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Author Topic: Advice please: Miserable Malalignment  (Read 5295 times)

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Offline dstevens

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Advice please: Miserable Malalignment
« on: May 06, 2007, 08:49:39 AM »
Dear all,

I'm 19, suffering from Miserable Malalignment. I met so many doctors here in Malaysia, and finally came across one that said he would do a surgery. I'm comfortable with this doctor; he tried his best to explain what is needed to be done, he also said that he never treated an adult before, and that almost all his previous cases are children, and therefore I'm the first adult he ever (would) operate. This worries me a bit.

From reading topics of others suffering the same problem, I see that different people have different procedures done. Lateral Release, Derotation Osteotomy..etc.
My doctor said that he would do a "derotation", that is - according to him - cut the bone and derotate it so the patella would change its position so my leg becomes normal. He said that the recovery time would roughly be 3 months, and that it would be difficult for me to continue my studies during those 3 months.
He also said that there are risks involved, including "infection" but he said risk is only 1%.

Another doctor from nearby country (but far more expensive) Singapore, said in one of his emails:
Quote
Most of the time you would need a derotation osteotomy on the thigh bone. The recovery time would be around 6 weeks. The patient walks quite comfortably during the recovery.

Very contradicting and makes me confused. Are the two procedures the same? does "derotation osteotomy" mean cutting the bone and changing its rotation?

My doctor said that I should talk this over with my relatives and think about it, indicating that this is a very serious procedure. I did ask him if it is, but he gave me no direct answer. is it a serious procedure?

I'm sorry if my topic's questions are answered elsewhere, but I'm not a native speaker of english, nor am I familiar with the medical terms. When I read the guides and other posts, its very difficult for me to follow.

Your time and input are greatly appreciated.
Sincerely,
David

Offline Leentje

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Re: Advice please: Miserable Malalignment
« Reply #1 on: May 06, 2007, 10:49:47 AM »
There is a risk of infection included in every surgery, even the simplest surgery can lead to an infection, don't worry, the risk is, like you said, so little.

Don't expect to be up and running after 6 weeks following a derotational surgery! It's invasive and major, recovery will be more like 3 months, like the first dr said. Studying won't be a problem, in my own opinion.

Get well informed and read alot, including doing research on the net. Go with the dr you feel most comfortable with and I am sure surgeon over there are good! I don't live in UK or USA and had a TTT realignment with the best results I couldn't even dream of!

Good luck!
Bilat patellar malalignment/PFdysplasia
00/06/83 L wrist #
11/12/00 L knee LR + chondroplasty
21/08/02 L knee TTT
02/03/04 L knee stretched PCL
11/09/07 L ankle dislocation/medial avulsion #
25/05/09 L ankle medial avulsion # AGAIN!
05/06/13 R ankle dislocation

Offline dstevens

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Re: Advice please: Miserable Malalignment
« Reply #2 on: May 06, 2007, 04:17:21 PM »
Hi Helena,

Thanks for the input.

If I go ahead with the surgery, then I will have it done 3 weeks prior to the trimester start (3 weeks is longest holiday here). So three weeks post-op I will need to walk almost daily to campus (about 10 minutes away), I wonder if that will be a problem? or if I will even be capable of that in the first place?
The doctor said he will do one leg at a time, so first derotate left leg, wait for it to fully recover then do the right.

One thing I notice here in signatures is that many people who have miserable malalignment have had several procedures/surgeries. The process in US/UK seems to include many steps, each taking a long period of time. Not a single operation.

I will be seeing my doctor again for X-rays and more thorough examination. Thank you for sharing this with me.

David

Offline cat

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Re: Advice please: Miserable Malalignment
« Reply #3 on: June 01, 2007, 02:57:40 PM »
Hi David,
Somehow I missed your post but wanted to reply. I think that the reason so many folks with miserable malalignment have other procedures done is that derotational osteotomy as a treatment for anterior patella femoral pain is relatively new. It is not a common procedure and not without serious risks and complications. It is so much easier to try something else first. From Techniques in Knee Surgery; Osteotomy in the Treatment of Patellofemoral Instability;Teitge, Robert A. MD-


Quote
If limb torsion exceeds normal by 20 degrees, realignment is felt to be beneficial. The surgical morbidity of osteotomy and the risk of non union or malunion with overcorrection or undercorrection of abnormal varus or valgus or flexion or extension deformity suggest that osteotomies of less than 10 degrees, although they may be helpful, should not routinely be attempted.

Keep us posted.
 ;D cat  ;D[/color][/b]
"Miserable malalignment"
 Lateral release, medial reefing, VMO advancement, and TTT-  3/2/04
Screw removal- 5/24/05
Cortisone injection to pes anserine- 7/27/05
Femoral derotation osteotomy, TTT revision- 10/18/07

Offline dstevens

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Re: Advice please: Miserable Malalignment
« Reply #4 on: July 12, 2007, 01:40:41 PM »
Hi Cat and everyone,

I went for X-rays, and was thoroughly examined, here is what I have:


http://img395.imageshack.us/img395/9366/kneeye3.jpg
(this is not my leg, i borrowed it for illustration)

- My bones are starting to deteriorate in the circled area above, this is because they keep frictioning eachother, and indeed, I do feel pain in that particular area when I walk continuously for over 30 minutes.

- The doctor said that he would need to do a derotational osteotomy on both my upper bone (thigh) and lower bone (Tibia?).

- Not sure how to put this in english, but he said that normal people have a 10 to 15 (or sometimes 20) degrees rotation, but I have 40 - 45 degrees instead.

