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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 59-65

Combining proximal fibular osteotomy with high tibial osteotomy – Is it better than high tibial osteotomy alone? Comparative evaluation of early outcome

1 Department of Orthopaedics, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Department of Orthopaedics, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
3 Department of Orthopaedics, Apollo Gleneagles Hospital, Kolkata, West Bengal, India

Date of Submission27-Mar-2021
Date of Acceptance10-Nov-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Dr. Manabendra Nath Basu Mallick
Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata - 700 054, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_20_21

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Introduction: Valgisation high tibial osteotomy (HTO) is a widely performed procedure for patients with medial compartment unicompartmental osteoarthrosis knee with varus malalignment of lower limbs. Over the last two decades, medial open-wedge HTO has been more popular than lateral closed-wedge techniques due to multiple advantages. Recently, isolated proximal fibular osteotomy/fibulectomy (PFO) has been advocated as a treatment for medial tibiofemoral osteoarthrosis in young patients. The role of fibulectomy as an adjunct to medial open-wedge HTO has been scarcely reviewed in the literature. Materials and Methods: This study is a retrospective comparative evaluation of clinical outcomes between patients undergoing PFO + HTO versus HTO alone. Functional outcome of ten patients in either group was assessed by Oxford Knee Score and Western Ontario and McMaster Universities score. Results: Patients undergoing PFO + HTO had a larger degree of angular correction. There were lesser complications related to HTO (no delayed union and nonunion). Furthermore, there was no loss of limb alignment. However, peroneal nerve (transient) palsy was reported in this group. Overall, patients had better pain relief and improved scores in the PFO + HTO group. Conclusion: PFO seems to be beneficial (albeit statistically insignificant in our cohort) in medial open-wedge osteotomy by allowing compression and promoting union at osteotomy site, maintaining limb alignment for longer period, and providing bone graft for osteotomy site. We recommend a larger prospective study to study the benefits of PFO + HTO for correction greater than 10°, osteoporosis, iatrogenic fracture of lateral cortex of tibia, and slope correction osteotomies. Care should be exercised while handling the common peroneal nerve during PFO.

Keywords: High tibial osteotomy, medial tibiofemoral osteoarthrosis, Oxford Knee Score, proximal fibular osteotomy, unicompartmental, Western Ontario and McMaster Universities score

How to cite this article:
Baliga S, Tunglut P, Arya P, Mallick MN. Combining proximal fibular osteotomy with high tibial osteotomy – Is it better than high tibial osteotomy alone? Comparative evaluation of early outcome. J Orthop Traumatol Rehabil 2022;14:59-65

How to cite this URL:
Baliga S, Tunglut P, Arya P, Mallick MN. Combining proximal fibular osteotomy with high tibial osteotomy – Is it better than high tibial osteotomy alone? Comparative evaluation of early outcome. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Dec 9];14:59-65. Available from: https://www.jotr.in/text.asp?2022/14/1/59/347360

  Introduction Top

Valgisation high tibial osteotomy (HTO) has several proposed advantages – fine-tuning correction during surgery, possible tibial slope correction, and easier conversion to Total Knee Replacement in future. The success and popularity of medial opening wedge HTO in recent times have been made possible by the availability of dedicated locking plate system.

Recently, isolated proximal fibular osteotomy/fibulectomy (PFO) was described as a treatment for medial tibiofemoral OA in young patients. The role of fibulectomy as an adjunct to medial open-wedge HTO has been scarcely reviewed in the literature.

We evaluated the role of combining PFO + HTO vis-a-vis isolated HTO in terms of improvement in joint function.

Aims and objectives

We aimed to evaluate the effects of combining PFO with medial opening wedge HTO in cases of unicompartmental (medial) osteoarthrosis of knee.

The following parameters were analyzed:

  • Union at osteotomy site
  • Maintenance of limb alignment
  • Bone graft for osteotomy site
  • Symptomatic and functional outcome.

