Upcoming TTT in December, any suggestions are appreciated

[bball123]

Hi guys! I am a 15 year old female and I have been facing patellar instability since the summer of 2007. Here is the history of all these issues...

My knee problems first started in July, the summer before 7th grade. My friend and i were fooling around and she jokingly pushed me and I actually fell (which I don't think she expected). The actual fall was not painful but my knee immediately KILLED! I had no idea what had happened, but I was in so much pain and tried to hold in the tears, but I just couldn't. I didn't think much of it because i didn't think it was possible to hurt myself from such a thing. After laying down and icing for a while I was still in a lot of pain, so my mom brought me to the hospital. After 6 long hours in the ER, I was told that I had SPRAINED my knee and I was sent home with crutches and a small brace. Well the next day came and nothing had improved. A few days later, I went to see an orthopedist, and he sent me for an MRI. The MRI results came back and I was told that I had dislocated my left knee. So long for that sprain... I was on crutches for a few weeks and I did PT.  I healed great and didn't have any pain after that.

The next year (8th grade), in October, I was fooling around with my brother and I was in a squatting position. We were trying to catch goldfish in our mouths, and I bent my knees a little and fell. (again just trying to be a normal kid but my knee clearly didn't like that) We assumed that it was the same injury... except it happened to my RIGHT this time! My mom took me to the hospital just and case and they took x-rays. They confirmed that nothing was broken, but that I had just dislocated my knee again. I was given an immobilizer and sent home on crutches. After PT for a few months, I was back to new.... not for long though. In June of 8th grade, I was playing mat-ball in gym (similar to kickball) and I was running to the next base and my left knee dislocated and I fell. The nurse came and I was brought in a wheelchair (so embarrassing) to the nurse's office where they called my mom. She left work to stop home and get my crutches... then she picked me up.  With my brace and crutches ready from my last injury, I did PT the entire summer and I was SORT OF back to new... 

I began my freshman year with all my strength back, but I was constantly in pain. I went back to my orthopedist, and he gave me no help at all. His "help" to me was that I would have to live with this for the rest of my life. Frustrated, I knew there was something else going on. In November, I saw an OS at the Hospital for Special Surgery in New York. I had MRI's on both knees before the appt for him to see. He told me that I had bone chips in my right and a minor tear, and the left and right could use tightening of the ligaments and stuff. My left knee was also on a huge tilt, which explains the lateral release I am due to have on Wednesday. He told me that I would most likely benefit from having these procedures... but they were obviously not necessary. However, that doctor didn't take my insurance so it was going to cost a lot of money to have both my knees done with him. I decided to wait things out a little more...

It got to be January of 2010 and I just could not handle the pain anymore. High school gym was killing me, the constant running was not doing my knees any justice. I was not able to play on the high school volleyball team like I had wanted to. I went to see another OS in Farmington, CT and he told me what the other OS had told me. This doctor took my insurance and we decided to go ahead with the surgery. I had my right knee operated on first. My surgery was scheduled for February 10, 2010 and I was a bit nervous but excited to get better. After being on crutches for 2 months and in a range of motion brace for about 2.5 months, I was noticing a difference. As I became more mobile, I noticed a lot more stability in my knees. I was still in pain over the summer though. I did PT 2 to 3 times a week, being told that I also had tendonitis in both my knees. PT improved that a little bit, but I mostly got used to the pain.

I started my sophomore year of high school still in pain from tendonitis, but I was going to PT 2 times a week, which seemed to help a little bit. I then dislocated my left knee again about a month and a half into the school year. I had a bottom locker that year so when I began to kneel down to put my books away my kneecap popped out AGAIN. I was taken to the nurse and they called my mom. An hour later, I was taken home. Later that day my mom took me to PT, luckily I am well known there. They checked me out and I was scheduled for more PT visits to rehab this knee. I managed to get off crutches in one week, but I remained in a brace for about 1.5 months. I was out of the brace for 1 day before I have an MPFL repair on November 24, 2010. It was planned to be a lateral release as well but when they got into surgery they decided it wasn't necessary. Immediately following surgery, my OS told my mom that everything went as planned, but that they were damage to the cartilage which might cause further problems..... and indeed it did! I rehabbed pretty much all through the summer and finally took a break at the beginning of august when nothing was improving. I went back to my doctor and he said that the TTT was the only option left. He said that the pain I'm having is from the damage to the cartilage and will not improve.

I just saw a new OS who is affiliated with the Hospital for Special Surgery in New York to get yet another opinion and her input on the TTT. I absolutely loved her. She explained things better than this stuff has ever been explained to be before... even when talking about a general knee dislocation. Basically the structural issues that she says are causing this problem but can be fixed by the TTT are as follows...
- I am knock-kneed
- I have patella alta
- and the groove that my kneecap is supposed to sit in is almost non-existent

Also, I have the beginning signs of arthritis which you can HEAR from the crunching in my knee when doing certain things.

