolving hematoma (30). Van Genechten et al. documented a mean HKA deviation of 1.2° and PTS deviation of 0.8°, with improved knee function and pain at six months in MOWHTO patients (31). Other studies, including cadaveric, comparative, and meta-analysis, have similar conclusions, demonstrating that PSI consistently yields more favorable corrections when compared to traditional HTO (32-34).

Studies consistently demonstrate that PSI significantly improves the accuracy of high tibial osteotomies, achieving radiographic alignment deviations typically within 2° of the preoperative plans. PSI enables surgeons to create highly accurate cutting guides, facilitating precise osteotomy cuts in HTO procedures. This technique represents a significant advancement over traditional HTO methods, which rely on intraoperative tools such as rulers, bovie cords, and protractors for alignment—tools that are often considered rudimentary and more susceptible to error. The increased accuracy of PSI highlights its superiority over traditional and navigation-guided techniques in regard to deviation from planned to performed correction. Furthermore, improved radiographic outcomes with PSI correlate with better early functional recovery and patient-reported outcomes (28,31).

Multiplanar osteotomies

HTO with PSI is uniquely equipped to address multiplanar corrections, including both coronal and sagittal alignment, due to its use of preoperative 3D planning. Increased PTS is an established risk factor for anterior cruciate ligament injuries (35). Therefore, in cases with a coronal deformity coupled with derangements in PTS, a multiplanar correction is preferable. However, multiplanar corrections are more technically challenging. Standard HTO techniques utilizes intraoperative fluoroscopy for correction, which makes multiplanar corrections difficult as the imaging is limited to two dimensions. The custom cutting guides in PSI, leveraging 3D preoperative planning, allow for execution of complex osteotomies and can address both varus/valgus deformity and PTS in a single procedure (28,29).

Multiple studies have evaluated the results of multiplanar osteotomies in HTO with PSI. Zindel et al. assessed 18 patients who underwent combined closed wedge high tibial slope correction osteotomies with PSI (36). They found a high degree of overall 3D angular correction accuracy (2.3°±1.1° for PTS, 1.9°±1.4° in the coronal plane). The authors concluded that high accuracy could be achieved in multiplanar osteotomies using PSI.

Similar results of multiplanar osteotomies are echoed in other studies evaluating the effectiveness of PSI in HTO. Munier et al. found that 3D patient-specific cutting guides enabled correction within 2° of the planned targets in both coronal and sagittal planes in nearly all cases (30). Zaffagnini et al. reported that custom-made devices for MOWHTO, consistently achieved multiplanar corrections within 3° of the targets in both HKA angle and PTS, with pilot cases confirming satisfactory clinical and radiographic outcomes at one year (29). These studies demonstrate the accuracy and reproducibility of multiplanar osteotomies utilizing PSI.

The integration of PSI in HTO represents a significant advancement in addressing complex, multiplanar deformities. Using detailed 3D preoperative planning and custom cutting guides, PSI enables precise correction of both coronal malalignment and PTS—an important consideration in patients at increased risk for anterior cruciate ligament injuries. The technical challenges traditionally associated with multiplanar osteotomies are mitigated by PSI’s ability to translate virtual planning into accurate surgical execution. Consistent findings across multiple studies highlight the high accuracy and reproducibility of PSI-assisted multiplanar corrections, supporting its utility in patients with complex deformities. However, slope corrections using a medial opening wedge technique are usually limited to <5 degrees of sagittal correction, as large sagittal corrections require very large coronal corrections to achieve this (37). Large slope corrections in the context of coronal realignment are still best served through a lateral closing wedge technique, which can also be templated with PSI.

Limitations

Although PSI can greatly enhance our accuracy and techniques with HTO, there comes some limitations, especially with the advent of new technology and enabling measures. Firstly, and most importantly, the use of this technology is not meant to allow surgeons with no knowledge base of osteotomy to start performing these procedures in great numbers. We feel it is critical for surgeons to have a basic understanding of osteotomy technique, surgical options (closing versus opening wedge, etc.) and fixation methods before tackling these cases, as they often require concomitant work and complications could be disastrous if respect is not paid to technique and indications. Additionally, the surgeon must be armed with options in case of intra-operative changes in the plan; ranging from the treatment of hinge fractures, suboptimal fixation, or soft tissue circumstances.

Conclusions

PSI, driven by advances in virtual planning and 3D printing, represents a significant advancement in HTO surgeries. By addressing the limitations of conventional techniques, PSI offers tailored surgical guides that enhance precision and reproducibility. These individualized tools reduce the reliance on intraoperative fluoroscopy and basic instruments, aligning with the evolving demand for accuracy in knee realignment procedures.

PSI has demonstrated benefits across multiple domains. It significantly reduces intraoperative radiation exposure and may shorten operative time. The costs of PSI vs. traditional osteotomy are nearly identical. There is a theoretical benefit in regards to hinge fractures with mechanical blocks and option to incorporate a hinge pin. Finally, studies have shown improved alignment accuracy with PSI in both single and multiplanar deformities.

The value of PSI in HTO is becoming more evident with time. With improvements in guide design and accessibility, PSI has the potential to become an integral component of modern knee realignment surgery. Future research should focus on long-term clinical outcomes, cost-effectiveness, and integration into routine surgical practice to fully define the role of PSI within contemporary knee realignment surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Brian Waterman, Alan Reynolds and Kevin Collon) for the series “The Medial Knee at Risk” published in Annals of Joint. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-44/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-44/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-44/coif). The series “The Medial Knee at Risk” was commissioned by the editorial office without any funding or sponsorship. M.A. is on the editorial board of Arthroscopy Journal and the Journal of Cartilage and Joint Preservation. He has stock in Overture. He also is a paid consultant for Cervos, Arthrex, Bodycad USA Corp, and Globus Medical, Inc. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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