revised osteotomy in prep for kneecap replacement? WWYD?

[sinequanonsarah]

I had a follow up appointment after my MRI today. There is a longer thread with my background and symptoms https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=79151.0 but short story is this:
I'm 39, have a long history of maltracking issues. I'm at a point where only options for dealing with pain and loss of function are surgical. Until my appointment today we thought the option going forward would be a partial replacement of the patelofemoral joint. However, MRI indicates that, despite an osteotomy designed to address this 20 years ago, my kneecap is still subluxing pretty severely, to the point that it isn't close enough to the groove in the femur to make the PF replacement viable. Awesome.
I was presented with 2 options:

1) make the PF replacement viable by doing a revision of the high tibial osteotomy. The idea here is that there would be 2 surgeries in succession: the first would be the HTO, in an effort to realign the bones in a way that facilitates better patella tracking. The second would be the kneecap replacement. These would likely be done in succession and not all at once, so the recovery time would be... oof.

2) move ahead with a full replacement instead. The concern here is that, well, I'm 39, and full replacements can come with their own sets of issues. The replacement would last until I'm... 60 or 70? So I'd need at least 1 revision.

Additionally, the surgeon said that, regardless, I would likely need a full replacement in 10 - 15 years.

What would you do in this situation? Thoughts?

[Brandon123]

Not an easy choice. But alternative 1 at least keeps the option open for alternative 2 down the road. Which is not the case the other way around. If you get 15 years out of the PF replacement, which I think is fully possible, you'll be around 55 when you need a full replacement. At that point, hopefully, materials etc. have improved to the extent that your full replacement could last for the rest of your life. You should probably factor in that recovery time for a full replacement is much longer than a PF replacement. So the recovery time all in all might not be thaaat much longer for alt 1 than a full replacment. 

[A_sure_sky]

I don't envy your choices at all.  For option 1, how long does it take to recover from both surgeries and, if all goes well, what will your knee allow you to do?  Have you looked into what are the success rates of the surgeries in option 1? 

I wanted to avoid a knee replacement myself and I am over a decade older than you so I certainly understand your hesitancy to avoid that surgery.  Best wishes.

[Dave33]

Woof, that's a tough one. I've had tibial osteotomies in both knees prior to my replacements, but more as a treatment option as opposed to a combination approach.

I guess I'd look at several factors:
1) How does the rest of your knee compartments present currently apart from kneecap? Any wear?
2) Does the added complexity of the osteotomies affect the likelihood of success of the PFJR?

Obviously, it would be better to spare as much bone and healthy tissue as possible, especially at a young age, and a PFJR is going to preserve a massive portion of your natural knee. But I'd want to feel confident from the surgeon regarding the two factors above.

Best of luck.