It is important to perform accurate bone cutting for the tibia and talus and to adjust soft-tissue balance when performing total ankle arthroplasty in rheumatoid arthritis cases with complex deformities to avoid prosthesis edge loading. We studied 38 cases with rheumatoid arthritis. A custom-made surgical guide was used for 24 cases since January 2007 to produce accurate osteotomies; the remaining cases used a conventional osteotomy guide. The tibial/talar component angular surface angles and tilting angle between components were measured with x-rays during standing. The error angle of the tibial bone cut was 1.9±1.5 degrees in the conventional group compared with 1.0±0.8 degrees in the custom-made group (P=0.02). The tilting angle between components was 0.3±0.4 degrees in the custom-made group compared with 1.1±1.4 degrees in the conventional group (P=0.01). The custom-made surgical guide based on preoperative 3-dimensional evaluation helped produce accurate and stable bone cutting. These benefits were enhanced by using malleolar sliding osteotomy to control the soft-tissue balance, with subsequent tilt between components being nearly parallel in the standing postoperative radiograph.