- That there is a huge risk of the bone not reuniting. Again, I'm 20, how risky it really is?

- That the recovery time if I chose to go ahead would be roughly three months. (if all goes well that is). And that he would do one leg at a time.

- The doctor said that I should try physiotherapy first, and see if it helps relief the pain. But I very much doubt it would do anything. I followed his advice and have an appointment next week for physio.


http://img396.imageshack.us/img396/221/painlo7.jpg
Green areas show pain centers when I walk for 30 minutes or stand for 1 to 1:30 hour, but pain is mostly when I try to keep my feet straight, otherwise its less, HOWEVER, if I keep my legs in their normal outwards position I lose stability, its difficult to walk in a stable way when I leave my feet in their normal malaligned position (outwards). I got used to walking the way I do (knees facing inwards, feet slightly outwards)

Despite the severity of my problem and the complications that may arise from me trying to correct it, I'm mentally all ready for an operation. Since the effect this malalignment has is beyond description. (yet I must say that when I went to orthopaedics section of the hospital, and saw other people with far worse conditions, I started to have second thoughts.. that I should just accept my leg the way it is.)
But again when a friend asks me out for a walk, or when I go out for any reason and have the pain, and feel my legs instable and going right and left.. not to mention look weird. I change my mind to 100% determined to go ahead.

Input on any of the above is greatly appreciated,
David
« Last Edit: July 12, 2007, 06:22:11 PM by dstevens »

Offline dstevens

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Re: Advice please: Miserable Malalignment
« Reply #5 on: July 18, 2007, 02:11:38 PM »
Me again

I just found out that "femoral anteversion" is another term for Miserable malalignment! .. which was helpful in finding some older posts here.. though I couldn't locate anyone similar to myself. many do have miserable malalignment, but all have had procedures I never heard of (or maybe its only the terms again?)

I would really really appreciate anyone who had derotational osteotomy as a treatment for miserable malalignment to share their experiences

Offline cat

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Re: Advice please: Miserable Malalignment
« Reply #6 on: July 18, 2007, 11:58:14 PM »
Hey and sorry for the delay in responding. I don't always check the boards and don't always get notified of posts like I used to.

Anyway, I think there are more folks with miserable malalignment than you might think. Usually kids get treated for it. ( My OS's nurse marvels that I am as old as I am and am just now having this addressed.) As adults there was/is the tendency to blame the problems on the knee joint itself and hence the many inappropriate lateral releases, medial reefings, VMO advancements, and TTTs. Only recently have I seen literature saying that torsion issues should be addressed with derotation and not a tibia tubercle transfer. Plus, there just aren't many docs out there able to do this kind of surgery. Now I get to have all the previous work undone plus a derotation. So far, it looks like I might get away with just a spinning of the femur.

Your measurement was 40-45? Was that for the femur or tibia? My OS tried to take measurements (spent 40 minutes with tracing paper and protractor overlaying CT films) and got a rough femoral measurement of 50. I'm not sure what he got for my tibias. He has to do another CT rotational study when I go back.

As for internet resources on the topic- NOT or at least very little. I ended up going to a medical library for info. Check out this post to Wolfling at http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=37771.0 I believe she's in a similar situation.  Geez, we're collecting numbers here. Almost enough to start our own twisted legs club. ;) Want to be a twister?

BTW, I got the impression that recovery would take more like a year. I think 3 mos is a bit optimistic though maybe you will be well enough to have the other leg done.

I have no opinions as to what you should have done. I'm a bit overwhelmed and wishy washy about all this myself. Add to that the fact that my insurance's typical first response to anything is, "The answer is no. Now what do you want?"  This is likely to cost me a bundle and I'm not thrilled about that.

Well, I was planning on pizza for dinner so I'm off. The kids have a way of morphing into monsters when their blood sugar gets low.
 ;D cat ;D


"Miserable malalignment"
 Lateral release, medial reefing, VMO advancement, and TTT-  3/2/04
Screw removal- 5/24/05
Cortisone injection to pes anserine- 7/27/05
Femoral derotation osteotomy, TTT revision- 10/18/07

Offline dstevens

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Re: Advice please: Miserable Malalignment
« Reply #7 on: July 20, 2007, 01:35:49 PM »
Hi cat

you will be undoing things now and have a derotation?! I have seen your album.. but the pics are a bit misleading (especially to someone like me)

Its complicated. Because that little twist at the top, makes everything below it twisted too (over the years), as all bones try to "compensate" for the big twister above them.

I wish it was as easy as just derotating the two main bones. Now that I read more about miserable malalignment, I figure that those people suffering from it (like myself, and your sweet self) will never be normal in the full sense. But again, what is normal? I hear that all people have different "twisters", we are just on the extreme side.

Offline cat

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Re: Advice please: Miserable Malalignment
« Reply #8 on: July 20, 2007, 07:54:04 PM »
Quote
but the pics are a bit misleading

Sorry, I don't understand what you mean by that. ???
"Miserable malalignment"
 Lateral release, medial reefing, VMO advancement, and TTT-  3/2/04
Screw removal- 5/24/05
Cortisone injection to pes anserine- 7/27/05
Femoral derotation osteotomy, TTT revision- 10/18/07

Offline dstevens

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Re: Advice please: Miserable Malalignment
« Reply #9 on: July 20, 2007, 11:41:13 PM »
oh. Sorry for the confusion.

I meant that they are not sequenced (as in not showing steps progressing, but random). and for someone who didnt follow (through posts), its difficult to figure out what is what (especially for someone who is not familiar with knee terms like me).

 :)