PROFORMA FOR THE THESIS OF MASTER OF SURGERY

(ORTHOPAEDICS )
ATAL BIHARI VAJPAYEE UNIVERSITY , LUCKNOW U.P
2022-2025

TITLE : A PROSPECTIVE STUDY TO COMPARE THE FUNCTIONAL

AND RADIOLOGICAL OUTCOME OF OPEN WEDGE HIGH TIBIAL
OSTEOTOMY VERSUS PROXIMAL FIBULAR OSTEOTOMY IN
OSTEARTHRITIS OF KNEE.

HEAD OF THE Dr. C.P. PAL

DEPARTMENT: (M.S. ORTHOPAEDICS)
Head And Associate Professor,
Department Of Orthopaedics
S.N. Medical college, Agra .
Dr. C.P. PAL
GUIDE:
(M.S. ORTHOPAEDICS)
Head And Associate Professor,
Department Of Orthopaedics
S.N. Medical college, Agra

CO-GUIDE: Dr. RAJAT KAPOOR

(M.S. ORTHOPAEDICS)
Assistant Professor,
Department Of Orthopaedics
S.N. Medical College, Agra

CO GUIDE: Dr RAVIKANT
(M.S. ORTHOPAEDICS)
Assistant Professor,
Department Of Orthopaedics
S.N. Medical College, Agra
NAME OF STUDENT: Dr. AVINASH KUMAR
PLACE OF WORK: DEPARTMENT OF ORTHOPAEDICS
S.N MEDICAL COLLEGE , AGRA

CERTIFICATE – Certified that aims, objectives, material and method have

been checked and approved. The work is feasible and statistician has been
consulted.
 INTRODUCTION

Osteoarthritis is a chronic degenerative disorder of multifactorial aetiology

characterised by the loss of articular cartilage, hypertrophy of bone at the
margins, subchondral sclerosis, and range of biochemical and morphological
alterations of the synovial membrane and joint capsule. It is usually
characterised by pain after prolonged activity or weight-bearing; and inactivity
induced stiffness. Pain, stiffness, disability, and fatigue in varying severity are
the most commonly reported symptoms [1].
The initial management is always conservative which includes the lifestyle
modification and drug therapies [2].
CLASSIFICATION

Kellgren-Lawrence scale for radiographic classification of osteoarthritis

Grade
0: Normal
1: Questionable : Doubtful narrowing of joint space and possible osteophytic
lipping
2: Mild : Definite osteophytes and possible narrowing of joint space
3: Moderate : Moderate multiple osteophytes, definite narrowing of joint space,
some sclerosis, and possible deformity of bone ends
4: Severe: Large osteophytes, marked narrowing of joint space, severe sclerosis,
and definite deformity of bone ends

The surgical options available for the management of unicompartmental

osteoarthritis of the knee are limited to Proximal Fibular Osteotomy (PFO),
High Tibial Osteotomy (HTO) and unicondylar knee replacement [3,4].
Osteotomy (HTO) was introduced by Jackson et al in 1961 and popularised by
Coventry in 1985. It gained acceptance for correcting deformities and reducing
pain in the treatment of unicondylar osteoarthritic knee.
The medial opening wedge HTO, which was originally described by Hernigou
et al is a well-established procedure for the treatment of unicompartmental OA
of the knee.
HTO has become the surgery of choice as joint preserving procedure for young
patients with OA involving the medial compartment,
High Tibial Osteotomy (HTO) is a widely accepted and performed procedure in
medial Osteoarthritis of the knee Goal of treatment is to unload the affected
knee compartment.
PFO has emerged as a new surgery to relieve pain and improve joint function in
patients with knee osteoarthritis as reported by Zhang et al. in 2015. The most
striking findings in the present study included medial pain relief and an increase
in the medial joint space. The majority of patients in our study had significant
pain relief immediately after PFO.
PFO also improved the axial alignment of the lower extremity in some patients,
especially in those with severe genu varus.
There is no extensive research comparing HTO and PFO in patients having
osteoarthritis of medial compartment of knee joint. Hence, the present study
will be conducted with an aim to evaluate and compare the functional and
Radiological outcome of HTO and PFO in medial compartmental osteoarthritis
of knee joint

