3D-planned HTO with patient-specific cutting guides: aiming for simpler, more accurate surgery leads to more complexity in the perioperative process

Background: High tibial osteotomy (HTO) surgical accuracy may be improved by using CT-based pre-operative planning and patient-specific cutting guides (PSCGs). This randomized exploratory study aimed to assess the feasibility and accuracy of HTO with the use of PSCGs and compare this to conventionally executed HTO. Methods: Patients scheduled for monoplane open-wedge medial HTO were randomly divided over two groups: HTO with and without the use of PSCGs. The groups were compared in terms of planned and achieved surgical correction angles, surgery time, costs and adverse events (AEs). Results: Logistically, the implementation of CT-guided HTO planning and surgery in the clinic was challenging. Radiologically, the use of PSCGs did not result in higher surgical accuracy. The surgery time was higher for the PSCG group (median 73 min (IQR 66–80) vs 51 min (46–60)), but PSCG surgery time decreased over the subsequent cases. PSCG surgery costs were €1163 ($1269) higher compared to conventional HTO. Two AEs in PSCG group: one wound infection and one planning deficiency. Conclusion: The implementation of PSCGs proved challenging and no improvement in precision or cost-effectiveness compared to conventional HTO was seen. Although PSCGs may be beneficial in more complex cases, the innovation faces barriers that prevent its widespread adoption, creating an innovation paradox.