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Author Topic: Looking for information on Tibial Osteotomy  (Read 1307 times)

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Raffy693

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Looking for information on Tibial Osteotomy
« on: April 04, 2012, 08:24:17 AM »
Hello, I'm new to this website and hoping to find some information about a possible Tibial Osteotomy.

Currently, I'm 18 years old and I have been having left knee pain for the past three years. I was an active skier and dancer but now that I am in school my activities have decreased significantly, however my pain has not. Over the past three years I have spent an extreme amount of time in physical therapy, seen countless specialists, and done every treatment possible with no relief. My primary problem is Medial subluxation and lax ligaments. I have never had surgery. This past July I was offered a procedure called a "Lateral Release" but decided against is because I thought it would cause a "Floating Kneecap" and cause more problems due to the fact that I have lax ligaments on my medial side.

Recently, my newest surgeon briefly talked about a Tibial Osteotomy. He said that the realignment would take the stress off of my knee and result in less pain. I will not see him again until June. It is also dependent on my Vitamin D levels increasing, due to the fact that they are very low. If my levels increase we'll talk about surgery. Now, I am all for surgery. I have no fears of surgical procedures, at this point it is the only thing I haven't tried and I am all for it. However, that being said I am hoping to gather some information about the procedure and recovery of a Tibial Osteotomy. Nothing is set in stone and there is no guarantee this will happen yet but I would like to be prepared with some information beforehand.

Thanks!
 
« Last Edit: April 17, 2012, 04:53:16 PM by Raffy693 »

Offline WonkeyDonkey

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Re: Looking for information on Tibial Osteotomy
« Reply #1 on: April 04, 2012, 01:46:26 PM »
Hi Kaitlyn

I had a HTO in November, and although it is a long recovery, so far I have felt the benefits of it. There is a osteotomy course on here, link below:

http://www.kneeguru.co.uk/KNEEnotes/node/559

If you further details, you can look at my post op diary, again link below:

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=58048.0;all

If you have any questions please feel free to email me.

WD

Raffy693

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Re: Looking for information on Tibial Osteotomy
« Reply #2 on: April 06, 2012, 01:34:45 AM »
Thanks so much! I read your post-op diary, it was very helpful and it really gave me an indication of what to expect... I appreciate you taking the time to record your progress!

Hopefully everything goes as planned and I will be offered this procedure, but only time will tell. I wish you luck as you continue to recover  :)

Offline lululocket

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Re: Looking for information on Tibial Osteotomy
« Reply #3 on: April 06, 2012, 03:56:23 PM »
Hi Kaitlyn,

I've just had an osteotomy on my second leg, as I had similar issues with sublaxations. The good news about lax ligaments is that you are less likely to snap any and need reconstructions! Haha, seriously sometimes we need those silver linings. Mine have so far been great though, my knee is unrecognisable from before. Good enough to go back for seconds!

The osteotomy course linked to is essential reading before you make a decision. Take a pen and paper with all of your questions written down, and make sure to ask your surgeon
-   how often he performs this surgery (because you want somebody who has practised it lots of times)
-   what the indications are that are making him recommend it (e.g. high or low patella/what is the groove like/how far displaced is the patella in mm etc) so that you really understand what the problem is which causes sublaxations and how the op would help. There are lots of variations in osteotomies, so you want to understand your knee.
-   what the downsides and risks are (you'll probably never kneel again afterwards, and my version gives an increased risk of arthritis)
-   if you are old enough (have your bones stopped growing - my OS waits until patients are 21).

I've also got a post-op diary going - here
http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=58973.0

Let us know of any more questions,
Lulu
2003 RK dislocation
multiple sublaxations (10+), both knees
2007 LK dislocation
03/2010 TTT on RK
03/2012 TTT on LK

Offline crankerchick

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Re: Looking for information on Tibial Osteotomy
« Reply #4 on: April 06, 2012, 08:30:46 PM »
What type of tibial osteotomy? There are a variety of osteotomies that could be done on the tibia, each addressing a different kind of problem. The osteotomy you are describing sounds more like the type to unload one of the compartments of the knee in the case of arthritis, while the symptoms you describer are more consistent with patellofemoral pain and instability. With the information provided, it sounds like the surgery doesn't match the symptoms. Can you provide any more information on what type of osteotomy your doc is referring to? What type of medical imaging have you had so far?

