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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 86-91

Prospective study of functional and radiological outcome of proximal fibular osteotomy for medial compartment osteoarthritis in elderly


1 Professor of Orthopaedics, Nimra Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India
2 Department of Orthopaedics, NRI Institute of Medical Sciences, Sangivalasa, Visakhapatnam, Andhra Pradesh, India

Date of Submission13-Jul-2021
Date of Decision10-Aug-2021
Date of Acceptance13-Aug-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Dr. Ravi Kiran Kakumanu
Department of Orthopaedics, NRI Institute of Medical Sciences, Sangivalasa, Visakhapatnam -531 162, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_13_21

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  Abstract 


Background: Osteoarthritis (OA) is the most common form of arthritis in Indian population. Proximal fibular osteotomy (PFO) is an alternative treatment to high tibial osteotomy and unicondylar arthroplasty or total knee arthroplasty. It is a surgical procedure for medial compartment knee osteoarthritis (KOA). The PFO helps in the correction of a varus deformity in KOA, which shift the loading force from the medial compartment more laterally. It, therefore, helps in decreasing the pain and satisfactory functional recovery. Objective: The objective of the study is to evaluate the clinical and radiological outcomes in medial compartment OA knee treated with minimally invasive PFO as a new and alternative modality of treatment. Materials and Methods: A total of 30 patients were selected (18 men and 12 women, age range between 50 and 72 years) from May 2019 to May 2020 who had undergone PFO for medial compartment OA knee were followed in a prospective manner. Preoperative and postoperative weight-bearing whole lower extremity scanogram was obtained to analyze the alignment of lower limb (femorotibial angle) and ratio of joint space (medial/lateral joint space). Functional outcome was assessed with American Knee Society Score (KSS), and knee pain was assessed with visual analog scale (VAS). Results: In our study, we had 30 patients who were managed by PFO and were followed up for a minimum period of 1 year. Following the surgery, all patients reported dramatic relief in pain with the VAS dropping significantly from 6.39 in the preoperative period to 2.1 postoperatively (P < 0.005). Weight-bearing lower extremities radiographs showed significant increase in medial knee joint space in 20% of patients. We also noted an increase in the medial joint space from 1.1 ± 0.29 mm preoperatively to 4.21 ± 0.7 min postoperatively. The femorotibial angle improved by around 7°, while the hip knee ankle angle improved by around 6°. Conclusion: PFO is a new alternative method in the management of medial compartment arthritis of the knee, which is minimally invasive, safe, and effective, relieves pain, and improves joint function. It helps in the correction of varus knee.

Keywords: Knee society score, osteoarthritis, proximal fibular osteotomy


How to cite this article:
Kakumanu RK, Kunadharaju RT, Ganesh C. Prospective study of functional and radiological outcome of proximal fibular osteotomy for medial compartment osteoarthritis in elderly. J Orthop Dis Traumatol 2021;4:86-91

How to cite this URL:
Kakumanu RK, Kunadharaju RT, Ganesh C. Prospective study of functional and radiological outcome of proximal fibular osteotomy for medial compartment osteoarthritis in elderly. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Jan 24];4:86-91. Available from: https://www.jodt.org/text.asp?2021/4/3/86/332939




  Introduction Top


Osteoarthritis (OA) of the knee is a progressive disease of the joint associated with degeneration of the articular cartilage, leading to pain, deformity, disability, and decrease in the range of motion of the affected joint.[1] Primary OA of the knee is more common than that of the other joints.[2] The main triggering factors for the development of OA are biomechanical due to microfracture of the subchondral bone or fatigue fracture of the collagen fibers. However, medial compartment of the knee is the weight-bearing component, and it draws upon itself 60%–80% of the load; none has accurately described the reason behind this nonuniformity of load sharing.[3]

The surgical management of knee osteoarthritis (KOA), so far, is mainly revolved around arthroscopic procedures, total knee and unicompartmental knee arthroplasty (TKA and UKA), or high tibial osteotomy (HTO). Recently, another minimally invasive surgical treatment of proximal fibular osteotomy (PFO) is proposed for the management of KOA. This procedure is becoming much more popular in the eastern world (China and India) than elsewhere. Its popularity is perhaps due to the fact that this procedure is more straightforward, is less expensive, and requires lesser rehabilitation than the alternative procedures such as HTO, UKA, and TKA. The PFO helps in the correction of a varus deformity in KOA,[4] which shifts the loading force from the medial compartment more laterally. It, therefore, helps in decreasing the pain and satisfactory functional recovery. Hence, the present study was conducted to determine the efficacy of the procedure in terms of clinical, radiological, and functional improvement.

