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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 107-110

Functional outcome of proximal fibular osteotomy in medial compartment knee osteoarthritis


Department of orthopaedics, Patna Medical College, Patna, Bihar, India

Date of Submission03-Nov-2021
Date of Decision25-Nov-2021
Date of Acceptance27-Nov-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Dr. Rakesh Choudhary
H – 29, Doctors Colony, Kankarbagh, Patna - 800 020, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_29_21

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  Abstract 


Aims: Medial compartment arthritis is very common in the Asian population because of a preponderance of varus knees. High tibial osteotomy and total knee replacement are technically demanding procedures, while proximal fibular osteotomy (PFO) significantly relieves pain and improves joint function in knee osteoarthritis (OA). This retrospective study was conducted at Patna Medical College and Hospital. The objective of this study was to assess functional outcomes after PFO and its correlation with bone mineral density. Settings and Design: The study design was a retrospective study. Subjects and Methods: Twenty patients with unicompartmental OA with varus deformity were included in the study. Inclusion criteria included patients with moderate-to-severe symptomatic medial unicompartmental OA of the knee, who had an indication for a surgical procedure, and who were able to give informed consent for the surgery. Exclusion criteria included patients with posttraumatic knee OA or inflammatory joint disease and patients with a history of previous operations or fractures the primary outcome was measured by calculating the ratio of knee joint space. The secondary outcome measure was pain measured by the visual analog scale (VAS). Statistical Analysis Used: Statistical analysis was performed by measurement of study variable. Results: Immediate postoperative pain relieved was noticed in all twenty patients. While at 1-, 3-, and 6-month follow-up, pain relieved was noticed maximum in osteoporotic group patients (n = 12). At 9-month follow-up, pain relieved was noticed equally in all patients. Radiographs of the weight-bearing lower extremity showed an average increase in the medial knee joint space postoperatively compared with preoperatively. The ratio of the knee joint space (medial/lateral compartment) improved significantly from 0.50 ± 0.30 preoperatively to 0.58 ± 0.28 postoperatively. Conclusions: PFO is a simple, safe, fast, and affordable surgery to relieve pain and improve joint function and the medial joint space in knee osteoarthritis, particularly in osteoporotic individuals.

Keywords: Medial compartment osteoarthritis, proximal fibular osteotomy, ratio of knee joint space, visual analog scale


How to cite this article:
Ranjan P, Anand R, Choudhary R. Functional outcome of proximal fibular osteotomy in medial compartment knee osteoarthritis. J Orthop Dis Traumatol 2021;4:107-10

How to cite this URL:
Ranjan P, Anand R, Choudhary R. Functional outcome of proximal fibular osteotomy in medial compartment knee osteoarthritis. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Jan 24];4:107-10. Available from: https://www.jodt.org/text.asp?2021/4/3/107/332946




  Introduction Top


Medial compartment arthritis is very common in Asian population, because of a preponderance of varus knees. High tibial osteotomy and total knee arthroplasty are the 2 methods used for treating knee OA. High tibial osteotomy is technically demanding procedure and may result in complications, including neurovascular injury, iatrogenic fracture, and nonunion.[1],[2] Total knee arthroplasty can correct lower extremity alignment, relieve pain, and improve function sig¬nificantly. However, for younger, active patients or patients with moderate OA, it may not be the treatment of choice.[3] In 2015, Zhang et al. reported that proximal fibular osteotomy (PFO) relieves pain and improves joint function in knee OA.[4] T-score is defined as the amount of bone compared with a young adult of the same gender with peak bone mass. A score above -1 is considered normal. A score between -1 and -2.5 is classified as osteopenia (low bone mass). A score below -2.5 is defined as osteoporosis.[5] In our study, we carefully evaluated functional outcome of PFO in medial compartmental knee OA in normal bone mineral density individual, osteopenic and osteoporotic individual.


  Subjects and Methods Top


Study population

This retrospective study was conducted at a teaching hospital for a period of 1 year between December 2017 and November 2018 and in that 20 patients with unicompartmental OA with varus deformity were included in the study.

Inclusion criteria included patients (age range 40 - 60 years) with moderate-to-severe symptomatic medial unicompartmental OA of the knee, who had an indication for a surgical procedure, and who were able to give informed consent for the surgery. Exclusion criteria included patients with posttraumatic knee OA or inflammatory joint disease and patients with a history of previous operations, ligament injuries, or fractures.

