Derotational Femoral & Tibial Osteotomy (Right: 7/8/10 & Left: 6/16/11)

[Teacher2Many]

Thought I'd post a quick update before my life resumes a state of chaos as I return to work this week and grad school next week! 

I had a post-op appt. w/my surgeon in Chicago this past Monday and things are progressing.  Re: the L side, the tibia is showing signs of healing but is not yet healed, nor is the femur.  Will see how this progresses over time and hope for continued healing.  There is marked pain along the joint line, particularly on the lateral side near the fibula head, which seems to coincide with the very evident fracture on the fibula (seems more evident now then when x-rays were done 11 days post-op).  There is still no improvement re: the foot drop and nerve damage so he's sending me for an EMG on 8/31 to see if the damage is permanent.  Not looking forward to that test...had it done twice before (once on my neck and once for my quads after the 2nd Fulkersons) and I then follow-up with my surgeon 1 week later, ensuring enough time to get the results.  He did agree that the use of an AFO is no longer needed as I have found ways to compensate w/walking and am not constantly tripping.  But he did say that if I find that to be the case once returning to work and being on my feet all day, to let him know and we can go ahead and get one made.  Hoping that's not the case as I think it would just throw my gait off more since I'll have it only on one leg, not to mention potentially making things more difficult at work.  The L quad seems slower to improve than after past surgeries and there is marked weakness of the hip muscles, which happened last year as well so not too worried about that at this time.

When I was reviewing my set of x-rays, I noticed that the gap between the fibula and tibia on the L side narrows as it nears the ankle but this is not the case on the R.  On the R side the gap is nice and even all the way from the patella down to right above the ankle but on the L side, it is just the opposite.  I did e-mail both surgeons to see what the deal was and if this was, in some way, contributing to the foot drop (maybe a nerve is getting compressed due to the lack of gap on the L side).  Who knows?  Think I'm just trying to figure out how my foot and toes move fine in recovery and then all movement and sensation is gone within the first 12 hrs. post-op. 

The R side is doing fairly well-still some quad weakness and the patella is still dislocating quite frequently each day but we are holding off on tweaking that until we can ensure it is not due to quad weakness (don't think it is as my patella was dislocating and subluxing 100x/day and my quads were super strong).  The R hip pain is GONE and I can now stand on the R leg without any sort of lean and can do side leg lifts.  Funny how the darn femoral hardware impacts muscle strength and muscle firing...take it out and all is fine.

Looking into other forms of rehab (particularly on the weekend as my two non-PT weekday days are my grad school days) including aquatic classes or working with a personal trainer but I need to wait until the end of September to ensure all is progressing with returning to work, school, PT, homework, lesson plans, research projects, etc.  Any thoughts on what would work best, from those who have 'been there, done that'?

Other than that, not much else is new.  My INR results keep dropping which means they keep increasing my dose of Coumadin.  I have a repeat doppler at the end of September to check the status of the two blood clots, as that will be 3 months post diagnosis and completion of 3 months of Coumadin therapy.  Still some discoloration of the calf (actually looks like the steri-strip marks; PT thinks it was the way the blood pooled around the area as the steri strips put a  bit of pressure) and it gets worse with prolonged standing/walking.

Well, I think that's in a nutshell!  I am off to get some last minute stuff done for work tomorrow and then hoping to get a full night sleep-hasn't happened since 6/14 and is long overdue!  Will update after my next visit either for the EMG or w/my surgeon the week after.

Beth

[wenikio]

Hi Beth,

I don't remember if I've commented on your thread or not before, but I just wanted to respond to your post today with some thoughts and commiseration

Sorry to hear about the clots and your INR- coumadin is always a bit of a circus to keep at the correct levels and the resulting blood draws can make you feel like a pin cushion! How long are they expecting you to be on it?

