Kneecap dislocation and TTT

[jewell0923]

Just needing some advice!  I have dislocated my knee cap five times in the past ten years.  The last time, I was doing Martial Arts and having a great time when it got knocked out of place by a friend.  It took a little longer than usual to go back in, but finally after several choice words it cooperated.  I finally decided to go to a OS and he referred me to his partner.  In the mean time I went to PT a few times a week and wore a patella stabilizer.  I went back to the OS on Friday who told me that my bones are "out of place" and need a TTT.  He also wants to do a MPL reconstruction.  I'm going for a MRI arthrogram this week and am going to go back to the OS to talk about surgery in a few weeks.  The problem is..I'm really not in pain.  I'm unsure if I have suffered any damage from the dislocations but am afraid that if this keeps happening bad things will happen.  OS feels that this surgery is not an emergency, but described it as a tire that needs to be changes before it "blows".  After reading all your stories of recovery, I'm scared that this is not a needed surgery for me.  What do you guys think? 

[Silkncardcrafts]

Hi there,

I would definitely get it treated before it gets worse. Have you had any plain x-rays or CT scans ? These are the best for showing patella problems.

You don't want to get to a point where you can't walk or is impacting your life really badly. That's how bad mine got and had to do something. Am pleased to say the surgery I had has helped my kneecaps. Still in the early stages of recovery.

[crankerchick]

I went back to the OS on Friday who told me that my bones are "out of place" and need a TTT.

Did this OS do any x-rays, specifically a lateral view with knee bent and a sunrise view to show how the patella tracks through flexion?

Like Silkncardcrafts said, x-rays and ct-scans are generally the best. The MRI will show if the MPFL is torn or not and it can reveal the tibial tubercle trochlear groove offset (which well tell if you need a TTT or not).

There's 2 issues here.

One is if a surgery is needed. Only you can answer that question. There's a point where everyone says enough is enough, but that point is different for different people.

The other issue is whether this is the right surgery for you. A TTT/MPFLr/LR surgery isn't the only type of surgery to have to treat patella dislocation issues. The important thing is to get to the root cause of why the patella wants to dislocate and then choose the procedure to address that root cause. The root cause could be an ill-placed tibial tubercle, a malalignment like knock-knees or bowed legs, a high-riding patella, tight lateral structures, muscle imbalance, rotational or bone deformity (of the tibia and/or femur), or some combination of all of these things. Getting to the root cause will also help making the first decision, on whether or not to even have surgery, an easier one to make.

Good luck and let us know how you get on.

[doublemom]

^^^ Ditto what Cranker said ^^^

There are a lot of different reasons why your kneecap could be dislocating.  Without knowing WHY it is not staying in place, it's impossible to know which is the correct way to fix it.  Surgery should always be a last resort, but you also don't want to leave it long enough to damage the patellar cartilage (like i did).  An MRI will show soft tissue/cartilage damage, but it's basically useless at showing patellar tracking.  To get to the root cause of the problem, you really need xrays/CT scan like Cranker mentioned. 

Hope that helps.  No matter what, it's always a hard decision to make, and there is no right/wrong answer, it varies from person to person.  I struggled with the decision to have surgery for 2 years, and finally underwent TTT/LR 7 weeks ago.  It's a hard recovery, but in my case it's been oh-so-worth it compared to if I'd let it be, in which case I would have needed a PFJR fairly soon.

If your OS isn't willing or able to figure out the root cause of the patellar problems (see all the possibilities that Cranker listed in her post), find a patellofemoral specialist who has experience and who can get to the root cause before you decided on any particular surgery or not.

Hope that helps... and keep reading up here on this forum, there is a huge wealth of knowledge here

Andi

[jewell0923]

I had several x-rays done and showed that I did not have a "groove" problem.  He measured the angles of the "bump" below my knee and said that it was off enough to need a TTT or Fulkerson procedure.  He was not in favor of a LR because he felt that that procedure sometimes causes more harm than good.  My PT said that I have a tracking problem and also a "tilt".  I am just so overwhelmed with information and just want to make a good decision.  I have the MRI on Friday..which appartenly involves needles..yuck!  Maybe it will give more info to help with the decision making process.  I go back to the OS on June 2nd.  Thanks for the info!

[jewell0923]

Had my MRI on Friday..Ouch!  I kinda freaked out when they put the contrast in, but did ok after.  I'm dying to know the results and don't go back until Wednesday.  I've looked at the films over and over and am feeling a little obsessed.  Have had a little pain but no dislocations since last month.  I'm still on the fence about surgery and am hoping to get some answers when I go back the OS on Wednesday.   