She wants me to have an MRI so she can get a better look at things, especially the cartilage damage. Also, she wants to measure my TG-TT offset. I have an appointment on November 3rd to get the MRI then I have an appointment with her that same day to discuss the results. I decided to go ahead and have the TTT with this surgeon as opposed to the one who did my 2 other surgeries because I liked her better and it is easier for me to get to her for follow up appointments than it was to get to my other doctor's office. I am tentatively scheduled for surgery on December 23rd, so that I do not miss as much school because I will have extra time to recover over Christmas break. My OS said I will miss a minimum of 2 weeks of school... eek

I would appreciate anyone's input on this surgery because I know a lot of people on these boards have had this surgery. For example, is there anything you wish you would have known but didn't before your TTT?

So far recovery for this surgery looks as follows (because I know every OS has a different protocol)... I will stay at least overnight, and it will be 2 nights if she has to re-do the MPFL repair. 6 weeks non-weight bearing so the bone can heal and I will have a CPM machine starting right about surgery. She also mentioned that I will not be allowed to bend by myself while the bone is healing. Also, can anyone give me more info about the CPM machine? It sounds kind of scary to be bending RIGHT after surgery. Does it hurt a lot?

[Runner1993]

So sorry bball to hear things are going in that direction.

First off, how much information do you know about your actual TTT? Which direction is she moving the tibial tubercle? Is she doing anything for the cartilage? Do you know how many screws she's using or if they will potentially bother you?

I wish I had been prepared for the amount of blood and bruising that would result from having the bone cut. It pools in your calf and really hurts... it so bad I went to the ER because I thought I had blood clots! Make sure you move your ankle a ton and elevate as much as possible! Be prepared for bruising that can be all the way down on your ankle.

I was out of school for about 2 weeks, but with the break, you should be fine with missing school. I didn't have a break and I was able to get caught up. Get work ahead of time. Email your teachers while you are out, too.

Sounds like my surgeon was more aggressive with rehab. I was allowed to place weight on my leg, in fact, my surgeon encouraged it, saying it prompts bone growth. However, I used both crutches for 6 weeks, and one crutch for an additional two weeks based on my progress. I was in my hinged brace for nearly 4 months. Make sure when you start to learn to walk again, you do it slowly and right!!

Don't be surprised if you get ankle pain or ankle stiffness.

I was allowed to bend my leg before the bone healed (which I assume is 6 weeks). I was allowed to bend up to 30 degrees for the first 3-4 weeks then increase 15 degrees a week. My brace was locked at 0 for a few weeks, then gradually opened 10-20 degrees every few weeks depending on my progress.
 
I didn't not have a CPM machine, but I believe it will be beneficial for you since I had such a hard time with ROM. If I have the surgery my doctor is suggesting, I will have one. Do you know when you start physical therapy? I started the next business day after my surgery.

I didn't stay overnight and found the pain that day manageable with pain pills. It was painful, but if you have a good pain tolerance, you shouldn't be suffering too much. They might offer you a femoral nerve block. I didn't want it because my iv sucked and I was tired of needles, but several find it helpful.

Get an ice machine or lots of ice! Swelling will happen, even in your ankle!

Keep in mind that I had a MPFL reconstruction, lateral release, and TTT all at once so if I can do all that, you can survive this surgery. Good luck

[lisa424]

I think I know which surgeon at hss you're talking about. People seem to like her.

But if you are knock kneed, I'm pretty sure a TTT doesn't correct that.

[bball123]

Runner,

I don't know that much about the TTT other than what i said mentioned because i have only had 1 appointment with her so far. I was so shocked with everything that I was told at that appointment that I couldn't really focus well enough to ask any questions about the surgery itself.

I am working on a list of questions for the appt following the mri and some of your questions were already on there but the other ones i will definitely add. My list is very long so far, I hope she doesn't mind lol

I already have an ice machine from my previous surgeries and it is DEFINITELY a good thing to have! I think the CPM will be a good thing to have although it sounds a little scary :/ I am almost glad I would be staying at least 1 night in the hospital because of the severe stomach issues I had with the pain pills last surgery. I think that the IV meds won't hurt my stomach as much and I will be able to be monitored to keep my pain under control. Side note, I am seeing a stomach doctor the same day as my MRI and OS appt in regards to pain control after surgery. I do not want to have stomach complications again.... those were AWFUL!

lisa,

the surgery doesn't fix knock knees but it will relieve (hopefully) the awful pain that I am experiencing all the time. By fixing the alignment in my leg, it will shift the weight away from the area of damaged cartilage. The doctor at hss is Dr. Shubin Stein. Do you know someone that has had surgery with her? ... I am very confident about her doing my surgery, especially because at one point she shadowed/worked with Dr. Fulkerson who invented this procedure.

[lisa424]

I've heard good things about her. She does a lot of TTTs so you should be in good hands.
She's not too far from me but unfortunately my knee problems are a lot more complicated than what they used to be and some of the surgeries I need are not ones that she does.

I would just say make sure you're aware of and comfortable with the post-op protocol. I was also non-weight bearing for 6 weeks and also not allowed to do any straight leg raises.  Because of that I still have a lot of atrophy in my quads almost a year later. Just make sure you get your legs as strong as possible before surgery.

