Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : RC05 - RC09 Full Version

Effectiveness of Proximal Fibular Osteotomy as an Alternative Treatment Modality for Pain Relief and Functional Improvement in Medial Compartment Knee Osteoarthritis


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/58150.17086
Pratik Ramesh Gandhi, Sumeet Sharad Patil, Maroti Raghoji Koichade

1. Assistant Professor, Department of Orthopaedics, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India. 2. Senior Resident, Department of Orthopaedics, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India. 3. Professor, Department of Orthopaedics, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India.

Correspondence Address :
Dr. Sumeet Sharad Patil,
Senior Resident, Department of Orthopaedics, Indira Gandhi Government Medical
College, Nagpur, Maharashtra, India.
E-mail: sumpatil92@gmail.com

Abstract

Introduction: Medial compartment knee Osteoarthritis (OA) is a painful and debilitating disease that hinders an individual’s day-to-day activities physically and psychologically. Therefore, amelioration of pain is of utmost importance, which can be achieved by decompressing the medial compartment by Proximal Fibular Osteotomy (PFO). PFO is a simple, novel surgical technique that leads to significant pain relief and functional improvement in patients with knee OA.

Aim: To assess the effectiveness of PFO in patients with primary medial compartment OA of the knee joint in terms of pain relief and functional outcome.

Materials and Methods: A prospective and interventional study was carried out in the Department of Orthopaedics at Indira Gandhi Government Medical College, Nagpur, Maharashtra, India, during the period from November 2017 to October 2020. A total of 58 patients with moderate to severe symptoms of medial compartment knee OA underwent PFO. Visual Analogue Score (VAS score), Knee Society Score (KSS), and Femoro-tibial Angle (FTA) were assessed preoperatively, postoperatively, and during follow-up visits at 1, 3, 6, and 12 months. These parameters (VAS score and KSS) were also compared with groups based on Body Mass Index (BMI) and Kellgren-Lawrence (K-L) grading. Paired-t test was used. A p-value of <0.001 was considered statistically significant.

Results: Remarkable pain relief was observed by the significant decline in mean VAS score from 8.04±0.68 to 2.65±1.14 at the final follow-up. Mean KSS at final follow-up was 69.82±3.03, which was significantly higher than the preoperative score of 43.38±2.39 (p-value <0.001). A change in mechanical alignment was seen with a decrease in mean FTA from 183.38±1.29° to 179.84±1.83° (p-value <0.001) at the final follow-up. Also, it was observed that results were much more encouraging and consistent in patients with BMI ≤24.99 unit kg/m2 and K-L grades 1 and 2.

Conclusion: The PFO is a simple, safe, reasonable, and effective surgical modality of treatment in patients with primary medial compartment knee OA that provides good pain relief and functional improvement. PFO can be an alternative treatment modality for pain relief in patients with medial compartment knee OA.

Keywords

Body mass index, Decompression, Kellgren-Lawrence score, Knee pain, Knee society score, Upper partial fibulectomy

Primary OA is one of the most ubiquitous chronic degenerative diseases of the knee joint, with an overall prevalence of 28.7% of the population (1). It is a chronic disabling condition characterised by persistent pain, stiffness, and restriction of range of movements, which encumbers the activities of daily living (2). Of all the three compartments of the knee, the medial compartment bears 60-80% of the load during weight-bearing in normal healthy individuals (3),(4), which makes it the most vulnerable site for OA. Another plausible reason based on the current belief for the involvement of the medial compartment is that the load is distributed along the mechanical axis, which normally passes medial to the centre of the knee (4). Majority of the patients with medial compartment knee OA present with varus deformity at the knee, indicated by FTA of more than 180° and narrowing of Medial Joint Space (MJS) (5).

Pain is one of the most disturbing presenting symptoms that impede an individual’s day-to-day activities physically and psychologically. This debilitating condition can be treated by various treatment modalities including conservative and surgical methods. The conservative management for OA of the knee incorporates analgesics, visco-supplementation, intra-articular injections of steroid or platelet-rich plasma, and physical therapy (6),(7). Total Knee Arthroplasty (TKA) and High Tibial Osteotomy (HTO) are the two established surgical modalities for knee OA, both of which are quite expensive and associated with procedural intricacies as well as various complications (5),(8).