Regarding your foot drop, I had that after my TTT years ago. Fortunately I recovered function a few months after the hardware was removed, but it was ssssllllllooooowwwwww to return and the peroneal nerve injury plagued me for eight years. When Doc did my surgery this past spring, he did a fasciotomy that got rid of the pain for good (*happy dance*). I completely understand your frustration, though. It's uber frustraing to will your foot to move with nothing to show for it. Unfortunately I don't have much to offer by way of helpful suggestions for that, though. I did use the AFO brace for nearly a year since I kept tripping, and after a while I didn't even think about it anymore. As far as pain, I had the best results with neurontin. That said, I hated its side effects but it would usually do the trick when the nerve flared up. Do you have much pain with yours?

As far as other types of rehab, I recommend the pool a hundred times over. I'm a weenie when it comes to being cold (especially as fall and winter are coming), but the effort is worth it. Being weightless so that you can move your whole body and not just the broken parts is so helpful. I have those hand paddle things that I used to swim laps when my leg was too irritated to use. Actually, I still use them when I'm kicking because it's a great upper body strengthener and you can make it as much of a cardio workout as you want. It happened so slowly during rehab that I didn't notice until the other day when I realized that I'm able to swim for longer periods of time without gasping for breath anymore, so double win! Sometimes I use fins to either swim laps or kick at the side of the pool, but that does put strain on the leg so I'd ease into that if you do. Sometimes I also just tread water. It's relaxing, doesn't require kicking (if you don't want), and a good cardio. Or most YMCA's and the like have those floaty belts that you can use to "walk" all around the pool. The benefit is that you can be social then if you want too

Hope at least something in there was worth the read!

[Teacher2Many]

Thanks for the post; it's always nice to know I'm not the only one who has the freak complications surface! 

As for the coumadin, I am scheduled for a repeat doppler this upcoming Tuesday, 9/27, to check out the clots.  Depending on how things like, they will either discontinue treatment, which was the original plan of 3 months of treatment, or continue for another 3 months.  Hopefully we will discontinue so that I no longer need to worry about side effects and precautions; always worried about falling at work since I am constantly tripping due to the foot drop while chasing my darlings around the classroom all day long!  :-)

As for the foot drop, I am hoping it resolves but so far, no such luck.  We tried the AFO for a while but found it to be too painful, as the straps were pressing on very sensitive areas due to the hardware and the blood clots.  We'll see how things progress...an AFO may be needed if the nerve does not resume, especially as I become more active at work.  I do have a decent amount of nerve pain which seems to be getting worse.  I notice it a lot at work and it is definitely something that I will address at my next visit.  I am not a fan of pills and am very cautious with adding new meds to the mix because of the blood clots.  But if it helps with pain and allows me to sleep (I haven't slept an entire night since 6/14), I'm game.  You did mention hating the side effects...can you elaborate more on that?

I've tried pool therapy in the past but it never agrees with me in the winter because of the asthma.  Being cold and then going out into the cool air makes for bad flare-ups, not to mention the chlorine smell, etc.  But once grad school calms down a bit, it's definitely something I'm going to look into or maybe even try now on the weekends.  Got to do something to get these issues resolved; didn't want to have to go through all of this surgery crap for nothing!

I am looking into seeing another doc who's local who does the deorational osteotomies to get his input on the complications, continued pain, etc. since I am currently unable to head up to MI to see the doc because of the pain and an inability to sit for 15 minutes in the car, yet alone for 5 hrs.  Not to mention the safety factors of driving that long when you can't move your foot and am constantly shifting in the seat because of the pain.  But I need to call and make sure he does the surgery the same way (ie not distally) before I go in for some consultation. 

Thanks again for the post...

Beth

[Teacher2Many]

So I realize I haven’t posted on here in forever and a day!  Life has been insane this past fall between work, grad school 2 nights/week and PT 3 nights/week.  Add homework and lesson plans to it and trying to maintain a somewhat normal life…yikes!  Can’t remember the last time I was in bed prior to midnight, some nights not even till 1 am!

