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Offline MWalker

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TKR vs Osteotomy
« on: March 04, 2006, 04:50:47 AM »
I am 39 year old male w/ a 6 year history of OA in both knees. Right now, my left knee is " bone on bone" and I am in alot of pain. I tried artoscopic surgery ( waist of time), PT, acupuncture, knee braces, massage therapy, all the Cox-2 meds and the glucosimine/chronditin pills. I finnaly went to a surgeon at the Hospital for Special Surgery in NYC and he told me that if I wanted to, I am a candidate for TKR. I then went to a surgeon at NYU'S Hospital for Joint Diseases for a second opinion. he is suggesting an Osteotomy. His rational is that it will give me " at least 5-7 more years" before I need a TKR.

My question to the board: has an body been in this predicament and has anyone had an osteotomy?

Any feedback would be greatly appreciated. I have a follow up appt w/ the 2nd surgeon on Monday. Thanks
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline katmomx2

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Re: TKR vs Osteotomy
« Reply #1 on: March 04, 2006, 02:05:05 PM »
Hi MWalker,

Sorry you had to find you way here, but this is a great site. I was 39 when faced with the same situation. My first question is what type of osteotomy is he recommending? Where is your damage (medial or lateral or both)?  What is your activity level?

Kat
OA lateral compartment left knee
Scope, chrondroplasty,debride, Menisectomy Jan 03 ,Hyalgan series
Lateral offloader brace
Over 30 degree valgus
Distal femoral closing wedge osteotomy 6/05
Loose staple, staple removal and another scope 11/05
Surg tech graduation 2/08
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Offline MWalker

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Re: TKR vs Osteotomy
« Reply #2 on: March 04, 2006, 03:41:17 PM »
Hi Kat,

I am very active.  I have been going to the gym as much as possible and trying to get ready for this thing.I work full time but I live in a 4 story walk up in Bklyn. My OS stated its a high tibial osteotomy. My pain is on the inner sides of my knee. So, can you tell me what to expect. I come from a family where TKR were common. I have no idea what to expect about this one. Pain, PT  how long I'll be on crutches, and how the osteotomy will make the inevitable TKR possible. I really, really appreciate your feedback. Thanks
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline katmomx2

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Re: TKR vs Osteotomy
« Reply #3 on: March 05, 2006, 12:12:44 AM »
Hi MWalker,

Oh my 4 flights of stairs on a daily basis. I could not even imagine. I only have 5 steps to deal with. I avoid stairs.  I can tell you what happened with me. My osteotomy was a femoral. I have lateral damage to my knee. I walked on mine so long I developed a valgus deformity of 30 degrees. This mean I am severe knockkneed with the tibia and fibula bowing out. I had the osteotomy to offload the weightbearing to the healthy side of my knee. I am still looking at tkr in the future. My goal is to get 10 years.  This may be over optimistic. I am also very active. I am a single parent of 2 boy's 13 and 4. I am also a full time student. Osteotomy's are big operations. But it was not as bad as I expected. The first 10 days were the worst for me. I was NWB for over 3 months. I was off work for 4 months. I did not have a extensive PT program. This was my surgeons protocol. The tkr is still possible. They just take a little more work . An ideal tkr is a knee that has had no surgery. Again my experience was a different operation. If you look on the arthrits board, look at changing forces through the joint you will find more people who have had HTO. Also check the post op board.
There is one in particular, I think it is Knee will be great. He just recently went through HTO. I am happy to help and chat. Please keep us informed of your progress.