The PFO is a new emerging surgical modality, which has been reported as an alternative surgical option for patients with primary medial compartment knee OA (4),(8),(9),(10). PFO is a straight forward, safe, technically less challenging, and affordable procedure. It is suitable for both the young and elderly population, associated with minimal blood loss and short hospital stay (9). PFO significantly ameliorates pain and improves knee functions in these patients (10). However, this procedure is not a definitive one and has immense potential in deferring the need for TKA. In the future, TKA or HTO if required can be done easily without any hurdles to the knee which has undergone PFO beforehand (8). In this part of the world where TKA and HTO pose a great burden on patients with OA as surgical treatment, PFO can provide a cost-effective treatment modality with significant relief of pain and functional improvement, with shorter hospital stays and early rehabilitation.

Though PFO is an evolving modality in the treatment of knee OA, there are very few studies available related to its outcome. On the other hand, the effect of BMI (11),(12) and the relation of K-L grading (13) with the outcome of PFO have also not been taken into consideration by previous studies.

Hence, the present study was undertaken to assess the effectiveness of PFO in patients with primary medial compartment OA of the knee joint, in terms of pain relief (clinical outcome), improvement in range of motion (functional outcome); probable correction and realignment of the mechanical axis (radiological outcome). Also, to establish the relationship between BMI and K-L grading with the functional outcome of this procedure. Thus, the study aimed to evaluate the effectiveness of PFO on pain relief and functional outcome in patients with medial compartment knee OA.

Material and Methods

A prospective interventional study with a quantitative research design was carried out in the Department of Orthopaedics at Indira Gandhi Government Medical College, Nagpur, Maharashtra, India, from November 2017 to October 2020. The study was commenced after appropriate approval from Institutional Ethics Committee (IEC) (3201/2017) and written informed consent from all the patients were obtained. Sample size was calculated by using purposive sampling method (non probability sampling method).

Inclusion criteria: Knee pain with medial joint line pain having visual analogue score 5-9, age ranging from 45-60 years, BMI less than 30 kg/m2, patients with Grades 1, 2 and 3 of knee OA K-L (13) with genu varus up to 15º were included in the study.

Exclusion criteria: Patients with genu valgum, inflammatory arthritis, acute trauma, tumours, and patellofemoral arthritis. The study included 58 patients visiting the Outpatient Department (OPD) and 18 patients were excluded from the study.

Study Procedure

A detailed history and clinical assessment were carried out for the patients with knee pain, restriction of movements, and radiological corroboration by full weight-bearing anteroposterior (AP) and lateral views of both the knees. Patients were divided into various groups as shown in (Table/Fig 1) based on BMI (11),(12) and K-L grading (13).

Surgical technique of PFO [4,8,10]: Under spinal anaesthesia, the patient was placed in a supine position, and a pneumatic tourniquet was applied to obtain a clear surgical field. Using Henry’s postero-lateral fibular approach, approximately 5 cm incision was taken, 7-9 cm distal to the caput fibulae (Table/Fig 2)a-c. Subcutaneous tissue dissection was done and an intermuscular plane was obtained between the peroneus longus and brevis anteriorly and soleus muscle posteriorly (Table/Fig 2)d. For a few initial cases Hohmann’s retractors were used to retract the soft tissues which later on were replaced by Langenbeck retractors to expose the fibula. Osteotomy level was marked over the fibula, which was around 6-10 cm distal to caput fibulae (Table/Fig 2)e, and cuts were taken 1 cm proximal and distal to it. The osteotomy was carried out by oscillating saw in the first two cases, following osteotomies were done by using sharp 2.7 mm drill bits. A broad, curved osteotome was placed medial to the fibula to avoid damage to the underlying common peroneal nerve and interosseous membrane. The segment to be removed was held by bone holding clamp before making cuts to prevent medial migration followed by easy removal. Osteotomy was performed with the help of an osteotome and mallet (Table/Fig 2)f. Osteotomised ends were checked for any bony sharp spikes and were smoothened as necessary. Tourniquet was released and haemostasis was achieved. A thorough wound wash was given with 0.9% normal saline. Direct subcutaneous tissue closure was done without closing underlying muscle fascia followed by skin closure (Table/Fig 2)g.

The patients were permitted to walk full weight bearing without any support at the end of 24 hours after surgery. Postoperatively patient was assessed for Visual Analog Score (VAS score) (14), Knee Society Score (KSS) (15), and FTA (16) on antero-posterior and lateral radiographs of full weight-bearing knee (Table/Fig 3). All patients were discharged on the second postoperative day and were followed-up for suture removal on postoperative days 12-14. Subsequent follow-up of patients was done at one month, three months, six months, and at 12 months. At all follow-up visits, each patient was evaluated for VAS, KSS, and FTA. All the surgeries and follow-up visits were performed by a single surgeon.