Objectives of the study

  • To study the functional and radiological outcome of PFO for medial compartment OA in the elderly at the Department of Orthopaedics, of Anil Neerukonda Hospital under NRI Institute of Medical Sciences, Sangivalasa, Visakhapatnam
  • Particular attention will be given in careful choosing of the patient. Clinical and radiological evaluation was done post- PFO surgery and associated complications were documented.



  Materials and Methods Top


Study setting

The study was conducted at NRI Institute of Medical Sciences, Anil Neerukonda Hospital, Sangivalasa, Visakhapatnam.

Study design

This was a prospective study.

Study period

The study will be carried out over a period from May 2019 to May 2020.

Study population

After getting ethical clearance, all patients of both sexes who are satisfying inclusion and exclusion criteria will be taken in to study.

Sample size

A sample size of 30 patients was assigned into the study.

Inclusion criteria

  1. Patients with knee pain [Figure 1] and difficulty in walking due to medial compartment OA (Kellgren and Lawrence Grade 2 and 3)[5]
  2. Weight-bearing X-ray showing medial compartment OA knee [Figure 2].
Figure 1: Preoperative clinical varus

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Figure 2: Preoperative X-ray

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Exclusion criteria

  1. Genu valgus
  2. Lateral compartment OA
  3. Knee more than one compartment involved
  4. Early OA (Kellgren and Lawrence Grade 0 and 1)
  5. Bone-to-bone contact on weight-bearing X-ray
  6. Acute major trauma
  7. Inflammatory joint disease
  8. Malignant tumors
  9. Patient not fit for surgery (abnormal liver or renal functions)
  10. Patient not willing for surgery.


Surgical technique

The surgery was performed with the patient in the supine position under spinal anesthesia with antibiotic cover. Tourniquet was not used routinely in our series. The fibular head was palpated and marked and the osteotomy site was determined to be 7.5–10 cm from the head of the fibula. An osteotomy at a higher level would likely cause an injury to the common peroneal nerve whereas if done at a much lower-level than the optimum, intended effect of the osteotomy on the medial compartment arthritis would be lost. A 5 cm lateral incision [Figure 3] was made overlying the chosen site of osteotomy, and dissection was carried out through the skin and subcutaneous tissues [Figure 4]. The peroneus and soleus muscles were then separated to expose the periosteum of the fibula which was then incised [Figure 5], and a 1.5–2 cm of the fibula was then resected [Figure 6] and [Figure 7] with the help of an oscillating saw after placing a few drill holes at the osteotomy site. Curved Hohmann retractors were placed behind the fibula before osteotomy, and care was taken not to stretch the soft tissues too much to protect the nerve from potential damage. Occasionally, after the osteotomy, some of the fibulae tend to bleed quite profusely, and in that situation, bone wax was used to seal the cut ends of the bone. After ensuring hemostasis and giving wound wash, closure was done in layers and sterile dressing and compression bandage were applied. All patients were encouraged to stand and walk on the same evening of the surgery or on the 1st day of surgery and were discharged on the 3rd postoperative day after the first wound inspection. Intravenous antibiotics were given for 3 days followed by oral antibiotics for a period of 5 days.
Figure 3: Skin incision

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Figure 4: Superficial dissection

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Figure 5: Bone drilling

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Figure 6: Excised fibular portion

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Figure 7: C-arm image with increased joint space

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Follow-up

After discharge, patients were called for follow-up on postoperative day 10–12 for sutural removal. Postoperative weight-bearing X-rays [Figure 8] were then taken, and the radiological parameters were evaluated and documented. The patients were reviewed [Figure 9] and [Figure 10] at 1, 3, and 6 months and at the end of the 1st year where the VAS[6] and the Oxford knee scores[7] were evaluated and documented.
Figure 8: Postoperative X-ray

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Figure 9: Postoperative scar

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Figure 10: Correction of varus

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  Results Top


PFO was performed in a total of 30 patients with minimum age of 50 years and maximum age of 72 years, and the average age is 56.5 years. The patients were reviewed at 1, 3, and 6 months and at the end of the 1st year. Patients were analyzed for any complications, and their functional outcome was compared with their previous status. One patient in our study developed Extensor hallucis longus (EHL) weakness.