Hugs Kat
OA lateral compartment left knee
Scope, chrondroplasty,debride, Menisectomy Jan 03 ,Hyalgan series
Lateral offloader brace
Over 30 degree valgus
Distal femoral closing wedge osteotomy 6/05
Loose staple, staple removal and another scope 11/05
Surg tech graduation 2/08
Tech Labor and delivery

Offline kath

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Re: TKR vs Osteotomy
« Reply #4 on: March 05, 2006, 12:50:43 AM »
Hi MWalker,

I faced the same decision you are facing, but at age 49.  I had grade 4 OA in both knees medially (inside).  Both legs were becoming very bowed and it was painful walking even half a block.  (opposite to Kat, who has lateral damage).  I've had OA since I was in my 30s, and my father has had knee replacements 2x.  My choices were an osteotomy or a knee replacement on both legs, but I was very lucky to have an OS who admitted he couldn't decide between the two, and referred me to a specialist in replacements.  It turns out I was able to get away with PKR on both knees.

I dare say that rather than considering a total knee replacement, you may be a candidate for a partial knee replacement, as long as the OA is confined to one compartment.  If that is the case, your choice may end up being an osteotomy or a PKR.  There are other options available too, but I'm assuming the specialists have considered this.  An osteotomy has a longer recovery than a PKR.  However, based on your age, an osteotomy MIGHT be the best option.  It can buy you the same amount of time and even more than a prothesis before requiring a TKR.  Everything depends on the amount of damage to the knee.

As a next step, I would highly recommend you ask your OS if a PKR is an option, and then compare it to an osteotomy by figuring out recovery time and future quality of life.   

Good Luck!  Please let us know what you decide!

kath
Bi-lateral unicompartmental Nov 2004

Offline Heather M.

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Re: TKR vs Osteotomy
« Reply #5 on: March 05, 2006, 08:56:08 PM »
I'm on the same page as Kath:  if an osteotomy would be helpful, then that means your pain is in one compartment of the knee.  In that case, a PKR should also be considered--they take a lot less bone and are not as extreme as a TKR.  Not all doctors do them....so anyway, you might want to find out why they didn't suggest PKR for you. If it's because you aren't a good candidate (damage in more than one compartment, severe patellar mal-tracking), then the next question would be why would an osteotomy not be contra-indicated?

Also, one way to 'test drive' whether your pain is all from the medial compartment is to get an unloader brace and see if that helps your pain.  If so, then you can be more comfortable moving forward.

Another thing that caught my attention is your comment that you are very active....usually, doctors don't want to do TKR's on younger patients because they are more active.  They can cover 10 tims the mileage of an older TKR patient, which means the prosthesis will be 'used up' prematurely.  It's hard if not impossible to do more than one revision of a TKR.  So that's why most docs would recommend PKR and/or TTT/osteotomy over TKR in a younger patient.  It's worthwhile to try to put off the TKR as long as possible, by whatever means are possible.  For example, you may be a good candidate for pain management programs.  Many of these are very thorough and take a multi-disciplinary approach using meds, PT, massage, myo-fascial release, acupuncture, nutrition, bio-feedack, bracing, e-stim, and other techniques.  These may help you put off either surgery for an extended period of time.

Also, if you only have damage in one area of the knee, you may be a good candidate for a cartilage restoration procedure.  These include OATS/mosaicplasty, ACI/carticel, and microfracture.  If you are a good candidate, either one of these could buy you some time....

Your best offense is to be a well-informed patient, which you are doing by asking all these questions.  Keep asking and keep getting opinions until you find a doctor whose plan you are excited about.  And that may well be a TKR or something.  There's no right answer for every patient, just the right solution for you.  Your age is certainly one of the factors that should enter into the decision making, but hopefully it won't be a deal-breaker!  A lot of OS's simply won't consider a TKR on anyone under 55, which is very frustrating. If that's what you need, it's what you need.  Just understand all the other options and possibilities, and also understand that most doctors only work with one technique.  So a doctor that does TKR's may or may not have any experience with (and may even have negative feelings about) cartilage restoration.  It's strange, but true.  My current surgeon is a pioneer in microfracture...but he doesn't do ANY of the other cartilage restoration techniques (thinks they're too invasive and don't produce any better results than microfracture over the long run).  He's also fairly adamantly opposed to TTT/HTO procedures done to unload the kneecap or a damaged compartment, though his close partner performs them regularly.  So you have to understand that  each OS out there has his/her own philosophy on what is the best way to treat a certain condition.  They're not right or wrong, the patient is the one who has to decide which philosophy best suits his/her current situation and long-term goals.

