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Author Topic: High Tibial Osteotomy in 14 year old girl with varus/bowed deformity HELP!  (Read 1198 times)

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Offline abruce

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Hi:  I am the mother of a 14 year old daughter (she will be 15 in July) who has been struggling with knee problems for the past two years.  Problems started when she began distance running.  We have gone through the normal channels, did physical therapy for months, all to no avail.  Saw orthopedic surgeon who diagnosed plica syndrome and noted that she is bow legged and that this would need to be corrected (at that time she had not started menstruating, so we had to wait until now to discuss the bilateral HTOs).   She had arthroscopic surgery for the plica in September 2010, but she got no relief from the pain, so that was sort of a wasted surgery.  She is old enough now to consider HTO.

We've gotten two second opinions, both agree with our surgeon to go ahead with bilateral HTO (one leg at a time, though).  I have not been able to find anything in months of searching regarding how the recovery period is for kids.  For privacy/liability issues, doctors, hospital and physical therapists cannot give us the name of anyone to talk to who had this surgery done.  We just would like to hear how other kids' recoveries went, and if they are satisfied and happy with the outcome.  Does anyone know any kids who have had HTO?  I am desperate for information.  She cannot be physically active, and in fact cannot stay on her feet for any length of time at all.  She cannot participate in sports, she can no longer do any impact activities at all, gym class is even a trial.  Her quality of life is very poor, but I want to be sure that this is the answer.  The worst thing would be if we go ahead and put her through a year of surgeries and recovery and therapy, and she comes out of it still having knee pain.  I have seen a lot of positive posts from adults after HTO, but haven't seen anything on kids.  Any information anyone can give would be greatly appreciated!

Offline tibialpatient

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Sorry to hear that your daughter is going through this. 

I am 43 and am now going through the process.  I can share my story with you since you appear not have had had much luck elsewhere.  My condition was brought on from bowed legs, not to an extreme sense though, about 12 degrees.  I managed a very athletic existence from running, snowboarding, biking, etc. all in pretty long durations.  At about 38 I had to stop running due to pain in my knees, right mostly.  I had a meniscus repair done when I was 39 which helped the knee from "locking" up.   Like it just wouldn't go any further.  They repaired this and although the knee would not lock up, the pain just got worse over the years.  I tried the braces, ibuprofen, topical gels, and regular pain meds.  At age 42 I was having a difficult time walking more than a block or so. I just compensated by swimming, and biking, until I could not bike anymore.   

I have worn through the meniscus and cartilage on the inside of the right knee.  The outside of the knee looked in pretty good shape.

I saw three specialists prior to having my surgery, which ended up being a tibial osteotomy of the right leg with an external fixator.  If anyone is interested you can e-mail me and I'll send you a picture and an x-ray picture.  Now, the first two specialist were driven to perform a knee replacement.  The third specialist saved the day, indicating that the knee replacements would likely not work since I was over 12 degrees out and that at 43, I am a little too young to be doing something so drastic (not that what I have now isn't drastic).  He said that this procedure is so well documented and the results are so good, that he was confident that this procedure would be the best way to go.  AND... if it didn't work, the knee replacement would then be an option.  He indicated that it still may be an option in 10-15 years if the knee gave way.  I am 6’2”, about 190 and use athletics as my mental health prescription, so being sedentary is not a good thing for me.

One good advice that I took to heart was that a tibial osteotomy can be fixed.  I knee replacement is a no turning back condition as they chop a lot of bone.  Plus, technology is advancing.  Knee replacement recovery is much quicker than a tibial osteotomy.

So I opted for a tibial osteotomy with an absolutely great doctor from Stanford Medical Center.  I am at week 9.57, not that I am counting (okay I am counting, closely).  I have two external fixator rings and should have them for another 2.43 weeks (I am counting now).  GOAL:  To transfer the center of weight from the inside of the knee to the middle/outside of the knee where the knee is still good.  You can only do this by moving the foot to the outside, but reshaping the tibia.  Okay, breaking the tibia.  You will gain length in the tibia in the process (in my case about 10mm).

