Prof. Dr. (Dr.

)John
Ebnezar Foreword
"Padma Shri" Awardee-2016
Dr BC Roy National Awardee-2015
HONORARY DOCTORATE IN
MEDICINE- ORTHOPAEDICS (2016)
Former Vice President Indian
Orthopaedic Association Life is mobility and mobility is life. Osteoarthritis of the knees
Founder President, Geriatric
Orthopaedic Society of India (GOSI)
which is a common public health problem affecting nearly 14% of the
Founder Director, Geriatric World population, restricts the mobility in elderly affecting their quality of
Orthopaedic Association of India
(GOAI) life. The disease is complex and so are the treatment methods. While most
State Council Member, Indian Medical
Association
of the cases can be managed conservatively, few cases in their advanced
GUINNESS WORLD RECORD stages need partial or total knee replacement. TKR is now a well accepted
ACHIEVER IN BOOK WRITING –
2010 solution for severe arthritis. But there are so many patients in whom
GUINNESS WORLD RECORD
ACHIEVER IN SOCIAL SERVICE –
conservative methods have failed and patient is not a candidate for TKR
2015 especially in Medial Compartment OA.
GUINNESS WORLD RECORD
ACHIEVER IN SOCIAL SERVICE –
2016
GUINNESS WORLD RECORD
ACHIEVER IN HEALTH HTO and UKA have not been completely successful either. In
AWARENESS – 2017
GUINNESS WORLD RECORD such patients Proximal Fibular Osteotomy is providing very good relief. This
ACHIEVER IN HEALTH technique is developed and popularised by Dr L Prakash and has gained
AWARENESS - 2017
Winner of 200 International,National immense popularity and acceptance by the Orthopaedic Surgeons all over in
a very short period of time. So many have started using this technique with
positive feedback and hence a demand for this book. Who else other than
Dr L Prakash to author it?

He has done a tremendous job. There are 17 sections in the book.

Each section is well written with proper illustrations which makes the
and State Awards/Felicitations reading educative and enjoyable. The language is simple, lucid and free
flowing. The chapters are so well organised that each leads to the other
keeping the interest intact.

Dr L Prakash is a genius orthopaedic surgeon this country has

ever produced. He is not only an excellent surgeon but a writer, scientist,
researcher and a successful entrepreneur. He wears so many hats and is
proficient in everything what he does. His interest in propagating the
knowledge to fellow orthopaedic surgeons is commendable and he tours the
length and breadth of the country, writes extensively and is very active in the

v
 I am sure like all his other books, this book also will
be well received by his colleagues all over the World and
ultimately the patients will be benefitted by this excellent
technique which is cheap, simple and can be done even by an
average orthopaedic surgeon, in any set up, unlike the complex
TKR.

A ‘chance’ discovery is well on its way to become a ‘remarkable’

discovery is a story that could have been scripted only by Dr L
Prakash. He needs all accolades for converting his adversities
into great blessings for the benefit of the orthopedic community
and the society at large. I wish him all the best.

Dr John Ebnezar
A “Padma Shri” and “Dr BC Roy National” Awardee

vi
Foreword
My journey into the fascinating subject of orthopaedics
began some thirty six years ago, and since then knee
arthritis has been a subject of great interest to me. I was
extremely fortunate to work and train in England and
Europe, under innovators and creators of knee prosthesis,
including greats like Goodfellow (Oxford Knee) and Mike
Freeman (Freeman Knee). From those times knee arthritis,
especially isolated medial compartment arthritis in varus
knees have been my fascination and passion.
I began as one of India’s earliest arthroplasty surgeons
some thirty years ago in 1987, and during the initial stages,
total knee replacement was a rare surgery, rather
unsalvageable with failures, and reserved for very damaged
knees. In those times, Unicompartmental arthroplasties
were infrequently done, and High Tibial Osteotomy was not
always accepted by the patient. Isolated medial
compartment arthritis with varus thus remained an
unsolved enigma and an intriguing problem.
I discovered the wonderful procedure of Proximal
Fibular Osteotomy, rather by accident around 2003. At the
peak of 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 from medial
knee pain due to OA and varus disposition.