I had a type of tibial osteotomy that is different from the HTOs mentioned previously. I think in general the recovery is pretty similar among them is more dependent on the doctor and his/her protocol rather than the type of osteotomy.
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Raffy693

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Re: Looking for information on Tibial Osteotomy
« Reply #5 on: April 09, 2012, 01:28:50 AM »
Lulu - Thanks for the advice! I will be sure to keep those questions in mind... I still have a while to go before I even see my doctor again to discuss possible options of what to do, this was just mentioned briefly and I wanted to be prepared for the next time I see him. You're right about the lax ligaments too! My MCL has been very fortunate in that any small tear has been fixed by Prolotherapy. I appreciate you letting me know about the kneeling thing too, I'm only 18 so that is definitely something to think/ask about! I also hope your recovery is going well :)

Crankerchick - No, my doctor did not mention what type... he just briefly mentioned it as a possibility, but I can't do anything until my Vitamin D levels go up significantly. He did mention however that his purpose in the operation would be to cut a piece of my Tibia out and realign my patella. He said the ideal result of this would be to take the stress off of my joint so that the pain decreases. There is definite instability on the medial side of my knee, which is why I opted out of the lateral release. Most of my doctors have explained that it is because of my dance background and lax ligaments. As for patellofemoral, that was my initial diagnosis nearly 3 years ago. However, recently my doctors have been straying away from it due to the fact that I have plenty of muscle built from physical therapy among the other physical exams that have been performed. As for imaging studies I have had basically everything, x-ray's (including a full leg image), MRI's, CT-Scan's, and Ultrasound's. The full leg x-ray showed what I believe he called "bowed leg's". Regular x-ray's show that my patella is set higher than necessary, although it is not by any means extreme. The MRI's generally have the same consensus, as well a some chondromalacia. As for possible arthritis, I test positive for RA but after extensive blood work it has been ruled a false positive due to lyme disease. Although my knees do have the popping, clicking, and grinding there is never any swelling or stiffness so my doctor's don't believe I have arthritis...
« Last Edit: April 10, 2012, 05:38:03 AM by Raffy693 »

Offline crankerchick

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Re: Looking for information on Tibial Osteotomy
« Reply #6 on: April 10, 2012, 04:11:18 PM »
Ah well, it sounds like the tibial osteotomy being referenced is a TTT. There are still a variety of TTTs that can be done, but the most common one (note I said most commonly done, not necessarily most commonly indicated) is the Fulkerson TTT. The procedure is moving the shingle of bone where the patellar tendon attaches to the tibia to a more medial and often anterior location on the tibia to realign the patella. If you do pursue that surgery further, be sure you know what type of TTT specifically and be sure you are aware of when the particular TTT being offered is indicated. Every knee is different and there are indeed tests and measurements that the experts use as guidelines for surgical indicators. The accepted indicate for the Fulkerson TTT is a TT-TG greater than 20mm. Be sure to ask your doctor what your TT-TG is if you decide to pursue that topic further.

It sounds like you had a full leg, standing x-ray, is that correct? As in, an x-ray showing your entire leg from hip to ankle? That's good, if so. If it showed a bowed leg, then that is something that needs to be taken into account in the surgical recommendations. Sometimes doctors ignore the obvious problems for whatever reasons, and stick to the surgeries they prefer, so just make sure that you understand what your doctor says is going on in your legs and be sure that what they propose to fix makes sense and is applicable to your situation.

I wonder if your CT scan included a full rotational study of the legs. This is something to also ask your doctor and be sure that you have had before going down the surgery path.

If you are experiencing medial instability, it is kind of shocking that either a lateral release or a TTT (if indeed a Fulkerson TTT) was even mentioned. Lateral release has no place in an unstable knee ever, and further more, definitely no place in a medially unstable knee--that doesn't even make any sense. The TTT also doesn't really sound logical since if the patella is moving medially, why would it make sense to move it even more medially? That is of course predicated on the assumption that he does indeed mean the Fulkerson TTT.