  Materials and Methods Top

A retrospective analysis was carried out on twenty patients who had undergone medial opening wedge HTO for medial tibiofemoral osteoarthritis with or without PFO, at our institute between January 2016 and January 2018, and had completed at least 24 months of follow-up. Out of these twenty patients, ten patients had undergone HTO with PFO (Group A) and ten patients had undergone isolated HTO (Group B). The demographic data are detailed in [Table 1].
Table 1: Demographic data (Group A: High tibial osteotomy + proximal fibular osteotomy/fibulectomy, Group B: High tibial osteotomy only)

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All the surgeries were performed by a single surgeon and at a single center. The surgical procedure was carried out with the patient lying supine on a radiolucent operating table and under tourniquet control. All patients underwent arthroscopic knee debridement prior to osteotomy. The tibial osteotomy was done by a medial longitudinal incision [Figure 1]. Fibular resection was added whenever the gap at the medial edge of the tibial osteotomy measured more than 10 mm. The fibular resection (PFO) was done at a level 6–9 cm below the fibular head by a lateral longitudinal incision and included removal of a 2-cm segment of the fibula [Figure 2]. This fibular segment was split open longitudinally and used as bone graft at the tibial osteotomy gap.
Figure 1: High tibial osteotomy incision

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Figure 2: Proximal fibular osteotomy/fibulectomy + resected fibular segment

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HTO was performed by making a 5-cm vertical incision below the joint line, between the medial aspect of the tibial tuberosity and the posteromedial aspect of the tibia. Two guidewires were inserted at a point 3.5–4 cm below the medial joint line and passed obliquely toward the tip of the fibular head to reach 1 cm below the lateral articular margin of the tibia. After checking the appropriate location under fluoroscopic guidance, tibial osteotomy was performed immediately below the guidewires using an oscillating saw or an osteotome. The osteotomy line extended from tibial tuberosity along the posteromedial aspect of the tibia to 1 cm medial to lateral tibial cortex, parallel to the posterior tibial slope on the sagittal plane. Mobility at the osteotomy site was checked and the osteotomy was opened with a valgus force. Subsequently, a calibrated wedge was inserted until the osteotomy was opened to the desired extent. Alignment was ensured by fluoroscopy using a long alignment rod or wire cable centered over the hip joint and the ankle joint. Normally, this line crossed the knee at 62.5% of the width of the tibial plateau. All the tibial osteotomies were fixed with fixed-angle locking HTO plates from Depuy Synthes (TomoFix) or locking Puddu plates from Arthrex [Figure 3].
Figure 3: High tibial osteotomy fixation

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Rehabilitation comprised early joint range of motion (ROM) exercise, nonweight-bearing with the knee protected in a hinged brace allowing 0°–90° of motion for four weeks. ROM and weight-bearing were increased progressively between 4 and 8 weeks with the knee brace removed. Unprotected weight-bearing was allowed beyond 8 weeks. Maintenance of correction/alignment and bony union were assessed by plain radiography at 6 and 12 months postoperatively [Figure 4]. Clinical results were assessed by the Oxford Knee Score and WOMAC score, calculated at 6 and 12 months postoperatively and yearly intervals thereafter.
Figure 4: High tibial osteotomy + proximal fibular osteotomy/fibulectomy limb realignment orthoroentgenogram at 6 months

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  Results Top

The indication for HTO in five patients from either group was subchondral insufficiency fracture in medial femoral and tibial condyles secondary to medial meniscus tear or root tear with a varus knee. The remaining patients had symptoms related to primary medial unicompartmental osteoarthrosis with varus malaligned limb.

The mean age in Group A is outlined in [Table 1].

Both Groups A and B comprised either Grade II or Grade III (Kellgren-Lawrence) osteoarthrosis with or without an associated medial meniscal tear, which was documented during arthroscopy. The details of these findings are enlisted in [Table 2].
Table 2: Clinical data (Group A: High tibial osteotomy + proximal fibular osteotomy/fibulectomy, Group B: High tibial osteotomy only)

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The average duration of symptoms and range of preoperative knee movement were comparable in both the groups [Table 2]. The minimum follow-up duration for both groups was 24 months.

