PKR or Osteotomy???? What are the pros/cons?

[AlaskaMagnum]

I have a choice of PKR or Osteotomy.  Medial compartment is destroyed on my right knee, no meniscus and a pretty good lesion.  I have severe bone on bone (but no pain).  I am ACL deficient in that knee and the LCL is getting stretched due to the vagus position.  One ortho surgeon wants to do a PKR, but I am only 38.  He also mentioned osteotomy but tried to talk me out of it, stating the drawbacks.  The ortho is tied to the prothesis company to some degree, and all he really does is PKR or TKR for knees.  So I was wondering if anyone would or could explain the benefits of osteotomy over PKR.  ARe there any?

[crankerchick]

Wow sorry to hear about your situation! That is quite a bit.

What kind of activities are you hoping to return to?

Are you able to get a second opinion?

There are more seasoned arthritis vets here than me, but I think the general trend is if the lateral compartment is in good enough shape, then the osteotomy makes more sense. But then, I don't know how the acl dificiency fits into the mix. Is your cartilage wear due to the lack of ACL? Is your knee "loose"?

[AlaskaMagnum]

No,

My knee is not "loose", there is very little difference between the good knee and the bad knee.  I damaged the ACL playing football in high school and had most of my meniscus removed, and fifteen years later had an ACL implanted, but it failed after a few years.  Truth be told, I was a powerlifter for many years, with 600-lb squats, my extreme musculature probably adds stability to my knee.  Even today, I have very little to no pain, even though my x-rays look horrible.  About the only actiivity I will not do any longer is to sprint, and not because of pain, but because I fear what running full out might do to my knee.

My lateral side and patella are still very good, hence the osteotomy as a potential option.  If the answer is a PKR, I will not do it until the pain makes me do it, which could be days, or years, or maybe never.   If an osteotomy is the answer, it might be time to do it as a preventative measure, I am not sure.

[OrthoRep]

Sounds like you have a similar situation to mine except I do have pain.  I have pretty much no meniscus left on the medial side after 3 surgeries and have grade 3 arthritis at age 36.  Definitely staying strong and in shape helps out a lot.  My doc said if I wasn't in the shape I'm in I would be in a lot more pain more often.  Both procedures have pros and cons, but you need to ultimately look at what your activity level is and what your expectations are.  After a PKR you will be able to weight bear right away and an HTO will leave you on crutches for 8-12wks.  People do very well with both surgeries.  PKR will last as long as you take care of it.  You have metal and plastic that gets cemented into your knee, so pounding on it running or playing sports will likely reduce the life of the implant.  PKR is a very successful procedure and will last 10-20 years in the right patient, but in my opinion is not a good fit for me personally at 36.  The only way I'm sacrificing my bone and putting in a metal implant at my age is if I have exhausted all other options and the pain is that bad.  HTO has it's place, but as you know is a brutal procedure to recover from.  You will be non weight bearing for a while and from what I understand it's a longer road to recovery.  The positive side of things is that you get to keep more of your own bone for longer while technology improves.  You never know what will be available in 5-10 years to repair the articular surface.  Not so long ago carticel and meniscal transplant was just an idea.  Now many dr's perform these procedures on a regular basis, so I'm sure there will be a better solution at some point down the road.  Hopefully we will be able to take advantage of newer technologies one day.  Since you are not really having pain I would not jump into any surgery.  Get as many opinions from as many docs as possible and make sure they are docs that specialize in joint preservation and take your expectations and lifestyle into consideration.  I have learned over the years that not all doctors will have the same approach to the same problem.  One may say PKR because they did a fellowship in joint replacement and that's mostly what they do.  Another may say carticel with an HTO because they studied cartilage repair and preservation.  One surgery may be better than the other for one patient, but not for another.  I hope I didn't confuse you too much with all this.  Good luck.

[nosurrender]

Hi, this is my first posting although I've been following many of the threads here since I started having arthritis problems with my knees.  Some history, I'm 52 and have been very active my whole life; alpine and back-country skiing, surfing, back packing, soccer, mtn biking etc.  Two years ago my knees began to hurt to the point where I had to curtail basically all of these activities although I still work out in the gym and can do some easy surfing.  I had meniscus surgery when I was in my late teens and again when I was 22. Back in the day of open surgery.  I also damaged my left ACL when I was 22 but opted out of surgery and was able to stabilize the knee with disciplined regiment of knee excercises.