Figure:- Possible mechanism of pain relief and joint space improvement after
proximal fibular osteotomy. Left: Equal loads were distributed on the medial
and lateral tibia plateau in the normal condition. Middle: A greater load was
shifted to the medial tibia plateau. Right: The abnormal load was corrected after
proximal fibular osteotomy
 AIMS AND OBJECTIVES

AIM: : A Prospective study to compare the functional and Radiological

outcome of open wedge high tibial Osteotomy (HTO) versus Proximal Fibular
Osteotomy (PFO) in Osteoarthritis (OA) of knee.

OBJECTIVES :
1. To compare and assess the functional outcome between open wedge
high tibial osteotomy and proximal fibular osteotomy in osteoarthritis
knee.
2. To compare and assess the radiological outcome between open wedge
high tibial osteotomy and proximal fibular osteotomy in osteoarthritis
knee.
 REVIEW OF LITERATURE

In a study by Hui C et al., the mean OKS score for HTO cases was 40 and a
study by Robinson PM et al., the mean was 35.40 whereas in our study it was
38.50±4.91 after 1 year of followup [16-18].
Munshi N showed a mean recorded preoperative Oxford knee score 23.87±3.74
mm and postoperative score of 40.2±5.8 mm over one year follow-up.
Another study by Utomo DN et al., the preoperative and postoperative (over one
year followup) OKS was 25.66±4.18 and 36.80±3.00 .
n. A study by Shin CS and Lee JH over HTO the average preoperational VAS
score 6.6 with postoperative one year follow-up score 3.9
A study by Sabir AB et al., the VAS was improved from 7.33±0.72 to
7.13±1.64 at three months and remained the same at final follow-up [21].
Mahadik SK et al., concluded that functional outcome and improvement in VAS
were comparable in both the groups [22] , at first six months functional
improvements in both groups were comparable. But at 15 months interval those
stood 4.1±1.02 and 2.15±1.04 for HTO and PFO groups with a significant p-
value of <0.0001.
Zou et al.,[8] (2017) the preoperative mean femoro-tibial angles were 182.6° ±
2.3° and 183.4° ± 2.5° in PFO and HTO groups while postoperatively were
175.3° ± 1.6° and 168.9° ± 1.3°, respectively. This study emphasizes that HTO
group has better restoration of femoro-tibial angle as compared to PFO group at
1-year follow-up.
Yang et al. [9] (2015) conducted a study on 150 patients with medial
compartment knee osteoarthritis treated by PFO with a follow-up of 2 years
found that mean preoperative KSS score which was 45 ± 21.3 improved to 92.3
± 31.7 at final follow-up.
Liu et al. [10] and Wang et al. [11] In this study, it was found that KSS score in
HTO group was improved better than PFO group at the end of 1-year follow-up.
Utomo et al. [12] conducted a study on 15 patients with medial compartment
knee osteoarthritis treated by PFO found that mean preoperative KOOS score
which was 45.27 ± 3.28 improved to 86.25 ± 1.10 postoperatively.
Roos and Lohmander[13] showed improvement in mean KOOS score from
44.79 ± 13.05 to 71.91 ±
9.08 in patients treated with HTO.
Jaiswal, et al.: Comparision of open wedge high tibial osteotomy versus
proximal fibular osteotomy in patients with osteoarthritis knee
INCLUSION CRITERIA:
(1) age 40-70 years;
(2) Knee pain with medial compartment Arthritis
(3) Kellgren–Lawrence (K–L) grade </= 3
(4) Range of motion > 90 of flexion