[bball123]

thanks for the input! i already have on my list to ask her if PT is necessary or will help at all for before surgery. I will be NWB for 6 weeks as well... but wow... no straight leg raises? that stinks. i am also going to ask her about the protocol more in depth at my next appointment. good luck getting your knee problems sorted out! sorry to hear that they have gotten worse than they used to be

[shelly86]

Hi. Im from the UK and had my TTT done in June this year. I was in hospital for a total of 5 nights due to other problems after the surgery (nothing to do with my knees)

I can honestly say I wish I knew a lot more before I got the surgery. 4 months after my surgery and I have just got rid of my crutches, although my walking is still terrible. I am walking with a limp and cannot bend my knee alot. This is due to the surgeon keeping me in a brace for 8 weeks without bending at all, but despite all of this my knee feels so much more stable and I am glad I got the operation done. Just be prepared for a long recovery

A couple of things I will mention for when you come out of hospital. Make sure you have everything at hand, i.e. remote control, laptop etc as getting up and down all the time was a real struggle for me.

Good Luck with the operation and be sure to let us know how you are doing !

[SW71]

I've had TTT done on both knees. The amount of pain and rehab will depend on how far the knee cap needs to be moved - the further the kneecap needs to be moved then the less you will be able to bend your leg post surgery. A lot of the rehab is getting your range of movement back and in my experience this was the most painful part of rehab. The strength building is time consuming, but not really painful. It took me more than 12 months to get back to full strength.

The first two weeks after surgery aren't pretty, it hurts a lot but once you get through this milestone it gets better each day. However, be prepared for a tough first 2-3 weeks.

I have no hesitation in saying that the surgery was a good decision for me. The mechanics of my knee and my enjoyment of sport after surgery were so much improved. Yes it is painful, yes the rehab is long but it was all worth it for me, I was able to do lots more things functionally after the surgery.

Talk to your doctor about the state of your cartilage before your surgery. Your knee sounds like mine - patella alta (mine was a loonnng way high) and virtually no trochlear groove. Because of this I had suffered a fair degree of cartilage damage (grade III) before the surgery. After surgery I embraced sports like never before, especially cycling, but now I am going down the path of grade IV chondral lesions / OA. I had my TTT done 6 years ago, and my surgeon is now considering a revision TTT and moving the kneecap a bit lower to find some fresh cartilage for the knee cap to sit on.

This probably isn't that important because metal allergies are fairly rare for the types of metals they use in surgical screws, but you may want to check out any metal allergies before the surgery because you are going to have screws for a while (if not permanently).

Hope this helps

[knee2no]

If you get a TTT are you able to get a TKR (if necessary) at a later date?  I have been told yes and no by various orthopedic doctors.   

[KW]

If you get a TTT are you able to get a TKR (if necessary) at a later date?  I have been told yes and no by various orthopedic doctors.   

Yea,  you are able to have a TKR after a ttt.    The hardware will mostlikely need to be removed but no reason a tkr cant be done.   

[oohheykate]

I can't really give you any advice on this surgery bball but I'm glad you got a second opinion who seems to know what she's talking about and I hope this surgery works for you!

[knee2no]

I was also told TTT is best performed on "young" people.  Has anyone had this done in their 50's? 40s? 

[KW]

I was also told TTT is best performed on "young" people.  Has anyone had this done in their 50's? 40s? 

The proper knee for a ttt us based on measurements and the condition on the underlying surfaces not so much on age. If you read around here you will find plenty in 30's 40's 50's + who have had TTT/TTO surgery. You will also find people in their 30's 40's early 50's having replacement (partial and full). 

Sounds like you have a dr that is feeding you bad info!

[bball123]

Thank you everyone for the input. I will update after my MRI and doctor's appt on November 3rd. Meanwhile, there is not much else to say. Just living with the pain until we can do something about it...

[SW71]

Hi bball123,

I was just thinking I could have given some more practical advice in my first post, so here goes:

I would start on a physical therapy program in preparation for surgery. For my left leg which was done second I was better prepared. I would do the following if I had to have another TTT:


1. Stretch your quadriceps and ITB as much as possible before the surgery, preferably a couple of times a day. This will help make the rehab shorter and less painful because it will probably improve your initial range of movement after surgery and any head start is good.

2. Strengthen your quads as best you can. Again this will help the post surgery rehab. Your quads are going to waste a bit (a lot) while you are not weight bearing fully, so giving them a stronger pre-surgery position will help with your general mobility and strength building post surgery.

3. Stretch your hamstrings. This will really help with your mobility and getting things done after surgery. If you can't touch your toes now, it will be harder getting up off the floor/bed/into or out of a car etc. It will make a big difference getting dressed too - if you can't touch your toes easily then you might need help getting your underwear on  . I struggled with this for the first leg, but was well prepared for the second leg.

4. You've probably used crutches before given your history, but in case you haven't it is worthwhile practicing before surgery.

Hope this helps