In Group A, the mean preoperative varus was 7.5° (standard deviation [S.D.] ± 3.3°), whereas in Group B, the varus malalignment averaged 4.5° (S.D. + 3.5°). Postoperatively, the mean valgus alignment achieved was 6.7° (S.D. + 1.4°) and 7.5° (S.D. + 3.5°), respectively [Figure 5].
Figure 5: Correction of alignment achieved

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The average angular correction achieved in patients of Group A was 14.2° (S.D. + 3.7°), which was higher than that of Group B, in whom the mean correction was 12° (S.D. + 5.6°). Both the groups were comparable in terms of knee ROM achieved [Figure 5].

The Oxford Knee Score in Group A improved from a preoperative mean score of 34.3 to 6.8 by 24 months postoperatively. Similarly, in Group B, the score improved from 29.6 to 9 [Table 2] The P value was calculated to be 0.13.

The WOMAC score in Group A improved from a preoperative mean score of 68.1 to 16.7. Similarly, in Group B, the score improved from 63.3 to 20.3 [Table 2]. The P value was calculated to be 0.26.

An illustration of the radiological outcome at 12 months of a patient belonging to Group A has been demonstrated [Figure 6]. Similarly, an illustration of the radiological outcome at 3 months of a patient belonging to Group B has been demonstrated [Figure 7].
Figure 6: Preoperative and postoperative radiograph at 12 months after high tibial osteotomy + proximal fibular osteotomy/fibulectomy (Group A)

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Figure 7: Preoperative and postoperative radiograph at 3 months after high tibial osteotomy (Group B)

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In Group A, there were two complications, both related to PFO. Both patients developed transient common peroneal nerve palsy which recovered spontaneously in 4 months. All patients achieved painless full weight-bearing by 3 months.

One patient who underwent HTO alone (Group B) presented with loss of alignment correction within 6 months of surgery [Figure 8]. The other 19 patients progressed to maintained limb realignment at 24 months.
Figure 8: Loss of correction of alignment within 6 months after high tibial osteotomy (Group B)

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In Group B, there was one case of nonunion at osteotomy [Figure 9] followed by breakage of implant. Additionally, there was one case of delayed union, evidenced on persistent pain at tibial osteotomy site during weight-bearing up to 6 months. Union was noted at 9 months. All of the remaining 18 cases had an uneventful union of the tibial osteotomy.
Figure 9: Nonunion at osteotomy site due to lateral cortex breakdown in a patient with HTO (Group B)

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There was also one case of implant allergy [Figure 10] in Group B requiring removal of plate at 1 year. This, however, did not influence outcome, functional or radiological.
Figure 10: Metal reaction in a patient after high tibial osteotomy warranting implant removal at 1 year after union at osteotomy site (Group B)

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There was no incidence of compartment syndrome, weakness of ankle dorsiflexion, increased postoperative pain, ankle instability, or infection in any of our cases.

The master chart of the study sample is depicted in [Table 3].
Table 3: Master chart

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  Discussion Top

HTO is a surgical procedure performed to treat medial knee arthrosis in active, young, or middle-aged patients. Appropriate patient selection, proper technique of osteotomy, and precise correction of malalignment are essential to success of HTO. Drawbacks of the procedure include restricted motion during the bone union period and possibility of delayed union or nonunion. Successful outcome of HTO can be sustained for at least 8–10 years, delaying the need for conversion to knee replacement.[1]

Patient selection is an important factor contributing to the successful outcomes of HTO. This surgery does not subject the patient to permanent activity restrictions, as compared to total knee arthroplasty (TKA) where activity modification is mandatory. The advent of scientifically designed implants has nullified the use of plaster casts post-HTO. Chondral resurfacing techniques with concomitant tibiofemoral malalignment should be supplemented with a HTO for better results.[2]

In a retrospective study on 35 patients who underwent HTO, TKA was postponed by around 4–5 years (mean: 4.7 years). Favorable prognostic factors included patients younger than 60 years, angular deformity lower than 12°, pure unicompartmental disease, preoperative flexion of at least 90°, and without ligamentous instability.[3]