Forward to the present.  As a result of the meniscus surgeries years ago I know have stage 4 bone on bone arthritis in both my left and right lateral compartments.  My medial and center compartments are fine.  Just 4 weeks ago I had the ACL that I damaged years ago replaced with an allograft.  The knee was just getting too loose and excaberating the arthritis pain.  My future options appear, in both legs, either an osteotmy or PKR.

I was told that in either case the ACL needed fixing to stabilize the knee, so that was step one.  Once I fully recover I'll make a decision on the next step.  The ostetomy sounds brutal but is saves the joint.  Once you start messing with the joint there is no going back but the downtime and recovery is easier than an osteotomy.  Really tough choices. If it was me and I didn't have pain I wouldn't do anything except keep the knee strong.  There is a Dr Bugbee at Scripps in San Diego who is well known and REALLY good.  You might want to check with him about your options.  Definietly get one or more opinions.  I've had opinons from oh yeah your an excellent candidate for a knee replacement to statements like it would be malpractice if I replaced your knee.  Go figure.  I would also delay as much as you can to see what evolves with stem cell research.  Keep us posted.

[mmrocker13]

I will throw in here...

I am 33, and my first bout with a partial meniscectomy and full-thickness defect came when I was 12. As of last year, my femoral condyle was largely denuded; my tibial plateau was about 30-40% full thickness defect, and I lacked my meniscus (they had removed the last of it).

I had pain, but nothing I couldn't live with--it had been there for long enough I was used to it. However, the degeneration was spreading rapidly, and if I wanted to preserve the joint space--AND I wanted to continue with sports--I needed an osteotomy sooner rather than later.

Mine was a femoral osteotomy, (which traditionally has a longer and more intensive rehab than tibial, for a variety of reasons) as my lesions were lateral and a DFO has a good success rate for lateral (open wedge).

The rehab has not been that bad, truthfully. And I was never in much pain from the osteotomy. I was off pain meds within a couple days. My issue came b/c I managed to break my femur on the medial side (supracondylar femoral fracture)...which hampered my recovery--and that DID hurt.

Had I not had the second break, I would likely have been off crutches a while ago.

I don't want to downplay the procedure--it is very involved, and the risk for complications is much higher than an arthroscopy. And teh rehab and time on crutches is long (even if you heal properly) and inconvenient, and it is BORING as all get out. BUT...if you are active, and used to being patient with rehab and have a decent pain threshold (as most athletes do), it really isn't bad. I was suprised, actually.

[nosurrender]

Thanks for the info mmrocker13.  A DFO is what my OS has put in front of me as an option. How are you doing now and how did you break your leg.  What is the average rehab ime for a DFO?  What sports do you hope to get back to after the DFO.  It seems like the best course for me but I have to admit that it scares me and I'm afraid of the toll that the down time will take on my family.  Particularly if I need a DFO in both legs.  Should I even ask if you can have the procedure done in both legs at the same time.

[mmrocker13]

Thanks for the info mmrocker13.  A DFO is what my OS has put in front of me as an option. How are you doing now and how did you break your leg.  What is the average rehab ime for a DFO?  What sports do you hope to get back to after the DFO.  It seems like the best course for me but I have to admit that it scares me and I'm afraid of the toll that the down time will take on my family.  Particularly if I need a DFO in both legs.  Should I even ask if you can have the procedure done in both legs at the same time.

Take a look at both my and tailwind's diaries, and aturpin's, as well...we all had DFOs  (there are lots of types of osteotomies, and lots of reasons to have them). It will give you an idea of how varied the recoveries can be, and even how the procedure and rehab protocols will differ from person to person and surgeon to surgeon.

CAN you do both at once? I imagine you may find someone to do that...but I personally wouldn't. You would most likely be on crutches 6-8 weeks, at least--so wheelchair bound, if you did both. And then you'd lose strength in both legs, making rehab really difficult. Not to mention it's a lot to ask your body to repair all at once. Plus, there's a learning curve--the firt weeks you are figuring out how to renegotiate life, after that, things get smoother. Your second procedure would likely be a bit easier in terms of navigating around stuff.

I am married, and we have two dogs and three cats, but no kids. I won't lie, there IS a substantial burden placed on your significant other--cooking, cleaning, dog poop patrol, ferrying you about, helping you shower, going to the store, etc etc. Some of that abates as you become more self-sufficient...but that could be in two or three weeks...or eight to ten, if something happens.