vii
 The complete story of my discovery of the procedure is described in the book
later. I performed a few surgeries in prison, and many more outside since my release.
The results were consistently good, occasionally bordering on excellent. When I first
mentioned about this procedure in an orthopaedic meeting, I was treated by disbelief,
and scorn. Later when I presented a small study in an orthopaedic conference, I was
met with ridicule and criticisms of being experimental, and practicing non evidence
based procedures.
Subsequently, I posted this on social media, and also in a few academic
orthopaedic whatsapp groups. The response was entirely different. I received genuine
queries, and many surgeons began trying it in their hospitals. As more and more
surgeons discovered the effects of this wonderful surgery, and shared their 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.
Many surgeons unfamiliar with the procedure or those worried about
performing an experimental procedure sent messages, asking me to write a definitive
article or book, and get it published, so that they could offer the procedure to their
patients without fear. Many others also wanted the special consent that goes with all
new surgical procedures.
The subsequent hundred odd pages represent my entire knowledge on this
subject. My only advice to readers is that you must maintain meticulous records, and
share your results with colleagues so that we are soon able to establish the correct
indications, procedure and and standard documentation protocols.

L.Prakash
Chennai
7th April 2018

viii
 SECTION 1

1. INTRODUCTION AND
BACKGROUND
Just look at the two x-rays below. What pattelectomy. Around 20 years ago, he
does this tell you? sustained an injury, had a shattered
fracture of patella, and had a
patellectomy for that. At the same time
he had sustained a fracture of his fibular
shaft some 8 cm below the fibular head,
and for this he did not receive any
aggressive treatment.

What does the above X-ray teach

us?
The left knee has distinct medial
compartment arthritis, subchondral
sclerosis, reduced medial joint space, has
Let me tell you some history. the first is a 15 degrees of varus and is symptomatic,
50 year old police-man, with severe pain including severe pain on stair climbing
on inner side of left knee, with a totally and long distance walking. The right
asymptomatic right knee despite a knee is clinically and radiologically

9
normal without any varus. It is in a very early medial compartment
rather healthy 5 degrees valgus. osteoarthritis of his knee.
So this naturally leads to a few questions.
1, Does a varus disposition of the
knee cause medial compartment OA?
What is the incidence of varus situation
in Indian knees, and its correlation to OA
knee?
2, Does a shortening of a fibular
column of a knee, relieve medial
compartment stresses in a varus knee
joint?
2, Does resection of a small piece of
fibula at a correct level, increase the
medial joint space?

The second X-Ray is a young boy of

19 who has an exocytosis of proximal
fibula, causing a lateral column
lengthening, and this has lead to very
early medial compartment OA in this
young man!
The lesson learnt is that, shortening
the lateral column, somehow prevents
medial compartment arthritis of the
knee. It also prevents the progressive
varus of the knee joint that happens in
the Indian varus knees with with age. The
second lesson is that a lengthening of the
lateral column causes an increased
medial pressure, which in turn causes 3, Does resection of a small piece of
fibula at a correct level, decrease pain in

10
medial compartment osteoarthritis of the helped me to develop this procedure of
knee? Proximal Fibular Osteotomy.
4, Can we treat certain cases of These were the two studies, and
medial compartment arthritis of the knee their methodologies and results.
with a Proximal Fibular Osteotomy 1, Varus scenario in Indian Knees
alone, 2, Fracture fibula and its relation to
5, Does PFO have any role in medial compartment OA.
preventing medial compartment OA? In those times, I would just collect
6, Could PFO be a viable, data and observations, without specific
economical alternative for the higher aims and objectives in mind. Now in
priced unicompartmental knee leisure as I mine the data, and correlate
arthroplasty? my observations, I get new insights into
The above six points read like the nature and how our body works.
aims and objects of a post graduate
thesis, and today some 27 thesis and
research papers the world over use more
or less these six points to preface their
study.
However when I began this study, I
did not write down these points in this
order. I did not write them down at all. A
series of situations arose around me,
which pushed me to the concept and here
is the story of how I accidentally found
out about PFO sometime in 2003 and
performed my first surgery in 2007.
I was in prison from 2002 to 2015,
and during these 13 years had a closed
pool of few thousand patients, whom I
could observe, study and follow up for
prolonged periods. I managed to conduct
over a dozen studies, and the two
interesting studies which started
independently, but later blended into one
another and supported each other,

11