Hope this hasn't been too confusing.  I guess I would boil it down to suggesting that you see other doctors who address serious cartilage damage in ways beyond TKR and HTO--like PKR, conservative pain management and bracing, or any one of the three major cartilage restoration techniques.  You can find information on all of these on this web page (each approach has its own section at the bottom of the board) and on the Net in general.

Heather
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
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Offline MWalker

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Re: TKR vs Osteotomy
« Reply #6 on: March 06, 2006, 04:06:59 AM »
Thank you so much for your very generous response. I have an appt tomorrow with an OS to discuss a HTO. I tried to get an unloader brace but my insurance would not cover it. Funny that they will pay for full on surgeries but not as much for preventative measures. Anyway, I am looking seriously at HTO for my left knee. Hopefully, this will bide me time till I totally need a TKR.

Thank you so much and I will report back on my mtg with the OS.    Matt
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline Cari

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Re: TKR vs Osteotomy
« Reply #7 on: March 06, 2006, 06:30:32 AM »
Hi Matt,

6 years ago at 37 years old I faced the same decision as well and sought a Dr ALSO at NYU Hospital for Joint Diseases. My Damage is all patella and patella femoral joint area, I did have an Osteotomy instead of a TKR though it was a different type of Osteotomy and now at 6 years post-op, I have NO PAIN, no instability and full range of motion!!!!!!!!!!!  I know in the future I might still need a TKR but I am glad that I have been able to buy this time.  My OS retired in 2002 and I was heartbroken as I had NEVER met such a caring human being that was so skilled and talented but now I see a different one ( for my other knee..the good one) who is from The Hospital for Special Surgery.

Good Luck with whatever decision you make !!!! 

Cari
open lateral release 10/85, various scopes 1994-1998 for debridement, medial release 11/98,  TTT(Fulkerson)& lateral release 11/30/99, screw removal 6/27/00, tibial repair 2/13/01, dx RSD 6/25/01

Offline MWalker

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Re: TKR vs Osteotomy
« Reply #8 on: March 09, 2006, 03:52:41 AM »
Hi Cari

Thanks for the good wishes and feedback. Can you give me an idea of what post surgery experience I will be dealing with. I know so many in my family who had TKR and THR, but no osteotomies. Any feedabck would be appreciated. Thanks  Matt
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline MWalker

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Re: TKR vs Osteotomy
« Reply #9 on: March 09, 2006, 03:58:10 AM »
Hi Kat,

You have your hands full. Thanks for your e-mail  I am opting for the HTO. I am bo legged and he mentioned the Valgus ( sp?) deformity but only by like 10 degrees. I have bone on bone and will have my L knee done on 4/7. Little nervous but am relieved that it will give me a chance to put off TKR. NWB means crutches, right??? Or does that mean iam off my feet that entire time? How long were you in the hospital for and did you get an epidural?

Thanks again Kat!  Matt
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline Cari

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Re: TKR vs Osteotomy
« Reply #10 on: March 09, 2006, 04:42:13 AM »
Mat,