[JFVolleygirl27]

I have had around 8-10 dislocations during the past 8 years (my last one was on New Years Eve...ehh) and that was when I went in to see two OS's at my hospital. Like you, I was scheduled to have the Fulkerson procedure (TTT, MPFL, LR) on May 24. However, literally, one week before, I ended up talking with a specialist over the phone that I intend to see now once I get it worked out with insurance. I HIGHLY recommend speaking with a specialist. Crankerchick (who posted above) actually helped me out a lot on this - sometimes dislocations occur bc of bone deformities. My OS told me I was partially knock-kneed and that is why these dislocations occur, yet also said that there is no way to fix this and that that should not change the fact that I need the fulkerson. However I just could not knock off the feeling about this surgery not being the right thing for me....and after talking with a specialist, that just confirmed my fears. It REALLY is important to get CT scans to check for bone deformities before going through with the fulkerson bc if that is the root of the problem, that is what needs to be fixed first. Like me, since I found out i was knock-kneed, I googled correction surgery so I knew it exists (even though my OS said there is no way to fix it)....I just couldn't figure out why my OS wouldn't agree that it is important to fix the root of the problem before the problem itself. So after speaking with a specialist, I called off surgery...and now I am in the process of switching insurers (I have a very local network) and going to speak with a specialist. So many OS's out there do not get down to the root of the problem like they should....this problem really does require to see a specialist who will get to the root of the problem before jumping the gun and resorting straight to a TTT and LR. Just my 2 cents.

[crankerchick]

It's never a bad thing to get a second (or fifth) opinion, especially one from a patella specialist. Like JFVolleygirl27 and Doublemom said, everything should be ruled out.

I had several x-rays done and showed that I did not have a "groove" problem.  He measured the angles of the "bump" below my knee and said that it was off enough to need a TTT or Fulkerson procedure.

Not sure what your OS meant by a "groove" problem. I assume he/she means that your trochlear groove is not shallow, which is a good thing.

These are the x-rays that need to be done:
1. lateral standing x-ray with leg bent to 30 degrees
2. standing view of leg from hip to ankle
3. sunrise/merchant views of knee bent to various angles

These x-rays provide more information than just if you have a "groove" problem. They reveal a knock-knee or bowed leg malalignment, patella height, and patella tracking through flexion. I'm curious if your OS did these views in his exam. The CT scan will provide a lot, include the existence of a rotational deformity of the femur or tibia.

Whether the tibial tubercle (the "bump") needs to move medially should be measured using the TT-TG distance, from either MRI or CT scan, not so much by examining the leg.

Hope you get some good information at your appointment. Ask plenty of questions, write them down if you have to. An educated patient is a happy patient, so make sure you understand the answers he/she provides and that they make sense. Just remember, it is your leg, the one you have to live with for the rest of your life. This isn't just a question of whether to have surgery, but also what surgery to have.

[jewell0923]

OK-here's the results of my MRI:
     1.  A 2cm area of marrow edema in the lateral aspect of the lateral femoral condyle which is supportive of history of dislocations.
     2.  Patella alta-extensor mechanism are remarkable for patella alta
     3.  No definite articular cartilage abnormality identified.  No loose body is seen. 
My OS want to do a medial patellofemoral ligament reconstruction.  He thinks that this will be enough to stabalize my knee.  He talked about doing the TTT but felt that since my Q angle is only 19, that this is not something that is immediate or nessary.  Since I've only dislocated 5 times in the past 10 years, I'm not sure if I want to go through with the TTT.  He feels that if we do the MPLR that the likely hood of it staying in place would be 90% effective, if the TTT is done as well, he says it will be at 100%.  He left this decision up to me. What are your thoughts?  I scheduled just the MPLR for August 16th but have enough time to change my mind.   

[crankerchick]

I honestly would get a second opinion. A person who has dislocated a kneecap is bound to have a stretched/torn MPFL. This is a consequence, not really a cause.

The patella alta is not addressed with a MPLR, so that would still be a wild card out there that could contribute to instability. Patella alta is addressed with a type of TTT that moves the tibial tubercle down. This is the kind of TTT that I had to address my patella alta. The amount to move the patella down is determined from lateral x-ray.

These things can be tricky. It's important to address the root cause(s). A second opinion is not a bad idea.

[JFVolleygirl27]

Ditto ^