Outcome measures

The primary outcome was measured by calculating the ratio of knee joint space. The medial joint space was determined by a vertical line (A) between two horizontal lines (C and D) that were drawn from the lowest point of the medial condyle of the femur and medial plateau of the tibia, respectively. The lateral joint space was determined by a vertical line (B) between two horizontal lines (E and F) that were drawn from the lowest point of the lateral condyle of the femur and lateral plateau of the tibia, respectively. The ratio of the knee joint space (medial/lateral) was determined by the ratio of A/B [Figure 1].[6]
Figure 1: Measurement of ratio of knee joint space

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The secondary outcome measure was pain measured by the visual analog scale (VAS).[7]

Methodolgy

Preoperatively, every patient's bone mineral density was checked using DEXA scan and weight-bearing AP, and lateral radiographs of the affected knee were taken.

Under spinal anesthesia, the patients were placed in the supine position with the lower limb tourniquet inflated. First, the fibular head was marked. To avoid injury to the common fibular nerve and tibial attachments of the soft-tissue structures crossing the knee joint, a lateral incision of 3 cm to 5 cm was made at the proximal third of the fibula. The fascia was then incised in line with the septum between the peroneus and soleus, the muscles were separated, and the fibula was exposed. A 2-cm section of the fibula was removed 6 cm to 10 cm below the fibular head with the use of an oscillating saw [Figure 2]. Following resection, the fibula ends were sealed with bone wax. The muscles, fascia, and skin were sutured separately after the incision had been irrigated with a large volume of normal saline. Postoperatively, the patients were ambulated as soon as pain could be tolerated.
Figure 2: Image shows resected part of the fibula in a kidney tray

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Follow-up

Patients were followed up at 1, 3, 6, and 9 months postoperatively and annually thereafter. Weight-bearing AP and lateral radiographs of the affected knee were taken at each follow-up.


  Results Top


Among 20 patients, 8 were males and 12 were females, and 17 of the patients had only unilateral OA and only three patients had bilateral OA. The right knee was involved in 14 patients, and the left knee was involved in six patients. The age of the patients had ranged from 45 to 50 years with a mean age of 48.5 years. The majority of the patients were between 49 and 50 years. Preoperatively, all patients reported limited range of knee motion, varus deformity, and severe knee pain, especially after increased weight bearing. Preoperatively, AP radiographs of the affected knees revealed narrow joint space in the medial compartments and sclerosis around femorotibial joints. Preoperatively, DEXA scan study revealed, out of 20 patients, 12 patients were osteoporotic, 5 patients were osteopenic, and three patients had normal Bone mineral density (BMD). Immediate postoperative pain relieved was noticed in all 20 patients. While at 1-, 3-, and 6-month follow-up, pain relieved was noticed maximum in osteoporotic group patients (n = 12). At 9-month follow-up, pain relieved was noticed equally in all patients. No postoperative complications were observed including wound infection, delayed healing, or nerve damage. Preoperatively, VAS had ranged between 7 and 9, which decreases significantly at 9-month follow-up and had ranged between 1 and 3. Radiographs of the weight-bearing lower extremity showed an average increase in the medial knee joint space postoperatively compared with preoperatively [Figure 3] and [Figure 4]. The ratio of the knee joint space (medial/lateral compartment) improved significantly from 0.50 ± 0.30 preoperatively to 0.58 ± 0.28 postoperatively. Both radiological and functional improvements were observed more among patients with osteoporosis.
Figure 3: Image shows preoperative X-ray AP view of osteoarthritic knee joints in a 54-year-old female

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Figure 4: Image shows X-ray of knee joints after 3 months of fibulectomy

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  Discussion Top


Bone mass decreases as a part of the normal aging process.[8] In the proximal tibia, the lateral support of the fibula to the lateral tibial plateau routinely leads to nonuniform settlement, which is more severe in the medial plateau than in the lateral plateau. The slope of the tibial plateau arising from nonuniform settlement results in a transverse shearing force, with the femoral condyle shifting medially during walking and sports. Furthermore, side-slip aggravates the nonuniform settlement of the tibial plateau, especially in the medial plateau. Accordingly, a cycle of increasing the load distribution in the medial compartment and nonuniform settlement occurs.[9] Based on these assumptions, in 2015, Yang et al. hypothesized that the lateral support of the fibula to the tibial plateau is a key factor that leads to the nonuniform settlement of the bilateral plateau and the medial shift of the mechanical axis, resulting in degeneration and varus deformities of the knee joint. Proximal osteotomy of the fibula weakens the lateral fibular support and leads to a correction of the varus deformity, which can subsequently shift the loading force from the medial compartment more laterally, leading to decreased pain and satisfactory functional recovery.[10]