A lot has gone on since my last update so…

The right hip and knee feel pretty good.  Still a bit of weakness with the right hip and glute muscles but we are really working those in PT so am hoping by the end of spring, the weakness will be gone.  The right patella is constantly dislocating, sometimes locking in a dislocated position with an inability to pop it back into place.  I feel like we're playing a waiting game to see what to do about this one.

The left hip is still very achy with prolonged sitting and those muscles are still quite weak.  What’s odd is that there are strong with the different muscle tests in PT but functionally, they shut down.  Think part of it is due to compensating and the fact that you can hold your leg up with all your might for a few seconds while they try to push it down but trying to be functional is another story.  The left tibia has continued to cause problems.  The lateral pain was horrible, along with very painful crepitus and constant dislocations.  The peroneal nerve damage has improved but over the past two months, no improvement.  Seems like we’ve come to a standstill in that regards-still unable to dorsiflex past neutral and unable to dorsiflex at all when standing (i.e. tapping your foot) or move my big toe up by activating my EHL when dorsiflexing.  So clearly, there’s a problem with the ‘chain of command’ with activating those nerves/muscles.

So…my surgeon in Chicago who has been treating my knees for the past 3.5 years, performed a right proximal pole scapulectomy on 1/4/2012.  This involved surgically removing a portion of my scapula.  My scapula has been causing problems for the past 14 months and since it got to the point where the clunking that it did after it caught would cause my ribs to dislocate, surgical intervention was decided on.  After much ‘begging’ on my end and Dr. T’s go ahead that the tibia was healed enough, the tibial plate and screws were removed on the same day, at 6.5 months post-op.  This was the best thing ever!  The lateral knee pain along the fibula head has almost completely disappeared and I am hoping that the nerve will improve a bit more without the irritation from the plate and screws.  The downside…the part of the tibial incision got infected.  Doc thinks that somehow my body reacted to the Vicryl stitches which caused an inflammatory response which let bacteria in.  Not really sure I go with that story as it’s only a small part of the incision that got infected and these were incisions/operations #21 and #22.  Find it hard to believe that after 21 successful operations, my body would start rejecting them now.  But so be it…he put me on Bactrim twice daily which is almost done with and I am ‘draining’ my knee every night after my shower.

So all that’s left for me, surgically, is:

1-get this darn femoral plate removed (found this awesome doc at a hospital 15 min. from my house who knows Dr. T and Dr. T knows him and is willing and able to take it out.  I’m hoping for early April when on spring break but this doc says that at 10 months post-op, would require spending time on crutches which isn’t an option.  I return to see him in mid-February and we’ll decide then.  The plate needs to be removed in enough time for me to heal prior to the summer, as I am doing a full-time internship working with children with disabilities birth-age 3 and their families in their homes, which will involve a ton of sitting on the floor, getting into different positions, etc.

2-Investigate and then treat the cause of the painful crepitus on the left knee.  My fear is that it is the chondral defect that never had a chance to fill and harden after the ACI due to 2 years of excessive malalignment exerting abnormal forces/pressure through the patella which they think is the cause of the huge chondral defects to begin with.

3-Figure out in what direction and why the patellas are subluxing/dislocating a minimum of 50 x/day each leg and again, what would be the best way to fix it. 

4-Continue to address the peroneal nerve issues from the foot drop and then the issue with dorsiflexion.  Might need to pursue seeing a podiatrist for assistance in this matter but hopefully a bit more aggressive PT and possibly some active release will help with some of that tightness.

I return to the new OS I saw in mid-February to address the plate removal and my current OS at the end of February to address #2 and #3.  We’ll see about #4!  

Hopefully by the end of 2012, all of these knee issues will be behind me without the need for further surgical intervention and life will move on!   

Hope everyone is having a great start to 2012!

