Dear Editor,
First, we would like to congratulate Laik JK et al. for their creditable research that that has been published in your journal.[1] Their prospective, interventional cohort study definitely adds to existing knowledge on this relatively new and cost-effective treatment method.
The positives of the study include clear inclusion and exclusion criteria, use of established outcome measures (VAS, Tegner Lysholm score, medial joint space and femoro-tibial angle) and clearly established surgical protocol for standardization of the treatment and measurement of clinical outcomes. The sample size, though small, helps to understand the outcomes prospectively.
Though the authors have mentioned the sample size to be 30 patients, the actual numbers appear to be 27 patients (30 knees) with three patients undergoing bilateral surgery. This could have been clarified better. Moreover, osteoarthritis of the knee being a chronic condition, it is important to assess the long-term outcomes in addition to the short-term gains. A follow-up of a minimum of two years in all the patients could add more value to the findings of the study.
We would also like to take this opportunity to stress upon readers the fact that proximal fibular osteotomy should not be considered a one-stop solution for all patients with medial knee osteoarthritis. The indications and predictors of good outcomes have been discussed in detail in systematic reviews on this topic. That said, the mechanisms proposed are multiple, also implying that the procedure and its mechanisms are still being understood.[2]
The risk of injury to the superficial and deep peroneal nerves in relation to the proximal fibula is known.[3,4] Hence, we stress on an incision 6 cm below the fibular head and downwards and also approaching the fibula posterior to the coronal plane to avoid the peroneal nerve and its branches which are anterior to the coronal plane. Hence a posterolateral approach between the peroneus longus and brevis muscle is advisable instead of a direct lateral approach.[2,3,5]
We would also like to cite the work of Vaish et al. where the authors have provided a detailed description of the recommended surgical technique in order to prevent injury to the superficial and deep peroneal nerves.
There is no doubt that this could be a useful method to treat osteoarthritis of the knee and prevent its early progression to a total knee arthroplasty, when performed for the right patients. However, to get to this point there is still a large way to go in the form of establishing strong evidence.
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Conflicts of interest
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References
- 1.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. doi: 10.4103/jfmpc.jfmpc_324_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Shanmugasundaram S, Kambhampati SB, Saseendar S. Proximal fibular osteotomy in the treatment of medial osteoarthritis of the knee–A narrative review of literature. Knee Surg Relat Res. 2019;31:1–7. doi: 10.1186/s43019-019-0016-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.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. [PMC free article] [PubMed] [Google Scholar]
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