Orthopedics

Letter to the Editor Free

Proximal Fibular Osteotomy: Mechanisms and Approach

Saseendar Shanmugasundaram, MS(Ortho), DNB(Ortho), Dip SICOT(Belgium), MNAMS; Luis Antonio Goytia Alfaro, MD, MCh

Abstract

Click here to read the article.

Abstract

Click here to read the article.

To the Editor:

We read with interest the recently published article by Prakash and Dhar.1 We congratulate them on providing an engrossing take on an evolving, complex, and controversial concept in the management of medial osteoarthritis of the knee. The illustrations provided and the mechanisms proposed improve understanding of the concept. We have also published on this topic.2 We would like to add some information to their outstanding article.

The history of proximal fibular osteotomy has been ambiguous. As with most other concepts, the technique appears to have evolved over time through multiple attempts, failures, and improvement. As noted by Prakash and Dhar,1 Hara et al3 first used proximal fibular osteotomy with high tibial osteotomy in 1994. However, fibulectomy in isolation was first reported by Yang et al4 in their retrospective series of procedures performed since 1996.

The next interesting and more important aspect of the procedure is the mechanism by which it acts. Multiple mechanisms have been proposed,2 meaning that no single theory is perfect and that the concept is still being comprehended. While the evidence and its understanding are bound to evolve and improve over time, currently there appear to be two primary clinical effects of proximal fibular osteotomy—late and early. The late effects are better understood and appear to revolve around the nonuniform settlement theory and the too-many cortices theory. The compaction zone concept mentioned by Prakash and Dhar1 can be a significant addition to these theories. The mechanism of immediate pain relief is puzzling but not inexplicable. This effect appears to be the result of the dynamic action of the muscles as explained by the competition of muscles theory and the dynamic fibular distalization theory.2

Finally, the risk of injury to the superficial and deep peroneal nerves with this procedure is finite.4,5 While the osteotomy is recommended at least 6 cm below the fibular head, we also stress the importance of an approach posterior to the coronal plane to avoid superficial and deep peroneal nerve palsies, even if transient. Thus, it is preferable to use a posterolateral approach between the peroneus longus and brevis muscles instead of a direct lateral approach.2,4

More evidence is needed to help us better define the indications for and more accurately predict the outcomes of the procedure. Only then will the technique be accepted worldwide or be included in the algorithm of management of medial osteoarthritis of the knee. If this technique can improve symptoms and delay progression to total knee replacement by at least 5 years, it can be deemed a success.

Saseendar Shanmugasundaram, MS(Ortho), DNB(Ortho),
Dip SICOT(Belgium), MNAMS
Apollo Hospital
Muscat, Sultanate of Oman
Luis Antonio Goytia Alfaro, MD, MCh
University Health Insurance Hospital and Cristo de las
Americas Hospital
Sucre, Bolivia

References

  1. Prakash L, Dhar SA. Proximal fibular osteotomy: biomechanics, indications, technique, and results. Orthopedics. 2020;43(6):e627–e631. doi:10.3928/01477447-20200812-02 [CrossRef]
  2. Shanmugasundaram S, Kambhampati SBS, Saseendar S. Proximal fibular osteotomy in the treatment of medial osteoarthritis of the knee: a narrative review of literature. Knee Surgery & Relat Res. 2019;31(1):1–7. doi:10.1186/s43019-019-0016-0 [CrossRef]
  3. Hara M, Ogata K, Nomiyama H, et al. New technique and results of fibular osteotomy in the proximal neck region in HTO. Orthop Traumatol Surg Res. 1994;43(4):1380–1382.
  4. Yang ZY, Chen W, Li CX, et al. Medial compartmental decompression by fibular osteotomy to treat medial compartment knee osteoarthritis: a pilot study. Orthopedics. 2015;38(12):e1110–e1114. doi:10.3928/01477447-20151120-08 [CrossRef] PMID:26652332
  5. Agarwal DK, Saseendar S, Patro DK, Menon J. Outcomes and complications of fibular head resection. Strategies Trauma Limb Reconstr. 2012;7(1):27–32. doi:10.1007/s11751-012-0133-8 [CrossRef]

Reply:

We appreciate this letter about our article.1 The letter in itself further enriches the literature regarding proximal fibular osteotomy. We thank the authors for commenting on and further discussing the material we have presented. Although we broadly agree with this letter, we think that there is a need to further clarify the points discussed.

The biomechanics of the osteotomy is a fascinating topic, and the literature regarding it is evolving. We believe that the nonuniform settlement theory, the too-many cortices theory, and the compaction zone concept can be discussed under the overarching “leaning Tower of Pisa concept.” The sequence would be that too many cortices laterally cause non-uniform settlement medially, leading to a leaning tower. This tower can be made more vertical by the osteotomy by allowing the formation of a lateral compaction zone. We also believe that the compaction zone could be an important reason for the immediate pain relief reported by some patients. It is akin to inserting a new shock absorber.

As the authors mention, the other possible reasons for the early effect appear to be contributed primarily by the dynamic action of the muscles as explained by the competition of muscles theory and the dynamic fibular distalization theory.2 We have witnessed greater relief in patients with a more horizontal tibiofibular joint. We believe that the biceps surae is like a mountaineer, who is able to pull hard on the rope only when his feet are braced against the face of the mountain. A horizontal joint allows bracing, but a vertical joint does not. Biomechanically, a sliding joint would also allow a posterolateral pull, which might not be beneficial. However, this remains a topic of debate, and more research is required before definitive conclusions can be drawn. In future studies, it will also be important to measure the position of the fibula carefully relative to the tibia for all patients undergoing proximal fibula osteotomy. This will improve our understanding of the dynamics of the osteotomized fibula.

Lakshmanan Prakash, MS, MCh
Institute of Special Orthopaedics
Palakkad, Kerala

Shabir Ahmed Dhar, MS
SKIMS MC Bemina
Srinagar, Kashmir, India

References

  1. Prakash L, Dhar SA. Proximal fibular osteotomy: biomechanics, indications, technique, and results. Orthopedics. 2020;43(6):e627–e631. doi:10.3928/01477447-20200812-02 [CrossRef]
  2. Shanmugasundaram S, Kambhampati SBS, Saseendar S. Proximal fibular osteotomy in the treatment of medial osteoarthritis of the knee: a narrative review of literature. Knee Surgery & Relat Res. 2019;31(1):1–7. doi:10.1186/s43019-019-0016-0 [CrossRef]
Authors

The authors have no relevant financial relationships to disclose.

10.3928/01477447-20201023-02

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