This document summarizes a study on using proximal fibular osteotomy (PFO) to treat medial compartment osteoarthritis of the knee. PFO is presented as a simpler, less expensive alternative to procedures like high tibial osteotomy (HTO). The study included one patient who underwent PFO and was followed for 6 months, showing decreased pain scores and improved knee joint space. While PFO provided good short-term outcomes, more research is needed to establish its role compared to procedures like HTO and unicompartmental knee arthroplasty. PFO may be particularly suitable for resource-limited settings due to its low cost and technical simplicity.

1. Dr Atanu Kayal
post Graduate Trainee
Burdwan Medical College
Proximal fibular osteotomy for pain
relief and improvement of joint
function in patients with medial
compartment osteoarthritis of knee

2. Introduction and Aim
 Knee Osteoarthritis being a leading cause of
disability among older adults globally.
 Available surgical management : High Tibial
Osteotomy(HTO), Unilateral Knee Arthroplasty (UKA), Total
Knee Arthroplasty (TKA).
 Proximal fibular osteotomy(PFO) is an alternative treatment to
HTO and it is safe, simple, less expensive and requires lesser
rehabilitation, and the post- operative recovery period is faster
than with HTO.

3. Principle
 Mechanism ? still unclear?
 One possible explanation: The fibula supports one-sixth of the body
weight; thus, PFO may redistribute the load on the lateral and medial tibia
plateau after surgery.
 Another : Non-uniform settlement as proposed by Yang et al.

4. Non-uniform settlement
 The support of fibula over lateral condyle tibia transmit weight
but medial condyle tibia has no such support which , leads to
non -uniform settlement .
 Due to change of slope of medial tibial plateau produce
transverse shearing of force to cause a medial shift of femoral
condyle during weight bearing.
 It results in medial shift of mechanical axis ….........VARUS
deformity.

5. How
does it
work?
 After PFO the
proximal fibular
segment become free
from tibiofibular
syndesmosis and distal
fibula, leading to
relative increase
ROM of the proximal
tibiofibular joint.
 The lateral joint space
of the knee is
narrowed to
counteract the varus
deformity during
weight bearing.

6. Case Selection
 Inclusion Criteria
1.Varus Knee (>5 degree)
2.Moderate to severe medial
compartment OA when
conservative treatment
fail.
3.Age >40 years
4. Radiological grading of 1
and 2 (KL grading).
 Exclusion Criteria
1. Tri-compartmental
Osteoarthritis
2. Varus knee >10 degree
3. Obese patient
(BMI>30)
4. ligamentous instability
5. Kellgren Lawrence
grade grading(KL)- 3 and 4.

7. Methodology
• Sample Size: 1
• Study design: Institution based prospective
• Parameters to be studied:
-Visual Analogue Scale ( VAS)
- Western Ontario and McMaster Universities
Arthritis Index (WOMAC) sore

8. Procedure
 Placed in supine position under anaesthesia
 Pneumatic Tourniquet used
 6cm skin incision is made over right lateral aspect and fibula
exposed between peroneus and soleus.
 Fibular osteotomy performed removing 2-3 cm fibula from 8
to10 cm away from Caput fibulae.
 Allowed immediate mobilization and pain permitted weight
bearing as soon as possible.

9. Procedure

10. Result and Analysis
 The Patients was followed up for 6 months.
 Decent amount of pain relief are seen , graded by VAS ( For
pain) and WOMAC score ( For pain, stiffness and functional
activity).
 The ratio of knee joint space medial /lateral compartment
improved from 0.33preoperatively to 0.6 post-operatively.
VAS Score
Pre-op 7.6
Post Op 2.8
WOMAC Score
Pre op 45.2
Post Op 22.2

12. 6 months follow-up

13. DISCUSSION
 PFO has been proposed as an attractive option
for pain relief in patients with medial
compartment KOA .
 The most common complication: Transient
neural injury to peroneal nerve.
 Though provide good outcome in short term
follow up as a simple surgery, to reach to a
reasonable conclusion about its limited role.

14. PFO vs HTO vs UKA
Proximal fibular
osteotomy(PFO
)
High tibial
osteotomy (HTO)
Uni compartmental
knee Arthroplasty
( UKA)
 Simple, safe , fast,
affordable surgery.
 Does not require any
IMPLANT.
 Early rehabilitation
possible
 Technically demanding
procedure.
 Require IMPLANT ( TOMOFIX/
Locking T plate).
 High surgical training needed to
overcome correction error(
under correction and over
correction and excessive
posterior slope change)
 Delayed rehabilitation
 Technically demanding
procedure.
 Require IMPLANT .
 High surgical training
needed to overcome
correction error(
under correction and over
correction)
 Delayed rehabilitation

15. Limitations of Study
 Most of developing countries that lack of medical resources and
healthcare delivery limitations, proximal fibular osteotomy is an excellent
option for pain relief and improve knee functions.
 provide good outcome in short term follow up as a simple surgery, to reach
to a reasonable conclusion about its limited role .
 Engaging with floor bending activities , squating of Indian populations
leads to chance of failure of Uni -condylar knee arthroplasty surgery.
 Average cost of total knee replacement of a single knee cost around 1.4 to
1.8 lakhs, in India where average income of Indian household is
approximately 1.2 lakh/ year which means for one knee surgery they have
to spend entire income of 1 year.

16. Take home message
Correct patient selection is the key to success
Correct level of osteotomy is essential
Radiological opening of medial joint space does
not always correlate to clinical improvement.
How much time one can
saving .......................... for TKA?
Thank you