Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence?
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Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence? knee osteoarthritis, knee surgery, total knee replacement, osteoarthritis, knee pain, elderly, https://kneesurgrelatres.biomedcentral.com/articles/10.1186/s43019-019-0016-0
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Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence?
- 1. Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence? Dr Saseendar, MS, DNB, Dip SICOT, FISOC (USA), FASS (Sing), FAPKASS, FASS (Korea), Consultant Shoulder and Knee Arthroscopy Surgeon, CARE Sports Injury, Chennai and Apollo Hospitals
- 2. Saseendar S, Kambhampati SBS, Samundeeswari S. Proximal fibular osteotomy in the treatment of medial osteoarthritis of the knee – A narrative review of literature. Knee Surg & Relat Res 31, 16 (2019) doi:10.1186/s43019-019-0016-0.
- 3. Medial osteoarthritis of the knee • Knee - commonest site of osteoarthritis (OA) • Significant research & advances in treatment of medial OA • Surgical options for treatment • High Tibial Osteotomy • UKA • TKA
- 4. Conservative options PRP injection Hyaluronate injection
- 6. Another group studies • Propose proximal fibular osteotomy or upper partial fibulectomy • to reduce knee pain in medial OA
- 7. Aim • Attempted to review existing literature • To assess origin, biomechanics, indications & outcomes of this procedure
- 8. Methodology • Keyword: ‘proximal fibular osteotomy’ • Pubmed – 223 • Medline – 8 • Embase – 10 • Scopus – 204 • Cochrane Library – 7
- 9. Methodology • Articles in English • Articles which combined PFO with other surgical procedures (eg. HTO, UKA) were excluded • Bibliography of the articles were also searched • Total ten articles that assessed clinical or biomechanical effects of PFO in medial OA • Outcomes and mechanisms proposed were studied • Systematic review could not be done (few long-term studies)
- 10. RESULTS • Origin • Mechanisms and Outcomes • Prognostic factors for better outcomes • Surgical procedure • Complications • Future scope
- 11. Biomechanics of the varus knee • Femur • Functional decrease in femoral neck-shaft valgus • Lateral bowing of the femoral shaft • Reduction in the condylar shaft angle • Mechanical axis shifts medially Matsumoto T, Hashimura M, Takayama K, Ishida K, Kawakami Y, Matsuzaki T, et al. A radiographic analysis of alignment of the lower extremities--initiation and progression of varus-type knee osteoarthritis. Osteoarthr Cartil 2015;23(2):217-23.
- 12. Biomechanics of the varus knee • Tibia • Tibial plateau compression leads to steeping of medial plateau in early OA • Bowing of tibia occurs later • Mechanical axis shifts medially Matsumoto T, Hashimura M, Takayama K, Ishida K, Kawakami Y, Matsuzaki T, et al. A radiographic analysis of alignment of the lower extremities--initiation and progression of varus-type knee osteoarthritis. Osteoarthr Cartil 2015;23(2):217-23.
- 13. Biomechanics of the varus knee • Load-bearing in proximal tibia happens primarily in trabeculae rather than the peripheral cortex Hvid I. Mechanical strength of trabecular bone at the knee. Dan Med Bull 1988;35(4):345-65. Aging Trabecular osteopenia Trabecular collapse Steeping of medial plateau
- 14. Origin of Proximal Fibular Osteotomy • Yazdi et al (2014) • Survey of joint reaction forces in cadaver knees after fibulectomy (fibula cuff resection for nonunion tibia, fibular tumor resection, fibula graft harvest) • Found decrease in the medial compartment pressure and • Increase in the lateral compartment pressure • Suggested that performing fibulectomy along with tibial osteotomies can have protective effect 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(7):1285-89.
- 15. Origin of Proximal Fibular Osteotomy • Yang et al (2015) • Published results of retrospective series of PFO surgeries performed since 1996 • Third Hospital of Hebei Medical University, Hebei, China • Zhang, the senior surgeon attributes the idea to one of his students from a rural hospital in China 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(12):e1110-4.
- 16. Rationale behind PFO 1. Concept of nonuniform settlement 2. Too many cortices theory 3. Slippage phenomenon 4. Concept of competition of muscles 5. Dynamic fibular distalisation theory
- 17. Concept of nonuniform settlement • Term used in Architecture
- 18. Concept of nonuniform settlement • Bone density of fibula higher than medial tibial plateau • Osteoporosis leads to settlement • However, fibular support does not allow lateral tibial plateau to settle • Resultant varus deformity Dong T, Chen W, Zhang F, Yin B, Tian Y, Zhang Y. Radiographic measures of settlement phenomenon in patients with medial compartment knee osteoarthritis. Clin Rheumatol 2016;35(6):1573-78.
- 19. A - Normal knee medial tibial load-bearing capacity = cumulative lateral load-bearing capacity (tibial+fibular) B – osteoporotic knee medial tibial load-bearing capacity < cumulative lateral load-bearing capacity (tibial+fibular)
- 20. Settlement value • Height difference between highest point of lateral tibial condyle and the lowest point of medial tibial condyle Dong T, Chen W, Zhang F, Yin B, Tian Y, Zhang Y. Radiographic measures of settlement phenomenon in patients with medial compartment knee osteoarthritis. Clin Rheumatol 2016;35(6):1573-78.