A meta-analysis of 10 comparative studies was compiled which demonstrated that HTO patients obtained more ROM after surgery. There was no significant difference in the knee function scores; all patients had excellent/good surgical results. The analysis proved that HTO was more suited for patients with high-demand activities.[4]

PFO to treat unicompartmental osteoarthrosis of the knee joint was propounded in the early 1960s when Wardle published one of the first papers on PFO in 1962.[5]

Many more papers followed suite, advocating isolated PFO. In one such paper, the author reported a series of 51 patients (87 knees) with medial compartment OA who were treated by PFO. The length of the resected fibular segment was 1.5–2 cm, and the distance from fibular head to the proximal cut was 6 to 9 cm. The patients were followed up for almost 2 years. The Visual Analog Scale (VAS) score improved from 6.7 to 2.2 postoperatively and the mean functional score too improved from 54.4 to 77 by the end of 1 year.[6]

A prospective study of 45 patients, including 67 knee joints, with medial compartment knee osteoarthrosis who underwent PFO revealed a significant improvement in Hospital for Special Surgery (HSS) knee scores. Regression analysis identified five factors that influenced outcome: change in the vertical distance between the fibular head and tibial plateau, KL score for tibiofibular joint arthritis, body mass index, inclination of the tibiofibular joint, and the preoperative HSS score. Distal displacement of the fibular head contributed to greater ROM of the tibiofibular joint, with significant improvement of postoperative symptoms of knee osteoarthrosis.[7]

Yang et al. analyzed the results of 110 cases of PFO, with a mean follow-up of 49.1 months (24–189 months). There was a significant decrease in femorotibial angle, lateral joint space, and VAS score. Medial joint space and Knee Severity Scores increased. Four patients had numbness in the leg (two superficial peroneal nerve injuries and two common peroneal nerve injuries). However, all of these were cases of neuropraxia and resolved between 3 and 10 months.[8]

The mechanism of efficacy of PFO remains unclear. Normally, equal loads are distributed on the medial and lateral tibia plateau. In the osteoarthritic knee, a greater load is shifted to the medial compartment. One hypothesis proposed is that by removing two cortices of the fibula, the knee becomes more balanced with unicortical support on either side [Figure 11]. One other possible mechanism described was that PFO removed the fibula support that may cause genu varum.[9]
Figure 11: Mechanism of action of proximal fibular osteotomy/fibulectomy

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After PFO, the proximal fibular stump is no longer subject to constraints from the distal fibula and the tibiofibular syndesmosis. This allows for increased relative ROM of the proximal tibiofibular joint. The soleus and peroneus longus muscles, which take origin from the proximal fibula, pull the fibular head in a caudal direction. This tensile force is simultaneously transmitted from the fibular head to the lateral femoral condyle, thereby narrowing the lateral knee joint space and counteracting knee varus deformity. This reduces pressure on the medial compartment of the knee and relieves medial knee pain.[7]

A cadaveric study on the effect of partial fibulectomy altering contact pressure of the knee demonstrated the effects of partial fibulectomy (2 cm of bone being harvested) at 12 cm above the lateral malleolus on compartment pressures in the knee. Medial compartment pressure was reduced and lateral compartment pressure was correspondingly raised. As a consequence, however, total pressure on knee joint decreased, which had a protective effect on knee osteoarthritis. However, since the study was based on only 6 cadavers, the author recommended further studies to evaluate the clinical importance of partial fibulectomy.[10]

Three cases of Extensor hallucis longus (EHL) weakness were reported in a series of thirty patients who underwent PFO. The cause was postulated to be due to excessive stretching of the nerve due to the placement of Hohmann spikes. The authors recommended that Langenbeck retractors were safer in preventing this complication.[11]

A meta-analysis of 47 articles including seven books showcased the advantages of combining knee arthroscopy with partial fibular ostectomy in patients suffering from knee osteoarthrosis and varus deformity.[12]

Zou et al. conducted a prospective comparison study involving 40 patients with PFO and 52 patients with HTO for unicompartmental varus knee. They reported a significant decrease in surgical time, perioperative bleeding, time to full weight-bearing walking, and VAS pain score. Consequently, there was a significant increase in the Japanese Orthopaedic Association score in the PFO group. The authors conclude that PFO had superior short-term and long-term surgical effects on varus knee osteoarthrosis, superior to those of HTO.[13]