I was fortunate to be able to work from home--which I did until up to this week (I am at 10.5 weeks out). COULD I have gone back earlier? Maybe. Desk jobs are def. easier. But I am glad I didn't have to (largely though b/c of my building and work environment, not b/c of pain issues or anything).

I broke my leg (the second time) when I bent forward to put on a sock, and the stress caused a crack to develop out from the osteotomy site. It travelled across to the medial side of the bone, and up, breaking off a fragment about an inch long. Because that side was unstable (for several reasons, we elected not to have another surgery to pin it), I was put on bed rest for about 8 weeks total. That's where virtually all of my pain came from, and it is the reason I am still on crutches and will be for another 4-8 weeks.

BUT...as far as complications go, it is VERY rare. Totally unexpected. And really, aside form a longer rehab, relatively benign. It didn't endanger the osteotomy at all (provided it didn't shift--which is why the bed rest), nor did it hurt the nerves/tendons/ligaments/etc. or cause a clot or make the hardware fail. In other words, it was a freak occurrence, and not something that you'd even think about happening (and I thought about ALL the possible complications...and looked at full color photos. That will make your hair curl, trust me :p).

The two most painful things that have happened this entire time were the second break, and when I broke my toe this week. I s**t you not. Had those two not happened, I would have said my partial menisectomies and chondroplasties and coming back from them was far, far more painful and difficult. Right now, I have a twig for a leg, but my ROM came back easily, and is actually probably better now (about 130) than it was before surgery.

Tailwind is at about 8 or 9 months, I think, and aturpin well over a year...so they can both address the later stages of recovery. (Check their journals...you'll see as folks get better, they post less and less :p)

If you look me up on facebook (megan rocker), you can see pictures of my incision site, post op xrays, etc. I also have a blog (although most of the pics and info there are on here and/or facebook).

As for my sports of choice, I am a triathlete more than anything else. I grew up a runner, and did that all through school, college, and after. I switched to tris following my microfracture in 2002, in order to cut down on my distance and days per week of running. I am starting back in the pool and on the bike now (in VERY baby steps), even though I'm still in the brace and on crutches. I hope to be riding outside and at a relatively normal intensity by late summer (and have a mountain bike race on the calendar for end of September, if I can swing it). I will not try land running again until probably next winter/spring. So, at least 12-16 months post op.

Feel free to PM/e-mail me if you have any specific questions. I also have a ton of journal articles about the procedure, if you're interested. They are on my work computer, but I can send them to you on Monday, if you want. Frankly, I've found that education is THE best thing you can have. Know what yoru options are, and what the options within the options are. It not only helps you understand exactly what is happening and what your prognosis would be in a variety of situations, but it also helps you select a surgeon or surgeons and a PT to meet your needs.

[crankerchick]

Thanks megan and everyone else for chiming in. I had a different kind of osteotomy than for arthritis, but I wanted to try to help with what I knew and hoped other more experienced with this type of osteotomy would chime in.

I can't imagine doing 2 legs at once, regardless of type. Mine has been a long recovery with just one leg, but 3 osteotomies on the one leg. Both legs would most certainly mean a wheelchair which is a pain. I was fortunate to have my retired in laws to help so the burden wasn't all on my husband. Its just a lot to endure and can't imagine have both legs at once!

[nosurrender]

Yeah, kind of sounds like I expected, doing a double osteotomy is a non starter.
Megan, thanks for all of the excellent information.
I agree 100% with you that education is absolutely necessary.  I can't imagine going into surgery without understanding all of the options and variations. It's not that surgeons or doctors are bad its just that they are people and have their own opinions and biases on how to approach things.

[nosurrender]

Forgot to ask, does anyone have an understanding of how well a lateral compartment partial knee replacement works.  in particular I've been told by my OS that the Arthrosurface  resurfacing technology enables one to continue with an active life style.  I've never spoke with anyone that has had the procedure so I'm not sure iwhat to make of my OS's comments

[mmrocker13]

Forgot to ask, does anyone have an understanding of how well a lateral compartment partial knee replacement works.  in particular I've been told by my OS that the Arthrosurface  resurfacing technology enables one to continue with an active life style.  I've never spoke with anyone that has had the procedure so I'm not sure iwhat to make of my OS's comments

My surgeons have indicated that the progression for me is: DFO, arthrosurface, PKR

I def. think that arthorsurface is a better option than traditional PKR, as it maintains your bone and joint (as much as possible). In other words, it doesn't burn any bridges, and leaves the door open for additional procedures.