The surgery is quite simple, the installation of the fixator rings is an art, along with the pins.  The two rings are approximately 9” in diameter.  They are spaced roughly 6 inches apart.  Each ring is pinned (screwed) to your tibia.  One ring is pinned to the lower half of the tibia, and one to the upper half, which is within a few inches from the actual knee joint (just at the thicker part of the tibia as it comes up).  In between the rings are six bars that have a turnbuckle on them.  This allows the patient to adjust the distance and angle between the rings.  Each turnbuckle is at an angle, allowing for better adjustments.

So the procedure starts with simply cutting the tibia, installing the rings, pins, and turnbuckles.  This is where your surgeon makes or breaks the results.  This is the starting point.  You will not start adjusting until Day 7 or so.  So the leg is pretty much in the same position as when you went into the hospital.

The surgeon, utilizing a computer and calculation, knows the angle of each turnbuckle, separation, and rings and then calculates how each adjustment is to be made to each turnbuckle at what time and for how long.  So the rings start off at an angle and then he tells you at the end they will be perfectly parallel, which they did after 5 weeks!

So, in my case I had to adjust three turnbuckles, either 0 mm or 1 mm each day.  So 1, 2 and 3.  Then next day I would do 4, 5 and 6.  One in the morning, one at noon, and one at night.  They do this so that they “trick” the bone into thinking it is healing so that it continues to grow.  When you straighten out your leg, you create quite the gap in between the two bones which needs to be filled by new bone and cannot be done by simply setting it the first time.  Additionally, the top of the tibia really doesn’t move all that much in one plane as that would defeat the purpose of leaving the knee alone.  Remember the outside of the knee is fine so they want to utilize the current structure and position of the knee, just not the tibia and foot.

I was in the hospital for 2 days.   Here is the part you asked about, the recovery. 

The first day in the hospital was the hospital, uncomfortable.  I am used to surgery from other accidents to my shoulder, a splenectomy from a snowboard accident, etc.  The second day of the hospital I had a more difficult time in controlling the pain as the first day was a drip.  But, we got in under control before I left after the second day.  Two nights and three days at the hospital.  I did get up and try to move around the hospital a couple of times with an assistant.  This is really essential for your recovery.  Staying in one place simply slows the healing process, in my opinion.

The first two weeks at home you need constant support as you cannot fend for yourself.  I would suggest getting a walker for those trips from the bedroom to the bathroom to make it easy on yourself.  Pain medication is an evil requirement.  I say evil, because it was very difficult coming off of it at week 7.  I will not lie, the first several weeks were very uncomfortable for me.  The pain, although managed, was difficult and the medications make you sleepy but at night you can’t sleep soundly.  Some sleep medication was helpful which allowed at least a 4 hour sleep window.   Use lots of pillows and try to rest the fixator against a pillow to one side or the other.  Keep elevated if you can.  If you are a stomach sleeper or side sleeper, you’re doomed for awhile.  IT DOES GET BETTER though.   When showering, get a garbage bag with the pull strings, cut a hole in the bottom, and slip it on your leg.  Just at the knee cap, tie the strings tightly.  The most comfort I was able to get was in the shower.  Put a chair in the shower in a place that you can elevate your leg.  Then take a shower sitting down with your leg elevated as so that water does not get inside your bag.  As soon as my pin sites were healthy enough, I was able to take a shower with no problems.  Since you adjust for about 4-5 weeks, your bone really never heals.  This made my process very uncomfortable since I needed to get back to work and mentally I needed to move around as much as possible.  I constantly found myself having to lie down, pushing myself too hard, and generally frustrated with the process.  But, that is what this is about.  No pain, no gain.

Until about week 6, it takes awhile to sit down, dry off your apparatus, put cream on, gauze pads, and then get ready for work (say 30 minutes are so additional time).  CAREFUL NOT TO SLIP on anything.  After week 6, it was simply drying off the fixators and continue as normal, albiet hopping and sliding a lot.

