Proximal fibular osteotomy for medial compartment knee osteoarthritis: clinical effectiveness and biomechanical rationale: a systematic review.

BACKGROUND

Proximal fibular osteotomy (PFO) has emerged as a joint-preserving procedure for medial compartment knee osteoarthritis (KOA). This review evaluated clinical effectiveness, radiographic outcomes, safety profile and biomechanical rationale of PFO.

METHODS

A systematic review was conducted according to PRISMA 2020 and registered with PROSPERO (CRD420261386493). MEDLINE, Scopus, Web of Science, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched from inception to May 2026. Clinical studies evaluating PFO for medial compartment KOA and biomechanical, cadaveric and anatomical studies investigating its mechanism were included. Risk of bias was assessed using Cochrane Risk of Bias 2 and Newcastle-Ottawa Scale. Owing to heterogeneity, findings were synthesised narratively.

RESULTS

Forty-five studies included 38 clinical and seven biomechanical/anatomical studies, representing 2,855 knees. Most reported improvements in pain, function and PROMs. Radiographic findings demonstrated modest correction and increased medial joint space width, although symptomatic improvement often exceeded radiographic correction. Operative time and hospital stay were generally short, blood loss was low, and early mobilisation was common. Transient common peroneal nerve dysfunction was a frequently reported complication; permanent neurological injury was documented, while the incidence of serious complications remains uncertain because of inconsistent reporting. Biomechanical studies demonstrated reduced medial compartment loading with redistribution of forces towards the lateral compartment.

CONCLUSION

Current evidence suggests PFO is associated with symptomatic improvement with rapid postoperative recovery, while biomechanical findings support a load-modifying rather than deformity-correcting mechanism. However, confidence in clinical effectiveness and safety is limited by predominantly observational evidence, heterogeneous designs and limited long-term comparative data.