Dr L.

Prakash’s teaching initiatives

Proximal Fibular
Osteotomy
BOOK ADDENDUM
Proximal Fibular osteotomy as a
treatment for medial compartment
Osteoarthritis of the knee joint, is

PFO updates rather quickly proving to be a

game changer in Arthroplasty
versus Preservation game

Proximal Fibular osteotomy as a treatment the past few weeks is increasing

for medial compartment Osteoarthritis of exponentially.
the knee joint, is rather quickly proving to
be a game changer in Arthroplasty versus As my younger colleagues consider me as
Preservation game, and its popularity in the pioneer in this surgery, and as the first

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youtube videos of the procedure are my Most cases have a followup of 6 months
postings, it is only natural that I get many or less, though some have been followed
X-rays, asking me about the suitability of up for three years. In the initial stages,
PFO. For the month of May, 800 X-rays some significant problems have cropped
were sent to me for evaluation and in my up, and this pdf is about the updates and
opinion, some 85% were suitable cases. the facts of the procedure which will help
you to avoid problems with PFO.
To date, surgeons have shared with me
results and data of some 1600 cases done
over the last three years, and as I tabulate
the preliminary findings, I find that PFO is It is well known that bad technique will

indeed a wonderful procedure. The bring disrepute to a good procedure, and

following are the salient points that emerge to avoid this absolute game changing

from the cases shared with me so far by surgery to be maligned, it is essential to

colleagues from all parts of the world. perform the technique perfectly, if you
want good results.
1, 9% of patients had neurological
problems. This ranges from numbness
on dorsum of foot, EHL weakness, The three problems that have emerged so
and an occasional foot drop. However far.
these are transient and recover in three
to six months. 1, Benefits of surgery are short lived, and
last just three months. This is caused by
2, 8% patients reported short lived the incorrect level of PFO.
benefits, with recurrence of pain after
three months or so. 2, Neurological problems, EHL weakness,
dorsum foot parasthesia, and an
3, Very heavy bleeding due to laceration occasional foot drop. Reported in 9% of
of posterior branch of lateral popliteal patients so far. Most often recovers. This
artery or medullary bleed from fibula! is also caused by incorrect level and
faulty technique.

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3, PFO has not worked at all or not worked Both these factors cause a stretch and
beyond a week or fortnight. Here the tension in soft tissues, including the nerve,
reason is that, the case chosen was not leading to neuropraxia, sometimes taking
ideal. Inappropriate indication. up to three months to recover. To avoid
this use the following tricks!

1, Larger incision. 7 to 8 cm or 3 inches

The first X-rays are of a patient in whom long incisions are a must.
the pain relief rapidly disappeared in six
weeks and X-ray at that stage showed a 2, Avoid using Homman retractors, which
narrowed medial joint! Here the Level is due to their long lever arm cause massive
Wrong! The correct level is 7.5 to 9 cm tissue stretch.
from the head of the fibula.
In case you get an EHL weakness, loss of
The anatomy picture shows the nerves, sensations on dorsum of foot, or even foot
their forking around 5 to 6 cm and drop, don't panic. Administer pregabalin
spreading on either side of fibula as they orally and Injection Vitamin B12 IM for six
travel downwards. The osteotomy site to twelve weeks. They invariably
should be 7.5 to 8 cm in a short individual, disappear.
and 8 to 8.5 or even 9 cm in a tall
Here I am describing the steps in detail as
individual. Always use a scale to measure
an addendum to my book. Please do the
both pre operatively and intra operatively.
procedure properly if at all you begin doing
Wrong level doesn't work.
it! Let not bad technique malign a good
Not only does wrong level not work, it is path breaking procedure.
also bad for the nerve. Higher the level,
If you plan to do a study, thesis, or a
more the danger of injuring the nerve. The
research paper, please feel free to
picture below tells us of the anatomy of
message me personally, and I shall be
the nerve and its course.
happy to share with you all my current
There are two principal reasons research!

1, Use of Homman Retractors

2, Use of a very small incision

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 This is approaching to the

Very high level. Will cause nerve correct level. The patient will

problems. May not cause long get good symptomatic relief,

term relief of symptoms but there is a small risk of

neuropraxia.