Fibular osteotomies that accompanied high-tibial osteotomies were safest when fibular excision was from the lower half. They had the least incidence of peroneal nerve palsy and also did not compromise the stability of the ankle.[14],[15]

During our search for literature, we found very few publications analyzing a combined HTO + PFO procedure. We thought combining PFO with HTO might:

  • Allow compression at the osteotomy site, thereby aiding in early union
  • Maintain limb alignment for a longer period, by removing the lateral strut (fibula)
  • Provide bone graft for the osteotomy site without an additional surgical procedure.

  Conclusion Top

HTO corrects varus malalignment as well as relieves pressure on the medial tibiofemoral compartment. PFO removes the lateral strut which pushes the knee into varus and allows for a greater angular correction. The excised fibular segment can also be used as a source of bone graft for the tibial osteotomy site, to enhance union. Both these procedures complement each other to enhance the benefits of surgery in cases of varus medial tibiofemoral osteoarthrosis.

The sample size in our study is a limitation. However, the two groups have comparable demographic and preoperative clinical data. Our results appear to be encouraging in the short term. We continue to increase patient cohorts as well as follow up these patients annually in order to establish the longevity of clinical as well as radiological benefits in patients undergoing a combined HTO + PFO procedure.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lee DC, Byun SJ. High tibial osteotomy. Knee Surg Relat Res 2012;24:61-9.  Back to cited text no. 1
Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg 2005;13:279-89.  Back to cited text no. 2
Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr. Factors influencing long-term results in high tibial osteotomy. Clin Orthop Relat Res 1991;272:192-8.  Back to cited text no. 3
Cao Z, Mai X, Wang J, Feng E, Huang Y. Unicompartmental knee arthroplasty vs. high tibial osteotomy for knee osteoarthritis: A systematic review and meta-analysis. J Arthroplasty 2018;33:952-9.  Back to cited text no. 4
Wardle EN. Osteotomy of the tibia and fibula in the treatment of chronic osteoarthritis of the knee. Postgrad Med J 1964;40:536-42.  Back to cited text no. 5
Prakash L. PFO – Proximal fibular osteotomy in medial compartment arthritis of the knee with varus deformity. EC Orthop 2019;10:5.  Back to cited text no. 6
Qin D, Chen W, Wang J, Lv H, Ma W, Dong T, et al. Mechanism and influencing factors of proximal fibular osteotomy for treatment of medial compartment knee osteoarthritis: A prospective study. J Int Med Res 2018;46:3114-23.  Back to cited text no. 7
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. 8
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. 9
Yazdi H, Mallakzadeh M, Mohtajeb M, Farshidfar SS, Baghery A, Givehchian B. The effect of partial fibulectomy on contact pressure of the knee: A cadaveric study. Eur J Orthop Surg Traumatol 2014;24:1285-9.  Back to cited text no. 10
Jayanta KL, Ravi K, Ritesh K, Somit S, Manish G. 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. 11
Pham TN, López AÁ, Medina FD. Partial fibular ostectomy and arthroscopy for varus knee osteoarthritis. Rev Arch Med Camagüey 2018;22:244-51.  Back to cited text no. 12
Zou G, Lan W, Zeng Y, Xie J, Chen S, Qiu Y. Early clinical effect of proximal fibular osteotomy on knee osteoarthritis. Biomed Res 2017;28:9291-4.  Back to cited text no. 13
Wootton JR, Ashworth MJ, MacLaren CA. Neurological complications of high tibial osteotomy – The fibular osteotomy as a causative factor: A clinical and anatomical study. Ann R Coll Surg Engl 1995;77:31-4.  Back to cited text no. 14
Ogbemudia AO, Umebese PF, Bafor A, Igbinovia E, Ogbemudia PE. The level of fibula osteotomy and incidence of peroneal nerve palsy in proximal tibial osteotomy. J Surg Tech Case Rep 2010;2:17-9.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

  [Table 1], [Table 2], [Table 3]


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