Comparative outcomes of proximal fibular osteotomy versus high tibial osteotomy in patients with medial knee osteoarthritis: A retrospective analysis

High tibial osteotomy (HTO) is a widely used procedure for delaying knee arthroplasty, correcting alignment, and relieving symptoms in patients with knee osteoarthritis. Recently, proximal fibular osteotomy (PFO) has emerged as a less invasive and more cost-effective alternative. This study compares the outcomes of HTO and PFO to evaluate whether PFO can deliver results comparable to HTO in similar patient populations. A total of 96 patients treated between 2018 and 2022 were analyzed, with 54 patients undergoing HTO and 42 undergoing PFO. Subgroups were also created based on body mass index (BMI): non-obese HTO, obese HTO, non-obese PFO, and obese PFO. For each patient, we recorded demographic data, preoperative and 1-year postoperative Oxford Knee Scores (OKS), visual analog scale (VAS) scores, medial joint space (MJS) measurements, mechanical axis deviations (MAD), Kellgren- Lawrence grade (KL), medial proximal tibial angle (MPTA), and any complications. Both HTO and PFO led to significant improvements in OKS, VAS, MJS width, and MAD. Age, KL grade distribution, BMI, and MPTA values were comparable across the groups. Overall, HTO showed superior clinical (OKS, VAS) and radiological (MJS, MAD) outcomes, particularly in non-obese patients. Among obese patients, HTO and PFO achieved similar clinical improvements, although HTO maintained a radiological advantage. Importantly, a lower preoperative MPTA was associated with poorer clinical outcomes in the PFO group. In conclusion, while PFO can produce meaningful clinical and radiological improvements, HTO remains the more effective option in terms of both clinical and radiological outcomes in patients with a BMI below 30. For patients with a BMI over 30, HTO preserves its radiological superiority, although its clinical benefits are comparable to those of PFO. Additionally, a low preoperative MPTA is significantly linked to worse OKS scores in patients undergoing PFO.