Depending on which procedure you'd need, not all of the HemiCaps are widely avaiilable in the US. The Femoral Condyle implant is available internationally, but still undergoing clinical trials, I believe, here in the U.S. (or at least it was when I last checked a couple of months ago).

[aturpin]

Just thought I'd chime in here and try to lend my experience to a couple of questions floating around here.  I am 1 year and 4 months post-op from DFO.  Cartilage - Down to the bone on the femoral condyle, still some cartilage remaining on the tibial plateau.  My course of treatment was to have the DFO and then allograft transplant on the lateral condyle a year later.  After reaching one year post-op mark, we MRI'd the knee and found I was growing my own fibrocartilage (the same cartilage you grow after microfracture procedure).  This can be a pleasant side effect of unloading the injured area via DFO.  So, we have postponed the allograft procedure until I either show I am wearing through the new cartilage on my lateral condyle or I it becomes painful and burdensome.

As of right now, I am doing great.  Back to normal activities of daily living and back to pretty much everything I was doing before surgery.  I dont run or do plyometrics because I don't think its prudent; I know what its like to have a bum knee and I want to make mine last as long as conceivably possible...minimize the number of time I have to go through this.  However, I have done some running to the car when its cold or if Im in a hurry and running is no problem (the physical act of it, dont know how much it would hurt the knee if it was prolonged). I also am doing P90X now for those of you that have seen the commercials.  It calls for a lot of lunges, and some bouncing around... I feel like this has really helped improve my strength and my agility with the subject leg.  I wouldnt recommend for anyone under a year post-op.

Anyway, as to the question about PKR vs. DFO/HTO.  I have had a great result from DFO and recommend it highly.  I think the longer you can hold on to your own parts, the better.  DFO can prolong this.  I also agree with the poster who mentioned the emergence of new technologies and the impact that could have on protocol for these types of injuries going forward.  It would be great to be in a position to take advantage of a new procedure; once you do the PKR, I dont think that is a bell you can unring. Yes, the procedure is invasive and the recovery is long, but, I think the upside warrants the procedure.  Others who have had less successful procedures would likely disagree.  Much of this decision is personal and individually unique. Additionally, I think doctors have specialties and tend to make recommendations in line with what they know. I would suggest getting a second opinion from a more objective doctor who can give you a less biased opinon on your options.  Someone also mentioned Dr. Bugbee at Scripps Clinic in San Diego... he was my doctor and he is a flat out stud. Well published, extremely experienced, on the leading edge of this procedure. Id recommend him in heart beat.

My diary goes into pretty good detail about the recovery time and process. In summary, the pain isnt as bad as I expected.  The first month or two are the hardest. I started to really feel like myself again around the 6 month mark but have really good progress and gains around 4 months. At one year I felt back to my old self so to speak.  However, I dont think ever quite be the same, which is to be expected from any surgery and especially one of this magnitude. I am doing great now, no complications, much relief from pre-op situation, no problems with hardware, cant complain. Its definitely a scary procedure when you are on the front side considering your options.... In hindsight, it wasnt so bad and definitely gave me a longer leash on activiities and lengthened the horizon for future procedures.

[AlaskaMagnum]

Thanks for the info.  I am definatley going to go for the osteotomy after reading this and doing more research.  I am simply too young and too active to do a PKR.  Plus it looks like the open wedge HTO leaves all options on the table.  I also read where the new HTO in conjuction with microfracture or ACI are looking to potentially keep the TKR at bay for decades to indefinite, and THAT sounds good.  I made an appointment with Dr. Cole at Rush hospital next month, so we will see how things shake out.

[simondelalto]

FINALLY!! I have been looking everywhere on the web for a testimony on knock knee correction! I am a 19 yr old, 6'4" male with a (what i consider) mild case of genu valgum. I do have knee pain everyday and I feel that surgery will really help, however, I am worried about the price and results. I have begged my parents to take me to see a Dr. but they always tell me my legs are fine and that its all in my head, but I know that the longer I wait the worse they will get. So for now all I can do is research to inform myself on my options. If you don't mind, may I ask you how much you paid for the procedure? How "back to normal' is your life now after the surgery? I am a very active person, (sports, run/walking, and a lot of dancing) so I am worry I will not be the same afterwords. Please, if you don't mind answering these questions. I will REALLY REALLY appreciate it.

Thank You,
Simon