Happy healing,

Beth

[Teacher2Many]

Just got home and have exciting news to post (well exciting for me at least)...my femoral plate and screws are to be removed on April 9th with a doctor who does this crazy surgery at a hospital a mere 15 minutes from my house!  Femur is completely healed so no need for crutches, other than using them that first week post-op for balance, etc.  I am on spring break that week so it works out great-no need to get another sub for my room who will cause utter chaos with my darling kiddos!  It's an overnight hospital stay but the nurse did tell me that if I am one of the first patients of the day, I may be able to home in the late evening if I feel up to it.  And I get to choose my anesthesia-epidural is definitely not on the list of options this time around.  Both times with epidurals yielded both times with nerve damage so I am staying far away from that.  Granted, it could just be a coincidence but one I'm definitely not going to test.

I return to my Chicago surgeon on the 27th to investigate the possibility of the left chondral defect not having healed, as well as the dislocations.  My surgeon who's taking out the plates said he could test for the dislocation under anesthesia so I guess it'll just be a matter of who gets what done first.

All in all, a good day!  His nurse was surprised when I said how excited I was to have this surgery.  Guess most people aren't excited to go under the knife but with this being my 23rd surgical procedure (all but 1 have been orthopedic in nature and all but 5 of the orthopedic ones have involved the hips and knees), the 'nerves' don't usually get to me anymore.

Looking forward to being able to sit on the floor without squirming like a little kid who has to go to the bathroom due to the pain and inability to sit still!

Beth

[Teacher2Many]

4 more days until the femoral hardware is removed and we figure out what is going on with the dislocating patellas!  YIPPEE!!!!  Just need to be careful not to break the femur and to not injure the shoulder more than it already is with the use of crutches!

Can't wait....

Beth

[NickiAnn]

I hope your hardware removal went well!  I'm already excited to have mine out, and that's at least a year away! 

Hopefully you will be feeling stronger and have less pain in no time!

[Teacher2Many]

Hi Nicole,

Removal went well but this was the first of 23 surgeries that left major bruising & the worst muscle soreness ever!  Post-op appt. this coming Wednesdsy for follow-up & stitches removal!  BUT I'm finally able to sit for longer periods of time without great pain (aside from some of the soreness from sitting by the bruising, etc.)

Aren't you having your other leg done soon?  Maybe you can get the hardware removed then (he took mine out on the right when he derotated the left at 11 months post-op) but this year the tibial hardware was removed at 6 & femoral at 10!

Hope your little guys first Easter was great!

Beth

[crankerchick]

Sorry I haven't been posting too much or keeping up with KG, but I will say that after my hardware removal I was sooooo sore too, more than the original surgery. It took like 3-4 weeks for the soreness to cease. I guess it is normal...

[Lyndsey]

I agree with both of you guys! The femoral plate removal caused alot of soreness, but I think that was because I never babied it at all. No limiting of movement or anything like that. I didn't expect it to be so painful, so I had the left and the right removed at the same time. I'm still glad I did it that way, but I was a little surprised at how painful and sore it was.

Hope all is well, it's good to hear from you!
Lyndsey

[Teacher2Many]

Hi all...haven't posted on here in a while as life has gotten busy and there hasn't been much positive info to report and you get kind of frustrated with all the negative.  The hip is still causing a significant amount of pain and limitation and tomorrow I am heading back to my hip surgeon who removed the femoral plate 2.5 months ago to see what the status is.  The knee subluxations/dislocations are about the same...some days are a bit worse than others but that's been the course for a while.  There is an increased level of pain, overall discomfort, and a popping noise (like you're popping bubble wrap) with the left patella every time it goes from flexion to extension and vice versa.  This has been like this for the past two weeks with no decrease in intensity or frequency so I fear this is how it's going to be until the end of July.

I am having bilatearl MPFL reconstruction done via hamstring allograft in less than a month to help with the ridiculous amount of times they sublux/dislocate and was wondering if anyone else has had this procedure done and if so, any input as to what to expect, etc.  I am hoping that this is the last surgery needed to resolve the ortho issues but am fearful of findings regarding the ACI done 3 years ago, as I'm questioning it's success on the left patella.  Maybe just worry and paranoia but sometimes gut instinct is accurate-fingers crossed this time I am wrong!