EXCLUSION CRITERIA :
(1) AGE <40 OR >70 YRS
(2) Bi or tri-compartmental osteoarthritis.
(3) K–L grade ≥ 3
(4) History or active presence of clinically significant inflammatory articular or
rheumatic disease
(5) Congenital lower limb deformity
(6) Rheumatoid or post-traumatic arthritis
(7) Joint infection
(8) Unfit for surgery
 MATERIALS AND METHOD
STUDY AREA :
The study will be conducted in Department of Orthopaedics, SN medical
college and hospital, Agra

STUDY POPULATION:
Elderly individuals with a clinical diagnosis of Osteoarthritis presenting to the
OPD and ED of Department of Orthopaedics, S.N. Medical College and
hospital , Agra

STUDY PERIOD :
From October 2022 to September 2024

STUDY DESIGN :
It will be a prospective Study

SAMPLE SIZE :
Patients who fulfill the inclusion criteria of the study during the survey period
will be selected as a sample of the study.
STATISTICAL ANALYSIS:
Statistical analysis will be done after data collection with appropriate statistical
technique, applications, methods and tests etc.

Operative technique
Open wedge high tibial osteotomy
After spinal anesthesia, the patient is laid supine and a tourniquet is applied
over the thigh, the lower limb is prepared from mid-thigh to ankle joint and is
draped and tourniquet is inflated after exsanguinations of the limb with
Eschmarc bandage.
HTO with plating
5–6 cm incision given distally such that it lies 2–3 cm posterior to the tibial
tubercle and 1 cm distal to the joint line, the skin and subcutaneous tissues are
reflected on either side, and the deep fascia is incised in the line of skin
incision. Plane made between the bursa and underlying medial collateral
ligament.
The long fibers of the superficial medial collateral ligament are then carefully
detached until the posteromedial cortex of the proximal tibia is exposed [Figure
1]. Two 2 mm parallel k-wires aiming toward the upper third of the proximal
tibiofibular joint are drilled into the tibial head under image intensification to
mark the direction of the osteotomy. First, the posterior wire is inserted at the
cranial border of the pes anserinus just in front of the posterior tibial ridge.
The second wire is placed about 2 cm anterior and parallel to the first wire.
The depth of the saw cut is 10 mm less than the value measured against the
wires in order to leave a lateral bone hinge.
The horizontal osteotomy is performed with the oscillating saw below the two
guide wires that act as guide rails, with very little pressure, and under constant
cooling of the saw blade by irrigation.
After spreading of the osteotomy gap to the desired width, the legs again placed
in extension. In this position, the leg axis can be evaluated clinically and
radiologically. Puddu plate fixed anteriorly and posteriorly with appropriate
screws. Wound was irrigated, closure done in layers.

Technique of proximal fibular osteotomy

After spinal anesthesia, the patient is laid supine and a tourniquet is applied
over the thigh, the lower limb is prepared from mid-thigh to ankle joint and is
draped and tourniquet is inflated after exsanguinations of the limb with
Esmarch’s bandage. A sandbag is applied under the gluteal region to keep the
lower limb in slight internal rotation [Figure 2]. The caput fibula is palpated,
and a 5–7 cm longitudinal incision is given over the proximal fibula starting
about 5 cm distal to its caput, the skin and subcutaneous tissues are reflected on
either side and the deep fascia is incised in the line of skin incision.
A plane is developed between peroneus and soleus muscles which are then
subperiosteally erased, and fibula is exposed. About 2–3 cm long cuff resection
from shaft of fibula at a level about 6–10 cm from caput fibulae is performed
with a power saw, and the cut ends of the fibula are sealed with bone wax.
Wound is irrigated and closed in layers.
METHOD OF COLLECTION OF DATA:
History taking
Clinical Examination
Investigations
Pre-operative as well as post operative follow-up
Patients follow up visits will be at 1 Month, 3 Month followed by every 6
Month, until conclusion of the study.
Complete routine blood investigations.
viral markers of patient.
Baseline cardiac clearance with ECG and 2D ECHO( if needed)
RADIOLOGICAL INVESTIGATION
X ray knee with thigh AP and Lateral
X ray knee with leg AP and Lateral
X ray knee skyline view
STATISTICAL ANALYSIS:
• Functional outcome of open wedge HTO with reference to PFO in
patients with Osteoarthritis Knee will be measured in terms of relief of
Pain Improvement in walking distance and going up and down stairs
using KOOS Scale.
• Radiological Outcome of open wedge HTO with reference to PFO in
patients with osteoarthritis Knee will be measured by Femoro-Tibial
angle.