I had done alot of research so I was prepared for what I was going to face post-op plus my OS was brutally honest about it all.  I was suppose to be in the hospital just overnight but due to a problem with my IV I could not use crutches for a few days so I wound up being in the hospital for 4 days. I have a desk job and it was my left leg that was operated on so my OS wanted me home from work for 6 weeks but he agreed to let me go back to work 4 weeks post-op. I was suppose to be non weightbearing the whole 6 weeks but at 3 weeks and a few days post-op my OS allowed me to be partially weightbearing. I had the bledsoe post-op brace locked in the straight position for the 6 weeks 24/7( even sleeping).  I was only allowed to start being my leg at 2 weeks post-op but only when sitting. I was allowed to be up and around as long as I followed my weight bearing instructions, so the answer to your question is no you do not have to remain in bed. MY OS felt that formal PT was not needed until I was ready to be full weight bearing and to walk without the brace so I did not start PT till 8 weeks post-op BUT...I was instructed certain exercises to do at home to make sure I could bend my knee to the required amount my OS set the brace for. When walking the brace had to be locked and I could only unlock it to do my bending exercises.

I thought the pain post-op was alot better then I expected. When I lowered my leg from an elevated position ( even just sitting in bed) for the first few seconds you get a horrible blood rush pain to the site of the osteotomy ( surgical fracture) but after about 2 weeks time that pain reduces greatly. I had NO kneepain whatsoever immediatley post-op!! The pain and grinding was immediatley gone, I had incision pain and pain where my tibia was fractured and the screws were. I knew then that the surgery worked for me. My OS and his Resident told me that night and the following day that what they planned worked, my keecap made a perfect fit where they moved everything.

In fact today I went to my current OS for my other knee and he checked the one that had the osteotomy and said it still looked good and it still feels good,  so after almost 6 1/2 years there are no problems.

If I can be of any help please feel free to post or message me.

Cari


open lateral release 10/85, various scopes 1994-1998 for debridement, medial release 11/98,  TTT(Fulkerson)& lateral release 11/30/99, screw removal 6/27/00, tibial repair 2/13/01, dx RSD 6/25/01

Offline MWalker

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Re: TKR vs Osteotomy
« Reply #11 on: March 09, 2006, 12:59:55 PM »
Hi Cari,

Good morning. Does every one wear a brace after this procedure? I am having a HTO - is this the same one you had. I am certaintly getting a lesson in anatomy on this site. To be honest, it can all be so confusing. I am a psycho-therapist in Bklyn. I am planning to take the 6 weeks. I was told by my OS that I could be in the hospital overnight, but could expect an extra day or two to see how I make out with crutches and steps.

So, was your brace uncomfortable? How did you sleep at night and were you allowed to shower with it. I have so many questions, part anxiety i guesss, so I appreciate your help and patience. Much thanks Cari!

Have a great day and talk soon.   Matt

ps. are you getting your right knee done??
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline Cari

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Re: TKR vs Osteotomy
« Reply #12 on: March 10, 2006, 02:51:31 AM »
Hi Matt,

My Osteotomy was a bit different then yours. My damage was to my patella and patella femoral joint so the pressure needed to be removed from my patella as well as lining up my patella to a more normal position. My OS cut the bone referred to as the Tibial Tubercle which is the bump below your knee and moved it over to the medial ( inside more). Then in order to elevate my kneecap in the manner needed you usually need a bone graft but my OS made a larger then normal cut in my bone and used this in such a way as a wedge to elevate the kneecap. This was then fixed together with 2 huge screws. Your Osteotomy is to relieve the pressure on one of the compartments of the knee either medial or lateral.  With yours a wedge of bone in a triangular type shape is cut to move the pressure off the area needed and then reafixxed with screws etc.

Not all OS's use braces but most do. I was told there was a chance I would need a plater cast but the brace worked out fine. Sometimes they use a plain immobilizer that is not adjustable as far as bending is concerned but my OS felt why use 2 different things when the brace would work. The brace didn't hurt, it was uncomfortable as it went from my hip to my ankle and it was heavy. I had a problem for a few weeks where one of the straps pressed on where the screws were causing alot of pain but my OS had someone adjust the brace and it was better. It is tiring to walk around with your leg straight ( even non weight bearing) with the brace or immobilizer on and the crutches so be prepared to be exhausted at times.

