High Tibial Osteotomy (HTO), Unicompartmental Knee Arthroplasty (UKA), and Proximal Fibular Osteotomy (PFO) for Medial-Compartment Knee Osteoarthritis: A Narrative Review of Comparative Mechanisms, Clinical Outcomes, and Decision-Making

Background: Medial-compartment knee osteoarthritis with varus alignment is treated surgically by realignment (high tibial osteotomy, HTO), resurfacing (unicompartmental knee arthroplasty, UKA), or proximal fibular osteotomy (PFO), which aims to indirectly unload the medial tibial plateau. Methods: We conducted a structured narrative review (PubMed/MEDLINE, Google Scholar; 2000–2025; last search 30 August 2025) of comparative clinical, biomechanical and safety data for HTO, UKA and PFO, including prior meta-analyses and mechanistic reports. One hundred fourteen studies met prespecified criteria. Results: HTO reliably corrects coronal alignment and unloads the medial compartment; long-term survivorship varies by selection and technique, and complications include hinge fracture, delayed/nonunion and hardware problems. UKA typically yields faster early pain relief and recovery in pooled analyses, with implant-specific failure risks and mid-term revision dependent on design and surgical experience. PFO cohorts consistently report early pain and function gains with plausible biomechanical rationale, but evidence is dominated by small, heterogeneous series with short follow-up and limited comparative data. Adjusted head-to-head comparisons generally favor UKA for early pain yet show HTO and UKA can achieve similar patient-reported improvements in selected younger cohorts; robust comparative trials including PFO are lacking. Conclusions: HTO and UKA are established, mechanistically distinct options best matched to patient age, alignment, activity goals, and comorbidity. PFO is a low-burden, promising alternative with uncertain durability; longer-term, controlled evaluation and registry surveillance are required before broad adoption. Findings should inform shared decision-making while acknowledging differences in evidence maturity. © 2025 by the author.