ETHICAL CONSIDERATION :
Ethical clearance will be taken from the Thesis Review Board and the
Institutional Ethics Committee.

CONSENT:
Written and informed consent will be taken from the patient and the procedure
will be explained to the patient in a language they best understand
 KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE (KOOS)
Scoring instructions
The KOOS's five patient-relevant dimensions are scored separately: Pain (nine
items); Symptoms (seven items); ADL Function (17 items); Sport and
Recreation Function (five items); Quality of Life (four items). A Likert scale is
used and all items have five possible answer options scored from 0 (No
problems) to 4 (Extreme problems) and each of the five scores is calculated as
the sum of the items included.
Interpretation of scores
Scores are transformed to a 0–100 scale, with zero representing extreme knee
problems and 100 representing no knee problems as common in orthopaedic
scales and generic measures. Scores between 0 and 100 represent the percentage
of total possible score achieved.
 CASE RECORD SHEET

Central Registration number:

Name:

Father‟s/Husband‟s name:

Age: Sex:

Address:

Date of surgery:

Date of examination:

Limb involved:
pre op. follow up

Femoro Tibial angle

KOOS SCORE :
 Certificate of Consent

I have been invited to participate in research about “A PROSPECTIVE STUDY TO

COMPARE THE FUNCTIONAL AND RADIOLOGICAL OUTCOME OF
OPEN WEDGE HIGH TIBIAL OSTEOTOMY VERSUS PROXIMAL FIBULAR
OSTEOTOMY IN OSTEARTHRITIS OF KNEE. I have

read the foregoing information, or it has been read to me. I have had the opportunity to ask
questions about it and any questions I have been asked have been answered to my
satisfaction. I consent voluntarily to be a participant in this study.

Name of Participant

Signature of Parent/Guardian

Date

Day/month/year

If illiterate

I have witnessed the accurate reading of the consent form to the potential participant, and the
individual has had the opportunity to ask questions. I confirm that the individual has given
consent freely.

Name of witness Signature of witness

Date

Day/month/year

Thumb print of participant

Statement by the researcher/person taking consent

I have accurately read out the information sheet to the potential participant, and to the best
of my ability made sure that the participant understands that the following will be done:

• Clinical examination

• Functional tests.

I confirm that the participant was given an opportunity to ask questions about the study, and
all the questions asked by the participant have been answered correctly and to the best of my
ability. I confirm that the individual has not been coerced into giving consent, and the consent
has been given freely and voluntarily.

Name of Researcher/person taking the consent

Signature of Researcher /person taking the consent

Date
 REFERENCES

[1] 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 shortterm prognosis. PLoS One.
2018;13(5):e0197980.

[2] Sabir AB, Faizan M, Singh V, Jilani LZ, Ahmed S, Shaan ZH.
Proximal fibular osteotomy: Is it really an option for medial
compartmental osteoarthritis knee? Our experience at tertiary centre.
Indian J Orthop. 2020;55(Suppl 1):228-[3]. Doi: 10.1007/s43465-
020-00289-y. https://pubmed.ncbi.nlm.nih.gov/34122774/. [22]
Mahadik SK, Pandey S, Belsare NS, Shinde GS, Deshpande SB.
Proximal fibular osteotomy vs High tibial osteotomy in medial
compartment osteoarthritis of knee. Asian Journal of Medical
Sciences. 2021;12(6):69-74.

[4] 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.

[5] 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.

[6]. 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. 10. 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

[7] 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;15:858-61.

[8]. Roos EM, Lohmander LS. The knee injury and osteoarthritis outcome
score (KOOS): From joint injury to osteoarthritis. Health Qual Life
Outcomes 2003;1:64.