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Proximal Fibular Osteotomy versus High Tibial Osteotomy for the Correction of Varus Knee Deformity: Systematic Review
Waleed Albishi1, Omar A Aldosari1, Abdullah I Alturki2
1Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Background:
Varus malalignment accelerates medial compartment knee osteoarthritis, for which high tibial osteotomy (HTO) is the standard joint-preserving treatment but involves implants and delayed rehabilitation. Proximal fibular osteotomy (PFO) has emerged as a less invasive, implant-free alternative, yet comparative evidence between the 2 procedures remains limited.
Purpose:
This study aimed to clarify how PFO compares with HTO for managing varus medial knee osteoarthritis. We sought to determine whether PFO offers comparable pain relief, functional recovery, radiographic correction, and safety at short-term follow-up.
Methods:
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, we systematically searched major databases through April 2025. We included randomized and observational comparative studies evaluating adults undergoing PFO versus HTO. Data were synthesized using random-effects models, with risk of bias appraised using RoB 2 and Methodological Index for Non-Randomized Studies, and evidence certainty graded through GRADE methodology.
Results:
Eleven studies encompassing 550 knees (266 PFO, 284 HTO) met the inclusion criteria. At the most consistent follow-up point of approximately 12 months, pain outcomes were nearly identical (MD 0.01; 95% confidence interval -0.35 to 0.37), and improvements in functional scores did not differ in a clinically meaningful way. Radiographic alignment changes varied across studies without demonstrating a clear advantage for either procedure. Overall complication rates were similar, although transient peroneal irritation occurred only after PFO and hardware-related symptoms only after HTO.
Conclusion:
Current short-term evidence analyzed in this systematic review and meta-analysis suggests that PFO and HTO achieve broadly comparable improvements in symptoms and function for varus medial knee osteoarthritis, while PFO offers a simpler, implant-free alternative with immediate weight-bearing.
Level Of Evidence:
Level III: Systematic review and meta-analysis of level-I to Level-III studies.
