Ninety-eight patients with medial meniscus posterior root tears and mild varus deformity were randomized to receive open-wedge high tibial osteotomy aimed at the classic targeted alignment through the Fujisawa point (n=52) or neutral alignment (n=46). The primary outcome was the Lysholm score at final follow-up. Secondary outcomes included Hospital for Special Surgery (HSS) score, radiographic parameters (hip–knee–ankle angle, weight-bearing line ratio, medial proximal tibial angle, medial meniscus extrusion, Kellgren–Lawrence grade), and second-look arthroscopic findings of meniscal healing and cartilage status. Outcomes were assessed preoperatively and at a mean follow-up of 37.1 months. Overall, results showed no significant differences between groups in Lysholm or HSS scores (p=0.084), meniscal healing rates, or cartilage degeneration, though radiographic alignment measures differed significantly. The findings suggest neutral alignment achieves similar clinical outcomes to classic alignment, potentially avoiding overcorrection risks.