Complementary roles of standing, supine, and valgus-stress whole-leg radiographs in medial open-wedge high tibial osteotomy planning: supine minimizes bias, whereas standing and valgus-stress reduce outliers.

backgroundAccurate alignment correction is essential in medial open-wedge high tibial osteotomy (MOWHTO). However, conventional planning based on standing radiographs may not reflect postoperative intra-articular alignment changes. While differences between standing and supine radiographs have been investigated, the role of valgus-stress whole-leg radiographs in preoperative planning remains largely unexplored. This study evaluated the predictive accuracy of standing, supine, and valgus-stress whole-leg radiographs in MOWHTO planning and determined whether integrating these modalities improves alignment prediction compared with single-modality planning.

methodsThis retrospective study included 71 patients who underwent MOWHTO. Preoperative standing, supine, and valgus-stress whole-leg radiographs, along with 1-year postoperative standing radiographs, were analyzed. To minimize the influence of surgical execution error and allow the analysis to focus on planning error, the achieved wedge angle was back-calculated from postoperative bony correction and reapplied to each preoperative modality to simulate the postoperative weight-bearing line ratio (Post-WBLR). Accuracy was assessed by comparing simulated and actual Post-WBLR. Multivariable regression was performed to identify predictors of actual Post-WBLR and to compare a multimodal model with the best-performing single-modality simulation.

resultsIn the postoperative valgus subgroup (n = 48), supine-based simulation showed no significant difference from actual Post-WBLR (mean difference, 0.0% ± 6.9%; root mean square error [RMSE], 6.8%). In contrast, standing-based simulation underestimated alignment (-9.3% ± 7.8%; RMSE, 12.1%), whereas valgus-stress simulation overestimated it (15.2% ± 6.7%; RMSE, 16.6%). A multimodal regression model incorporating simulated Post-WBLR from standing and valgus-stress radiographs demonstrated significantly improved predictive accuracy compared with the supine-only simulation (R

conclusionsSupine radiographs generally provided the most accurate single-modality basis for MOWHTO planning. Standing and valgus-stress radiographs offered complementary information, and their integration improved prediction accuracy and reduced planning outliers. While further validation is required, a stepwise planning workflow-using supine radiographs as the default modality and multimodal integration when ∆JLCA