If you've been done the MPFL road and have any advice, info, input, strategies, stories, etc. to share, I would greatly appreciate it!

Hope everyone is enjoying their summer thus far,

Beth

[NickiAnn]

Oh my goodness, Beth.  Can't give you any info on your next procedure, but just wanted to let you know that I'm so sorry that your hips and knees are still giving you trouble.  I know you were hoping that hardware removal would help. 

May I ask where your hip hurts?  My derotated leg has very stubborn pain at the front of the hip, almost, but not quite, in the groin area. 

I was so hoping that the derotations would resolve your subluxations and am truly sorry to see that you are still seeking solutions. 

As I continue slowly, slowly, slowly to recover from my derotation, I have begun to understand how hard it is to always hurt.  It does become a chronic pain issue.  I still have a lot of hope, though, that I will turn a big corner before the year is out.  I certainly wish the same for you.  In the meantime, the only thing that keeps my spirits up is to really try to live in the moment and enjoy the little minute to minute pleasures.  I hope you are comfortable enough to do so.

Hope to see happier legs for you soon, Beth.

[Teacher2Many]

Thanks Nicole!  I was indeed hoping the hardware removal would help with the hip pain but I came to find out at my last visit with the hip doc who took the hardware out, that I am now suffering from hip impingement.  From what I understood, because the femur was derotated so greatly, any kind of hip flexion at 90 degrees (ie sitting in a chair, on the floor, etc.) is causing some impingement against the head of the femur.  So we are trying some ultrasound in PT and some anti-inflammatories twice daily to help with the inflammation.  If that doesn't work, either an injection, MRI, or scope would be necessary.  This issue wasn't present on the right side which adds to the frustration but also found out there is some asymmetry in the hip which isn't helping the situation either.  Oh well...the current course of treatment is helping a bit but was also told to avoid any activity that causes the impingement to which I laughed, as I am doing my internship in early intervention working with babies-three year olds with disabilities which involves a lot of sitting on the floor while playing with them.

I am confident that the bilateral MPFL will resolve the dislocating/subluxing patellas as I knew the derotation wouldn't fully address that, as the ligaments had become too lax and stretched out.  Keeping every body part that I can cross crossed in that this is the final orthopedic surgery but also have a gut instinct that it's not. 

Are you still planning on doing the other leg this summer?  How's your little guy doing?  Am sure he's at that age where he's mobile and getting into all sorts of fun things (or should I say things he thinks are fun)!  Hope you enjoy your summer with him and engage in many trips to the park, walks, and little sprinkler pads!

[Teacher2Many]

So haven't been on here in a long time and figured it's time for an update.

Prior to 7/25:  the right leg was doing great, aside from the constant subluxations/dislocations of the patella.  No hip pain, catching, grinding, etc.  Definitely a great outcome from that surgery in 7/2010.

Prior to 7/25:  the left leg had a lot to be desired.  The patella was constantly subluxing/dislocating and the left hip was causing constant issues & significant pain, particularly with sitting.  The femoral plate was removed in 4/2012 at 10 months post-op in hopes of it alleviating the hip issues like removing the plate on the right side did.  Much to my (and my doctor's dismay), it did not.  We tried a couple different things which helped but the underlying issue never went away.  Consensus was that I was suffering from some hip impingement with a possible labral tear, as a result of the derotational surgery (let me clarify though that the derotational surgery did not cause the impingement or the labral tear but there was an underlying asymmetry of the hip so when the left femur was derotated, the gap between the femoral head and the hip socket became too narrow, causing impingement).  Nothing was definite so I was sent to see a doc out of Rush, as the one I was seeing at Loyola transferred to Northwestern and since most of my other ortho care was out of Rush, it made sense.

So I saw this awesome hip doc who agreed with the findings on exam but wanted an arthrogram done just to be sure.  I had that done on 7/24 and met with him right after and it was confirmed that I have a labral tear, as well as impingement.  Surgery will most likely be needed but we are trying cortisone shots first to see if we can manage the pain that way.  Although hopeful it works, not staying too positive on that as cortisone shots, in general, do not typically work for me.