The patients were evaluated objectively by weight-bearing radiographs and subjectively by visual analog pain scale and knee society score (KSS) [Figure 11] and [Figure 12].
Figure 11: Postoperatively, the mean visual analog scale score of all patients was 2.1

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Figure 12: The mean mechanical axis in the preoperative and the postoperative group was 173 and 173.67, respectively

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Pain was analyzed using VAS both pre- and post-operatively. On the VAS for pain, majority of the patients had a score of 6.39. Following the surgery, all patients reported dramatic relief in pain with the VAS [Table 1] dropping significantly from 6.39 preoperatively to 2.1 postoperatively (P < 0.005).
Table 1: Comparing improvement in medial joint space with landmark studies

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Radiographic measurements were made on each of the operated knee. The median hip knee angle or the mechanical axis was calculated in each patient both pre- and post-operatively.

Medial joint space in the preoperative period is 1.1 ± 0.29 mm and it is significantly increased to 4.21 ± 0.7 in the postoperative period [Table 2].
Table 2: Comparing improvement of visual analog scale with similar studies

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The functional results were evaluated according to the KSS. The KSS is divided into a knee score and a function score. The knee score evaluates pain, range of motion, and stability. Maximum number of points is 100 [Figure 13] and [Figure 14].
Figure 13: The mean medial joint space in the preoperative and the postoperative group was 1.1 and 4.21, respectively

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Figure 14: An average of 92.38 points was attained after proximal fibular osteotomy compared to an average 70.5 points preoperatively

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  Discussion Top


Conservative modalities advocated in early stages of OA include intra-articular injection of steroids, Platelet rich plasma (PRP), or hyaluronic acid. Many studies have shown that these modalities lead to an acceleration of disease pathology due to excessive joint loading after temporary pain relief is achieved, and thus the harms outweigh pain relief in long term.[8]

The surgical options available for the management of medial compartment OA of the knee are limited to HTO and unicondylar knee replacement.

HTO correct the varus deformity associated with medial compartment OA of the knee, but it is associated with a longer recovery period and a prolonged period of nonweight-bearing walking until union of the osteotomy site. HTO tends to relieve pain by diverting the weight-bearing axis to the lateral compartment and effectively relieves pain. However, this needs surgical expertise and is costly. Infection, nonunion, common peroneal nerve injury are some of its disadvantages.[9] Another problem with HTO is that while converting these patients to total knee replacements (TKRs), one needs to remove the plate and then go for TKR. Technically, converting HTO to TKR is more difficult because of the distortion of the proximal tibial metaphysis and due to ligamentous imbalance.

Unicondylar knee replacement surgery is effective but requires highly specialized surgical expertise and specialized instrumentation. The high cost of surgery and revision cost are prohibitive factors for most of the Indian population because of low per capita income.[10] This procedure could be associated with problems such as progression of arthritis or loosening of components. Studies have demonstrated a high rate of revision for unicondylar knee replacement as compared to a TKR.

TKR is too radical surgery for a single compartment involvement and is cost-prohibitive. Furthermore, this requires expertise and can only be done in tertiary centers. After TKR, patients cannot squat as they cannot fully flex the knee, which is required for many of the day-to-day activities of common Indian population.

The mechanism[11] behind the development of medial compartment KOA suggests that there is an asymmetric load transmitted across both tibial plateaus with more stress being borne on the medial side which eventually leading to the development of a varus deformity and arthritic changes with degeneration of the articular cartilage. PFO acts by weakening the support laterally, corrects the varus deformity and shifts the stress from the medial to the lateral compartment, resulting in alleviation of pain, and gives a good functional outcome.

One of the recent studies done by Harshwardhan et al.[12] suggest good functional outcomes in varus deformity of the knee and reducing joint pain.

Cost[13] is also a prohibitive factor for TKR surgeries. The average cost of single-knee TKR is around 150,000–215,000, whereas total cost for PFO in our setting vary from 8000 to 15,000 for one knee. Thus PFO is an alternative approach suitable for low socioeconomic groups.

In a study by Yang et al.,[14] 150 patients with medial compartment arthritis were followed up for a period of more than 2 years. The preoperative KSS was 45 ± 21.3 while the postoperative KSS was 92.3 ± 31.7. The mean VAS preoperatively was 7 which significantly decreased to 2 postoperatively. They stated that PFO dramatically improves the function of the knee and gives good pain relief. In a study by Bo Liu et al.,[15] they had 84 patients with 111 knees being affected by medial compartment arthritis. The average preoperative VAS score was 7.08 ± 1.41. The average preoperative KSS and functional scores were 49.14 ± 10.95 and 44.97 ± 17.1, while postoperatively, it was 67.77 ± 11.08 and 64.66 ± 13.12, respectively. 51 knees were associated with a satisfactory clinical outcome while 77 knees had a significant improvement.