In 2015, Wang et al. concluded that medial pain relief was observed in all patients after PFO. The mean VAS scores significantly decreased from 8.02 + 1.50 preoperatively to 2.74 ± 2.34 postoperatively. In our study, preoperatively, VAS had ranged between 7 and 9, which decreases significantly at 9-month follow-up and had ranged between 1 and 3.[11] In 2015, Xiaohu Wang et al. concluded that the ratio of knee joint space (medial/lateral compartment) improved significantly from 0.40 ± 0.28 preoperatively to 0.58 ± 0.30 postoperatively. In our study, the ratio of the knee joint space (medial/lateral compartment) improved significantly from 0.50 ± 0.30 preoperatively to 0.58 ± 0.28 postoperatively, which is comparable with the study conducted by Xiaohu Wang et al. Immediate postoperative pain relieved was noticed in all thirty patients. While at 1-, 3-, and 6-month follow-up, pain relieved was noticed maximum in osteoporotic group patients (n = 12). At 9-month follow-up, pain relieved was noticed equally in all patients.


  Conclusions Top


We concluded that PFO is a simple, safe, fast, and affordable surgery to relieve pain and improve joint function and the medial joint space in knee OA, particularly in osteoporotic individuals. Immediate postoperative pain relieved was noticed due to counter-irritation effect (such as topical analgesic balms, tricking the nerve to confuse them between superficial and deep pain, and shifting the attention from medial to lateral and stitch pain), while long-term pain relieved was noticed due to mechanical axis realignment of knee, shifting loads from medial to lateral. Furthermore, these patients can still undergo TKA in future if it becomes necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wu LD, Hahne HJ, Hassenpflug T. A long-term follow-up study of HTO for medial compartment OA. Chin J Traumatol 2004;7:348-53.  Back to cited text no. 1
    
2.
Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis: Survival and failure analysis to twenty-two years. J Bone Joint Surg Am 2003;85:469-74.  Back to cited text no. 2
    
3.
Schnurr C, Jarrous M, Gudden I, Eysel P, Konig DP. Pre-operative arthritis severity as a predictor for total knee arthroplasty patients' satisfaction. Int Orthop 2013;37:1257-61.  Back to cited text no. 3
    
4.
Zhang YZ. Innovations in orthopedics and traumatology in China. Chin Med J (Engl) 2015;128:2841-2.  Back to cited text no. 4
    
5.
WHO. Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis: Technical Report Series 843. Geneva: WHO; 1994.  Back to cited text no. 5
    
6.
Wang X, Wei L, Lv Z, Zhao B, Duan Z, Wu W. Proximal fibular osteotomy:a new surgery for pain relief and improvement of joint function in patients with knee osteoarthritisJ Int Med Res, 2017;45: pp. 282-9. https://doi.org/10.1177/0300060516676630.  Back to cited text no. 6
    
7.
Huskisson EC. Measurement of pain. Lancet 1974;2:1127-31.  Back to cited text no. 7
    
8.
Newton-John H, Morgan D. Osteoporosis: Disease or senescence? Lancet 1968;291:232-3.  Back to cited text no. 8
    
9.
Segal NA, Anderson DD, Iyer KS, Baker J, Torner JC, Lynch JA, et al. Baseline articular contact stress levels predict incident symptomatic knee OA development in the MOST cohort. J Orthop Res 2009;27:1562-8.  Back to cited text no. 9
    
10.
Yang ZY, Chen W, Li CX, Wang J, Shao DC, Hou ZY, et al. Medial compartment decompression by fibular osteotomy to treat medial compartment knee osteoarthritis: A pilot study. Orthopedics 2015;38:e1110 4. https://doi.org/10.3928/01477447-20151120-08.  Back to cited text no. 10
    
11.
Wang X, Wei L, Lv Z, Zhao B, Duan Z, Wu W, et al. Proximal fibular osteotomy: A new surgery for pain relief and improvement of joint function in patients with knee osteoarthritis. J Int Med Res 2017;45:282-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Introduction
Subjects and Methods
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