I would proceed very cautiously with the little bit of surgical talk mentioned so far. Medial instability is a big deal and can often be brought on and/or exacerbated with the common patellofemoral procedures you've mentioned so far.
« Last Edit: April 10, 2012, 04:13:26 PM by crankerchick »
Mar '07 - plica excision
Oct '09 - femoral + tibial derotational osteotomy & TTT
Aug '10 - hardware removal
"You control your leg. Don't let it control you." -Smart trainer
"Get your a$$ in gear and go for it! Nothing will happen until you make it!" -Smart doctor

Raffy693

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Re: Looking for information on Tibial Osteotomy
« Reply #7 on: April 11, 2012, 04:46:04 AM »
First off, I really really appreciate all of the great information you're giving me! So thank you very much for sharing!

As for the Fulkerson TTT, I think he may have been referencing this for the following reasons... I believe the problem my surgeon is having is that the pain is not the same with every activity. For example, when I dance, walk at an incline, or sit the medial side hurts. When I walk on a flat surface or stand at work the pain comes from the lateral side quite literally where my tibia connects to the patella. When I'm skiing, the majority of the pain is in the patella tendon area. As a result of this, I think my surgeon is trying to fix the problem that affects what I want to continue doing that I currently cannot, which is to ski and walk my dog. This being said, I don't think the medial side is his priority but more the patella tendon and tibia. Up until this point the medial side was my concern because I was a dancer, but now that I am in college and working towards a career, dance is not a priority. However, I have been fortunate enough that my knee does not dislocate and with procedures like the Fulkerson and Lateral Release I fear it will.

Yes, the full leg x-ray is the most recent scan and the first one of its kind, so there is nothing to compare it to... I only say this because I'm not sure if bowed legs become worse with time or not.

Offline lululocket

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Re: Looking for information on Tibial Osteotomy
« Reply #8 on: April 11, 2012, 10:34:54 AM »
Hmm there is a bit of confusion going on I think. In your first post you said "my primary problem is Medial subluxation and lax ligaments". Sublaxation is where the patella moves sideways towards the edge of the groove it sits in (not quite far enough to dislocate). Medial sublaxation means the kneecap slides sideways towards the middle of your body (i.e. towards the other leg). This is less common - more people sublax/dislocate laterally where the kneecap goes away from the midline of your body.

Crankerchick's point is that if your kneecap really is going inwards, you don't want to pull the tibial tubercle even further in with a fulkerson, and you don't want to loosen the outside muscles with a lateral release.

However, you're talking about where the pain is, not where the kneecap slides.

Do your medical notes say medial sublaxation?
2003 RK dislocation
multiple sublaxations (10+), both knees
2007 LK dislocation
03/2010 TTT on RK
03/2012 TTT on LK

Raffy693

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Re: Looking for information on Tibial Osteotomy
« Reply #9 on: April 12, 2012, 02:27:38 AM »
Yes, I realize what I'm saying does cause confusion because there are so many things going. Regardless, I do mean medial subluxation. I am aware that it is significantly less common, but I do have medial subluxation... Before I found a brace specifically for medial subluxation I used to wear right knee braces on my left knee because it supported the medial side. As for my medical notes, I have seen 7 doctors/surgeons and 3 physical therapists. All agree and have documented medial subluxation except for one surgeon. This was the surgeon that recommended the lateral release. The reason he recommended it was because he didn't believe I had medial subluxation. However, because my kneecap ONLY moves medially I disagreed and decided not to have the operation.

As I mentioned before (and probably should have worded differently) MY primary problem is medial subluxation and lax ligaments. This is the biggest problem for me because it affects me most when I am dancing, which is what I was going to do as a career until all of these problems started. I also referred to walking at an incline, this was a strengthening exercise we did that I no longer do. The confusion is my fault, unfortunately, I am still caught up on leaving dance behind and talk about it as if I still do it... which is why I said that it was my biggest problem. When I talk about the pain on the medial side, it is painful when a doctor or myself move it medially (or participate in those activities), where the kneecap slides, as well as when a doctor attempts to move it laterally. Which as I said before, it does not do.

On the other hand, objectively speaking (which I'm guessing is how my doctor is looking at it) the medial pain should be the least of my concern because that part of my life has come to an end and the focus should be placed on the problem that inhibits me from what I would like to do in my adult life. Which is skiing and having the ability to take a walk with my dog for some exercise. Since this is the case, I believe his primary focus is fixing these problems which occur in my patella tendon and lateral side. Although, the concern in the matter is that even though he will ideally be fixing these problems, there is still the underlying problem of medial subluxation. Which as mentioned before, have the tendency to make things worse.