In our study, we had 30 patients who were managed by PFO and were followed up for a minimum period of 1 year. Following the surgery, all patients reported dramatic relief in pain with the VAS dropping significantly from 6.39 preoperatively to 2.1 postoperatively (P < 0.005). Weight-bearing lower extremities radiographs showed significant increase in medial knee joint space in 20% of patients. We also noted an increase in the medial joint space from 1.1 ± 0.29 mm preoperatively to 4.21 ± 0.7 postoperatively. The femorotibial angle improved by around 7°, while the hip knee ankle angle improved by around 6°.

The advantage of PFO over the other procedures is that it is a simple and safe procedure which is cost-effective and easy to perform. It gives dramatic pain relief postoperatively and is associated with a shorter recovery time. All patients can be mobilized with weight-bearing on the next day of surgery. If the procedure does not give good results in any situation, then the field for performing a TKA at a later stage is not altered at all. The limitations of our study were a small sample of patients and relatively short follow-up period. A longer period of follow-up is necessary to evaluate whether the beneficial effects of PFO are sustained over period of time.


  Conclusion Top


PFO is definitely an alternative procedure in the management of medial compartment OA of the knee. It is a simple, effective, and easy to perform procedure which is cost-effective and gives excellent relief of pain postoperatively. It has few surgical complications and a shorter recovery period as compared to HTO and unicondylar knee arthroplasty any how it is by no means a replacement for knee arthroplasty and HTO, which remain gold standard procedures in advanced KOA. After a review of the results of our study, it was revealed that this procedure is reasonably good both clinic-radiologically and can be recommended for medial compartment OA of the knee joint. A long-term follow-up is necessary to evaluate the beneficial effects of PFO are sustained over a period of time.[16] [17]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wu LD, Hahne HJ, Hassenpug T. A long- term follow-up study of high tibial osteotomy for medial compartment osteoarthrosis. Chin J Traumatol 2004;7:348-53.  Back to cited text no. 3
    
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Pan D, TianYe L, Peng Y, JingLi X, HongZhu L, HeRan Z, et al. Effects of proximal fibular osteotomy on stress changes in mild knee osteoarthritis with varus deformity: A finite element analysis. J Orthop Surg Res 2020;15:375.  Back to cited text no. 4
    
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Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res 2016;474:1886-93.  Back to cited text no. 5
    
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Briem K, Axe MJ, Snyder-Mackler L. Medial knee joint loading increases in those who respond to hyaluronan injection for medial knee osteoarthritis. J Orthop Res 2009;27:1420-5.  Back to cited text no. 8
    
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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. 9
    
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Burnett RS, Bourne RB. Indications for patellar resurfacing in total knee arthroplasty. Instr Course Lect 2004;53:167-86.  Back to cited text no. 10
    
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Vaish A, Kumar Kathiriya Y, Vaishya R. A Critical review of proximal fibular osteotomy for knee osteoarthritis. Arch Bone Jt Surg 2019;7:453-62.  Back to cited text no. 11
    
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Harshwardhan H, Laddha GK, Gupta P. Outcome assesment of proximal fibular osteotomy in medial compartment knee osteoarthritis. Int J Orthop Sci 2020;6:183-5.  Back to cited text no. 12
    
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Laik JK, Kaushal R, Kumar R, Sarkar S, Garg M. Proximal fibular osteotomy: Alternative approach with medial compartment osteoarthritis knee–Indian context. J Family Med Prim Care 2020;9:2364-9.  Back to cited text no. 13
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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.  Back to cited text no. 14
    
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Liu B, Chen W, Zhang Q, Yan X, Zhang F, Dong T, et al. Proximal fibular osteotomy to treat medial compartment knee osteoarthritis: Preoperational factors for short-term prognosis. PLoS One 2018;13:e0197980.  Back to cited text no. 15
    
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Prakash L. Proximal Fibular Osteotomy for Medial Compartment OA of Knee Joint (Book Addendum). 1st ed. Chennai: Institute for Special Orthopaedics; 2018. p. 2-5.  Back to cited text no. 16
    
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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. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2]



 

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