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Correct Levels of PFO. This will give best pain relief, along
with absolutely no neurological issues

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 The x-rays are evaluated for suitability. This is a
rather borderline case and the patient has been explained the
prognosis
Both knees are being done together
The knees are cleaned, prepared, and draped
The feet are draped in a stockinette and bandaged tightly to
avoid slippage during flexion extension of the knee.
Pre operative C-arm imaging
This patient is 5 feet 4 inches, so level planned is 8 cm below
head of fibula
The precise distance is measured with a sterile scale
A hypodermic needle is inserted to the bone at this level
5 to 7 cm skin incision. Be generous. Tight incisions are bad
Coagulate bleeders as no tourniquet is used.
Retract with Langenback retractors alone. Avoid Homman’s
at all costs
These should never be used
Finger dissect to the bone, carefully splitting the muscles
Skin and soft tissues are not at tension with Langenbeck,
while in great tension with Hommans

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Scrape with periosteum retractor
Mark the level of osteotomy with proximal and distal drill
holes
Use an oscillating saw and gently cut 1 cm of fibula
Hold the cut piece with a Kockers forceps and gently twist
The small piece comes out easily
Visualise the joint space under C-arm to see the widened
medial space
Routine closure
Post op X-rays
PFO is indeed a magical procedure if done properly in the
correctly indicated patient, and delays TKR by many years. It
is a SUBSTITUTE for UKA and does far better!
2
These have been treated in the past by conservation, high
tibial osteotomy, or Unicompartmental knee arthroplasty.
While conservation is not always successful, both HTO
and UKA are major procedures, and complications if any
can be disastrous at worst. Proximal Fibular Osteotomy is a
Isolated medial
simple alternative which produces dramatic, surprising and
compartment knee
unexpected results.
arthritis, with varus
Proximal fibular osteotomy is a rather simple
deformity has
procedure. It just involves removing a centimetre of fibula
remained an
some eight centimetres below fibular head. And somehow
unsolved enigma this produces dramatic relief from pain due to medial
and an intriguing compartment OA in selected cases.
problem to the
I discovered the wonderful procedure of Proximal Fibular
orthopaedic
Osteotomy, rather by accident around 2003. At the peak of
surgeons for ages. my career, I was imprisoned on false charges, and had to
spend 13 years in prison. During this period, I relearnt
orthopaedics, as I had to perform without any
infrastructure. It was in prison that I observed that
patients with a high fibular fracture, got dramatic relief
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from medial knee pain due to OA and this wonderful surgery, and shared their
varus disposition. results, PFO began to gain popularity, "

Professors began to suggest this as a thesis

topic for post graduates. Surgeons began
to travel from far off places to Chennai to
observe this procedure. Few papers were
published in the literature mostly from
China. And very slowly PFO began to gain
acceptance.

Today some 5000 surgeries have been

performed world wide with consistent
relief of symptoms, at least in the short
term.

The procedure is being performed in 26

I did my first index case on my aunt in countries
2008 and today almost a decade later, she
is still doing well and refuses TKR, a 22 theses and research projects are being
surgery for which she was already admitted done the word over, and I am a guide or
to the hospital many years ago. About mentor for majority of the projects.
three years back, I began doing them in Each day I get questions about the
numbers, and so good were the results, procedure, and messages from gratified
that I presented it in a few local patients and surgeons who have been
conferences and meetings. I was greeted immensely benefited with this procedure.
with ridicule, disbelief and scorn.
Surgeons unfamiliar with the procedure, or
Subsequently, I posted this on social those worried about performing an
media, and also in a few academic experimental procedure sent messages,
orthopaedic whatsapp groups. The asking me to write a definitive article or
response was entirely different. I received book, and get it published, so that they
genuine queries, and many surgeons began could offer the procedure to their patients
trying it in their hospitals. As more and without fear. Many others also wanted the
more surgeons discovered the effects of special consent that goes with all new
surgical procedures.
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To fulfil this demand, I am offering you my
new book

Payments can be made by net banking,

instamojo or paytm, using your accounts
or credit/debit cards.

Bank transfers, of Rs 1200 to the following

account. Account Details: - 

Lara Orthopaedic Solution private Ltd.

A/c No. 9791020615 Paytm bank

This is 100 pages hard bound book, on

glossy paper with over 300 pictures and Paytm number +919791020615
radiographs. The book comes with a DVD,
with detailed HD videos of the surgical
Instamojo link for credit/debit card
procedure and pdf files of important
payment:
issues, including the special consent form
for the procedure. https://imjo.in/tDsTpJ

The book and DVD cost Rs 1200/- Cash on delivery is available from Amazon
including delivery charges to anywhere in for Rs 1300/- which includes Amazon’s
India. Overseas orders will cost $40 charges.
including Fedex charges for door delivery.

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https://www.amazon.in/dp/8192435091 You will be a part of an International PFO
registry, and cases documented by you will
After making payment, please send
produce evidence for the efficiency of this
transaction screenshot by whatsapp to
procedure.
+919840182450.
You will get a preferential allotment, and
You will be sent the book and DVD.
special discount for the First PFO
First 100 books will be signed with best conference to be conducted in late 1918 or
wishes to your name, by Dr L.Prakash. early 1919.

You will be added to a Whatsapp PFO

group, where you can share your cases and
clear your doubts.

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