Statistical Analysis

The standard descriptive statistical method was used to describe parameters using statistical software, STATA, version 10.1, 2011. Continuous variables were described using means, standard deviations, and ranges, and tabulation was done accordingly. Inferential statistics included paired t-tests for comparison among various parameters such as VAS, KSS and FTA from baseline (preoperative) to one month, three months, six months, and 12 months period. A p-value of <0.001 was considered statistically significant.

Results

A total of 58 patients were included in the study, of which 38 underwent surgery for bilateral knees and 20 were operated on for unilateral knees. Among these, three patients were lost to follow-up. Thus, a total of 55 patients were evaluated postoperatively for upto 12 months. The demographic data of the 58 patients are illustrated in (Table/Fig 4).

The mean age of patients was 53.76±3.79 years, and there was a female preponderance. The mean surgical duration was 34.8±4.36 minutes for the unilateral knee. Postoperatively each patient was assessed for VAS, KSS, and FTA, and compared with the preoperative findings, which are illustrated in (Table/Fig 5), (Table/Fig 6), (Table/Fig 7), (Table/Fig 8).

Outcome values of parameters such as VAS, KSS and FTA at 12-month follow-up among the Groups A1, A2 and B1 were significantly improved when compared with their respective values at six months. Among Group B2, it was found that values of VAS and KSS at 12 months follow-up were quite reversed as compared to values at six months as depicted in (Table/Fig 6), (Table/Fig 8).

Complications such as Extensor Hallucis Longus (EHL) weakness were seen in two patients, of which one recovered completely over a period of eight weeks. Transient Foot Drop was reported in one patient, which resolved in 12 weeks. Paraesthesia on the Dorsum of the foot was reported in three patients, which settled down over 4-6 weeks.

Discussion

Knee pain secondary to primary medial compartment knee OA is one of the most common clinical presentations encountered. Incidence of knee OA is directly proportional to age, weight, and microtrauma to the knee joint secondary to cyclical loading (17). The initial stages of knee OA can be managed effectively with physiotherapy, Non Steroidal Anti-Inflammatory Drugs (NSAIDs), and local analgesic applications (18). Despite these conservative measures, patients with the progressive disease might require surgical interventions in the form of HTO and TKA (19). But, the procedural complexity and extensiveness lead to the patient reluctance. Hence, as of late a minimally invasive surgical treatment i.e., PFO has been proposed for the management of knee OA, which has become much more popular in the Eastern world (China and India) than elsewhere (4),(8),(9),(20),(21),(22),(23). The PFO helps in the correction of a varus deformity, shifts the loading force from the medial compartment, and therefore, diminishes the agony with satisfactory functional recovery (24). The use of PFO has become popular in the recent past and very few papers related to its outcome have been published so far.

In this study, the mean age was 53.76±3.79 years with 70.69% of them being females. The average surgical duration required for the unilateral knee was 34.8±4.36 minutes, which was quite similar to a study conducted by Wang X et al., (8). Efficacy of PFO in this study was assessed in terms of improvement in clinical outcome (VAS score), functional outcome (KSS score) and radiological outcome (FTA) measured at immediate postoperative and subsequent follow-ups and was compared to that of preoperative state. Wang X et al., followed 150 patients for two years and noticed significant decrease in mean VAS score from 8.02±1.50 to 2.74±2.34 at final follow-up and improvement of mean KSS from 41.24±13.48 to 67.63±13.65. In their study, they suggested that PFO could be a good alternative treatment modality for medial compartment OA (8). In a study conducted by Yang ZY et al., 150 patients with medial compartment OA, stated that there was significant decrease in mean VAS score from 7.0 to 2.0 at final follow-up. Mean KSS at final follow-up was 92.3±31.7, which significantly improved from 45.0±21.3 preoperatively. They concluded that PFO is safe and effective treatment for medial compartment OA (4). Prakash L and Prakash I found that there was decrease in VAS score from 6.7 (preoperative) to 2.2 (postoperative). There was improvement of mean KSS from 54.4 (preoperative) to 77 (postoperative). Mean FTA in preoperative period was 181°±1.9°, which changed towards valgus alignment and was 178°±2.0° postoperatively. They inferred that PFO was the simple, less invasive and it significantly reduced pain (25).