I had to sleep with the brace on for 7 weeks . I started sleeping with my leg elevated on pillows laying on my back but I don't like sleeping on my back alot so they had told me in the hospital to lay on the opposite side of the surgical leg and place pillows between the legs for comfort. I was able to sleep that way better...you just get use to it. At about 2 weeks in I started with the "why did I do this" and the "6 weeks is a long time" but I quickly got over that and the time passed.

The first 2 week I was not allowed to shower at all. Then for the next 2 weeks I was allowed to shower but NOT take the brace off at all so I covered it with a plastic bag and used a shower chair and propped up the leg. Although I was not allowed to get it wet in the shower, I was allowed to remove the brace and gently wash my leg avoiding the incision and any heavy pressure to the kee and tibia.

It is a very big proecedure with a long hard recovery but in my opinion it was worth it!!! So far 6 years have passed and my knee is still pain free and stable !!

My right knee ( the other one) is now worse then the operated leg was back then but I have not chosen to have any surgery now. I trust the OS I use now but he is not the one who did my other Osteotomy surgery as he retired in 2002 so I am not crazy about someone else doing this procedure. The OS I use now believes in the quality of life so if I wanted the surgery or a TKR he would do it. He feels I should try and buy as much time as I can until a partial knee replacement involving the patella and patella femoral areas only is perfected. They do that procedure now but it has a high failure rate.  I am now going for cortisone shots every 3 months as well as PT here and there for strengthening. I know that it is not time for me now to have the major surgery and like my other one I knew when it was time to have it fixed. Prior to my Osteotomy I had numerous scopes to clean out and debride my patella with relief not lasting more then a year each time so we are not going to go through any scopes. When I have had enough, I will schedule whichever surgery is better for me then.

I currently am not working due to a downsizing of the company that I was a Manager for for 10 years and thought about doing it now but I know emotionally I am not ready to take this step!!

Sorry to ramble on...I sure hope that this helps !!!!!!!!!!

Cari
open lateral release 10/85, various scopes 1994-1998 for debridement, medial release 11/98,  TTT(Fulkerson)& lateral release 11/30/99, screw removal 6/27/00, tibial repair 2/13/01, dx RSD 6/25/01

Offline MWalker

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Re: TKR vs Osteotomy
« Reply #13 on: March 10, 2006, 04:24:46 AM »
Cari,

It certaintly does! Thanks so much for all your help. My OS wants to do my L knee but my R hurts the most. My left knee is bone on bone and my R has some cartilige left. I have to go back to se what he says. Your very specific, concrete advice and details have been extremelly helpful. Thanks so much. Will keep you posted. I live in Bklyn NY, where are you from?   Thanks again, Matt
Dislocated knee in 1989 in Budapest, Hungary
Arthoscopic surgery in September, 2004 on left knee
HTO on right knee in April, 2006
Presently "bone on bone" in both knees
"I am too young for this"

Offline katmomx2

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Re: TKR vs Osteotomy
« Reply #14 on: March 10, 2006, 04:49:11 AM »
Hello MWalker,

As Cari said" my osteotomy was different than yours" Mine was a distal femoral. My femur and whole lower leg were realigned. I will give you the short story. I have a post op thread. I was in the hospital for 3 days. I was stuck at my mom's house for 3 weeks. Like Cari I did not have a real shower for a while. I had a knee imobolizer. Sleeping was not easy as I am a side sleeper.I was on crutches for 4 months. I lost my job. My internal fixation is bone staples. I had one come loose and take a tour. Osteotomies are big operations, but your do recover. As Cari stated" expect the other knee to be a little put out" I hope my input is helping.

Kat
OA lateral compartment left knee
Scope, chrondroplasty,debride, Menisectomy Jan 03 ,Hyalgan series
Lateral offloader brace
Over 30 degree valgus
Distal femoral closing wedge osteotomy 6/05
Loose staple, staple removal and another scope 11/05
Surg tech graduation 2/08
Tech Labor and delivery















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