- 21. Settlement value • positively related to knee varus • positively related to Kellgren Lawrence grading of OA of the knee
- 22. • PFO - support of fibula is removed • Lateral side “settles” down – Uniform settlement C – Post PFO knee medial tibial load-bearing capacity = lateral load-bearing capacity (tibial + fibular) B – osteoporotic knee medial tibial load-bearing capacity < cumulative lateral load-bearing capacity (tibial + fibular) • Correction of deformity • Relief in symptoms
- 23. Too many cortices theory • Medial condyle - supported by one cortex • Lateral condyle - supported by one tibial cortex and two fibular cortices • Leads to differential loading when medial side collapses in a varus deformed knee with intact fibula
- 24. Slippage phenomenon • In varus knee, femur slides to the medial side - coronal tibiofemoral subluxation or slippage phenomenon • Maintains a high Knee Adduction Moment (KAM) • Progression of varus deformity and pain
- 25. Concept of competition of muscles • Uniform settlement after PFO takes time • Can explain slow improvement in symptoms • What is the reason for early symptomatic relief? • Immediate improvement in HKA angle after high fibular osteotomy • A rectified non-uniform settlement wouldn't be expected to be evident immediately after a fibula resection
- 26. Concept of competition of muscles • Nie et al analysed the activity of muscles after high fibular osteotomy • increased in the long head of biceps femoris • decreased in the peroneus longus Nie Y, Huang ZY, Xu B, Shen B, Kraus VB, Pei FX. Evidence and Mechanism by which Upper Partial Fibulectomy Improves Knee Biomechanics and Decreases Knee Pain of Osteoarthritis. J Orthop Res 2018
- 27. Concept of competition of muscles • Competition of muscles between Biceps femoris & Peroneus after high fibular osteotomy created a vectior in the direction of valgus
- 28. Dynamic fibular distalisation theory • Qin et al - 67 PFOs • Clinical improvement proportional • to distalisation of fibula and • inclination angle of the proximal tibiofibular joint • Compressive forces from distal fibula not transmitted to proximal fibula 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(8):3114-23.
- 29. Dynamic fibular distalisation theory • Muscles attached to proximal fibula (soleus, peroneus longus) pulled fibular head in the distal direction - tensile force transmitted to LFC through LCL • Greater the distal displacement of the fibular head, better the correction of varus deformity & the more significant the improvement in symptoms 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(8):3114-23.
- 30. More outcomes • Huang et al – Valgus of 5-7 degrees at three months after the operation • Most studies – • increased valgus of knee • improvement in medial joint space Radiographs at one year • Wang et al24 - 46 patients with PFO, follow up of 12 months • Significant decrease in VAS • Improvement of knee and function subscores of American Knee Society Score • Increase in medial joint space Huang W, Lin Z, Zeng X, Ma L, Chen L, Xia H, et al. Kinematic Characteristics of an Osteotomy of the Proximal Aspect of the Fibula During Walking: A Case Report. JBJS Case Connect 2017;7(3):e43.
- 31. Prognostic factors for better outcome • Liu et al - 84 patients (111 knees) • Patients with near-normal HKA Angle (PFO can only partially correct varus deformity of tibial plateau) • Patients with higher settlement value (higher the settlement value, higher effect of lateral fibula support) 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(5):e0197980.
- 32. • Pre and postoperative radiographs • female 63 years old Utomo DN, Mahyudin F, Wijaya AM, Widhiyanto L. Proximal fibula osteotomy as an alternative to TKA and HTO in late-stage varus type of knee osteoarthritis. J Orthop 2018;15(3):858-61.
- 33. • Improvement in axial alignment • 79-year-old woman 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(1):282-89.
- 34. • Improvement in the joint space ratio 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(1):282-89.
- 35. Surgical Procedure • Resect a segment of the fibula • 6-10 cm from the fibular head • Nie et al – b/w extensor digitorum longus & peroneus longus/ peroneus brevis • Yang, Liu – b/w peronei & soleus
- 36. Surgical Procedure • Influenced by common peroneal nerve and its branches • Lower half of fibula – best • Why proximal fibula, why not distal fibula? • Incision in proximal half • should be posterior to the coronal plane • avoids peroneal nerve and its branches (lie in front of the coronal plane) Ogbemudia AO, Umebese PFA, 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(1):17-19.
- 37. Complications • Peroneal Nerve palsy • Yang et al • 1.8% common peroneal nerve(CPN) • 1.8% superficial peroneal nerve palsy which recovered completely between 3 and 10 months • 14.5% had weakness which returned to normal within 4 weeks Yang Z-YY, Chen W, Li C-XX, Wang J, Shao D-CC, Hou Z-YY, et al. Medial Compartment Decompression by Fibular Osteotomy to Treat Medial Compartment Knee Osteoarthritis: A Pilot Study. Orthopedics 2015;38(12):e1110-4.
- 38. Scope for future research • Double blinded RCTs • Male vs female patients? • Post traumatic varus deformity with medial osteoarthritis? • Maximum varus angle until which the procedure can be successful? • Combination strategies with? • Cell-based regeneration strategies? • Arthroscopy? • Longevity of survival before needing TKA/ HTO/ UKA?
- 39. Saseendar S, Kambhampati SBS, Samundeeswari S. Proximal fibular osteotomy in the treatment of medial osteoarthritis of the knee – A narrative review of literature. Knee Surg & Relat Res 31, 16 (2019) doi:10.1186/s43019-019-0016-0.
- 40. THANK YOU!