In this study, there was significant relief in medial knee pain after PFO, depicted by a declining trend in mean VAS of 8.04±0.68 (preoperative stage) to 2.65±1.14 at final follow-up (p-value <0.001). Also, there was significant progressive improvement in knee joint function, depicted by increase in KSS from 43.38±2.39 (preoperatively) to 69.82±3.03 at 12 months follow-up (p-value <0.001). Radiographic evaluation was carried out by assessing and calculating the FTA on weight-bearing AP radiographs of the knee joint. It was observed that preoperatively patients had varus malalignment with increased mean FTA (183.38±1.29°), which slightly changed to valgus alignment at subsequent follow-ups to 179.84±1.83º (p-value <0.001). Results of this studies were quite similar to the aforementioned studies as illustrated in (Table/Fig 9) (4),(8),(25).

In the present study, it was observed that patients belonging to group B2 (BMI >25.0 kg/m2 and K-L grade 3), had a recurrence of symptoms with the onset of pain. The increase in VAS score, FTA changing to varus alignment and a moderate decrease in KSS was encountered in group B2 at subsequent follow-ups and 12 months. This implicates that patient in Group B2 with high BMI and with more osteoarticular deformation as seen in K-L grading 3 had recurrence of symptoms and deterioration in parameters at 12 months. The fibula strut support which acts as a constrain, causes increased loading and wearing of the medial condyle as described by Yang ZY et al., in his non uniform settlement of bilateral tibial plateau (4) (Table/Fig 10)a,b. Removal of this fibular strut support leads to redistribution of load equally over both the tibial condyles (8),(22), decompression of the medial compartment, and realignment of the mechanical axis of the lower limb which all together bring about significant pain relief and improve knee function (Table/Fig 10)c. The significant improvements in various parameters from the preoperative stage to that of final follow-up shown by numerous studies conducted previously (4),(8),(22),(23),(24) are comparable to the results obtained in the current study.

Additionally, this study gives an insight into the impact of high BMI and Grade 3 OA on the outcome of PFO in such cases. Overall, it affirms that PFO is a dependent and safe alternative for pain relief and better functional outcomes in primary medial compartment knee OA. Though PFO is a safe procedure, a few complications were observed, which were-EHL weakness, transient foot drop, and paraesthesia over the dorsum of the foot. These complications occurred probably due to traction injury over the common peroneal nerve resulting in transient neuropraxia which recuperated over 6-12 weeks with methylcobalamin-pregabalin supplements. Common peroneal nerve injury was also encountered in four cases in the study conducted by Yang ZY et al., (4). Transient foot drop (one patient), EHL weakness (eight patients), and paraesthesia over the dorsum of the foot (seven patients) were encountered in the study carried out by Prakash L and Prakash I (25). A study carried out by Laik JK et al., also noticed EHL weakness in three cases (26). Sabir AB et al., also documented EHL weakness in five cases and paraesthesia over the dorsum of the foot in seven cases in the study (27).

Limitation(s)

The follow-up time period was limited. The short-term results turned out to be quite promising and encouraging but do not shed light on respect to the consistency of these outcomes for a longer duration of follow-up. Thereby, it is crucial to establish its effectiveness over a longer period as an alternative procedure and long-term side-effects on other joints such as the hip and ankle. A further detailed study is imperative to establish the exact biomechanics of pain relief, increase in the medial joint space, and correction of alignment in patients who had undergone PFO. Finally, the absence of a control group was another important limitation of this study.

Conclusion

The PFO is a prudent alternative procedure for pain relief and better functional improvement in primary medial compartment knee OA. It is a straight forward, pragmatic and efficacious procedure that is reproducible even in modest set-ups. The study figured out that PFO is more effective in patients with BMI ≤24.99 kg/m2 and K-L grade 1 and 2 as compared to patients with higher BMI and K-L grade. This procedure provides a midway path to the patients who are not willing for complex procedures such as HTO and TKA, additionally it defers the prerequisite of these intricate procedures. This modality is a simpler option, and also preserves the anatomy of the knee joint for future TKA, whenever required. A more extended period of follow-up is desirable to evaluate the longevity of the beneficial impacts, which PFO offers to the patients in the short-term as concluded in this study.

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DOI and Others

DOI: 10.7860/JCDR/2022/58150.17086

Date of Submission: Jun 02, 2022
Date of Peer Review: Jul 21, 2022
Date of Acceptance: Oct 18, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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