On 7/25, I underwent bilateral MPFL reconstruction using donor tissue as a way of finally settling the issue with the subluxing/dislocating.  My surgeon was (and always has been and always will be) awesome and was understood that he was to fix anything else he found wrong, particularly the cartilage defects from the ACI procedure done in 6/2009.  Surgery was short, maybe 1.5 hrs. total and also consisted of the hip doc coming in and doing the injection while under anesthesia.  Waking up in recovery was horrible-the pain was immense, emotions were high, and breathing was a bit difficult.  But this has been the course for me as eeach surgery seems a bit harder to come out of.  However, when my surgeon came in when I was fairly coherent and free of pain (compliments of a femoral nerve block on the left leg), his comment was that the patellas were extremely hypermobile (which was reassuring to hear that my thoughts were accurate) and he did some trim work on the ACI site but that everything else looked good.  I am in bilateral knee braces/immobilizers for 6 weeks with the first two being locked in extension and then slowly opened.  I am set to return to work in 3 weeks to prepare my classroom with a start date in 4 weeks so hoping things progress so that I can get back to my kiddies.  I'm realized it's fairly common to have an MUA done after this procedure as ROM is hard to get back due to swelling and tightness but since my joints are typically hypermobile, I'm hoping this isn't an issue for me.  It's only been 96 hrs. post-op and I am off pain meds, unless I need one at night to ensure a pain free, good-night sleep and am finding the greatest pain relief with the use of the cooling/compression machine.  Walking is awkward, which surprises me as I was in the same protocol with knee braces, etc. after the bilateral ACI was done and am wondering if it's because my bones are now straight, making it harder to ambulate (before, they were so excessively rotated, my legs were already at that awkward angle to swing them out and around when walking-not so much anymore).

I return to my doc on Thursday to have stitches removed, Rx for PT given, and hopefully less bulky braces but that's yet to be determined.

Only 1 more surgery on the horizon, which would be the hip one and only if the cortisone shots don't cut it, so keeping my fingers crossed I am done frequenting the OR multiple times each year, after just having had my 24th and 25th surgical procedures!

Happy summer,

Beth

[NickiAnn]

You have had quite the journey, Beth.  I'm so sorry that the hip impingement was confirmed.  I know what that sensation feels like as I would occasionally have that "catching" feeling before my derotations.  It is almost an electrifying pain.

You are a hero for going back to school so soon after surgery, though I understand that keeping up your regular routines helps you stay positive and focused on normal life.  I don't think I will go back to school until October 1st when I am eleven weeks post-op.  Between the soreness when sitting and the exhaustion of trying to stand on a less than perfect leg, I don't think that I could handle lecturing a full day plus my 45 minute commute until October.

The MPFL reconstruction sounds tough.  Do your knees feel very odd?  I hope you get great results and an end, finally, to the dislocations.  Did a surgeon in the Chicago area address your latest knee surgery or did you drive all the way to Michigan again?

I read your advice about keeping positive after surgery.  I don't think I'm quite as adventurous as you!  I did, however, start going down the stairs.  That was a huge step for me, but when I saw what a mess my living room was I kind of wished I had just stayed in my bedroom! 

I am getting antsy, but I remember from my last surgery being pretty exhausted after attempting outings on my crutches the first few weeks, so I am proceeding with caution.  I am afraid of getting over tired, stumbling onto my bad leg, and jolting out the hardware.  I've noticed that I am more clutzy than last time because my nine month post-op leg still isn't up to full strength and balance. 

The best distraction I have is, of course, baby.  Also I have to finish six online grade credits by the 15th, so that is keeping me pretty busy during the day.

I hope you are continuing to recover, and you will have lots to keep your mind off you legs soon with school starting!  Which reminds me that I better get on my sub plans soon! 

Take care!