CRUTCHES… WARNING!  Crutches on stairs are evil.  I am quite experienced with crutches and had a tremendous fall on my 5th week.  I was rushing to find a jacket for my son, we were late for school, and I was coming down the stair in a hurry, using my crutches.  My crutch got stuck on the step below and since I was moving forward, my crutch catapulted my over the next 4 stairs onto the stone floor.  I bruised some other bones and banged the fixator on the floor, which then went to my already very sore tibia.  I had it checked out on that following Monday (since it was a Friday), and all was well.  What a scare though.  Be careful on any downhill, use the railings and one crutch, not two and be very careful for slippery surfaces.

By week 4 I was able to go back to work for a couple hours a day. By week 5, 3-4 hours per day, and by week 6-7 about 4-5 hours per day.  I started driving about week 4, but only for short periods of time as the pain created was not worth the driving, but at least I managed to get to work occasionally.  Pain medication was still necessary for me.  Up until week 6 I really was uncomfortable, probably because I was utilizing my leg a lot more with my crutches, trying to get weight on it.  The doctor will continue to tell you to get weight on it SO that the bone heals, and it really does help with swelling, up until you aggravate it.  I even called the doctor and asked if my progress was going slowly as I really thought I would be off the crutches, and he said “absolutely not”.  He warned me it would be tough.  It is a catch 22 though, the more weight the less swelling, the greater the pain.  He said just do as much as you can, not more.  So… I continued with the crutches.  I did get rid of my walker by week 6 as I was able to hobble around the bedroom without it by then.

Okay, week 7 – WARNING!  Drugs can be evil.  I really needed to take my medication but found that I was just fed up with them and thought I was at a point where I could manage the pain with plain tylenol.  I was always tired, kind of unreality struck, couldn’t sleep well at night, mentally exhausted, and the list goes on.  So… that Sunday, I went “cold turkey”.  Got a cold on Monday, in bed on Tuesday with the flu (friends tell me it was the withdrawl from the oxi and hydrocodone), Wednesday, just watching the minutes go by in absolute misery.  Did a half day of work on Thursday and Friday, and didn’t feel like any sort of husband, father until Saturday.  By the following Sunday I was 90% recovered.  The following week I could put full days in at the office, make progress on the stack of work that I had put-off, etc..  What a difference a week makes.  Now I would say that mentally I am 95% recovered.

But, even at week 9.57 I can quickly, but feebly limp around the house without my crutches, but at least I can put my full weight on it if I put my mind to it.  Still on crutches for the walks greater than 10 yards or so, but a limp around in the house just fine without the crutches.  Still find myself having to lie down on occasion after being up and doing chores around the house to the best of my ability.

Sleeping at week 9.57 is doable.  Putting a healthy pillow between the legs and sleeping on my left side is very manageable.  Sleeping on the right side is a little more acrobatic but it can be done.  No stomach sleeping as of yet.  I have found a way to ride my bike short distances and on the flats.  I am sure that my doctor would raise an eyebrow or two, but it really helps my well-being.  No swimming yet as I am still worried about getting from the locker room to the pool safely and without too much notice.  Plus, I think that the fixator would sink a lot and not sure on how I would hold up with the kicking part.

PANTS – HINT!  I could not imagine what people do without a custom pair of pants.  I had two pairs made, both jeans, one light and one dark.  They have a zipper from the cuff to the belt line.  There is an added triangular pleat so that it can fit around the fixator, think 70’s style on one leg.  This works amazing and allows me to be publicly presentable in most situations (even a black tie dinner I went to).  Plus, it protects it and keeps the gawking down to a minimum.  I had mine made by a person who was recommended by one of the physicians.  It was not cheap though, about 150 per pants.  If you know someone good with the sewing machine they could probably do it for you.  The biggest thing is making sure you have enough room to slip the fixator in the pant between the crotch and wasteline.  This just fits through my pants (I’m a 34 / 34 in jeans).  Otherwise, I hope you like shorts and sweatpants (with one leg).  You can also get a cover for the fixator for outside.  This is a good idea to keep the dirt and gawkers off your leg.

Anyway, hope all the helps.  To anyone.