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Author Topic: HTO or PKR in left medial knee ... advice  (Read 2219 times)

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Offline JOW_103

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HTO or PKR in left medial knee ... advice
« on: January 10, 2013, 08:01:44 PM »
I am a 51 year old active male (still play recreational hockey) and I have had left knee problems for the last 15 months or so.  In January of 2012 I had a medial  meniscus repair to the same knee.  During the arthroscopy the OS also cleaned up the cartilage underneath the kneecap on top of the femur.

After the surgery the knee felt OK for a few weeks but soon the pain was back.  In July I stepped into my garage and experienced a very sharp intense pain to the front/medial part of my knee.  Almost put me on the ground it was so bad.  After that I decided to seek out a new OS because I didn't think my other OS was listening to what I was saying when I told him I was still having knee pain.

Went to the new OS who took X-rays of both knees.  Diagnosed with mild to moderate OS in both left and right knee although left was more symptomatic than the right.  OS's PA recommended  Euflexxa injections.  Did the round of three injections over the summer and knee felt OK.  Within 2 weeks of the last injection, experienced same intense pain as in July.  This time I was simply walking in the office.

Contacted OS who recommended they do a Vision Scope (needle arthroscopy) to look inside my knee.  had that done on December 14th.  Doctor confirmed grade 3 and focal grade 4 change of the medial tibial plateau.  He recommended unicompartmental PKR and referred me to another OS.

Saw new OS on January 4th who did not recommend PKR due to my age and that I am active.  He is recommending a Synvisc One injection first, followed by HTO if that doesn't work.  I'm not convinced it's going to do anything already having tried the Euflexxa with no relief.

I have two questions.  Does anyone with a similar condition experience occasional intense pain to the front/medial part of their knee and is it common to this type of OA?  Seem to getting that intense pain more and more simply walking.

Would I be better off to just get the PKR instead of the HTO?  From what I've read HTO is going to buy me about 5-10 years but I will likely end up with a PKR or TKR eventually.  Why go through the long, painful recovery of HTO and then a PKR.

Thanks for any advice or comments.

Offline ahenderson

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Re: HTO or PKR in left medial knee ... advice
« Reply #1 on: January 10, 2013, 11:41:17 PM »
hihi have you looked into kine spring? could be worth asking about and you are in the right age group

Offline JOW_103

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Re: HTO or PKR in left medial knee ... advice
« Reply #2 on: January 11, 2013, 12:48:44 AM »
I have never heard of this implant so it was not discussed with my OS.  Certainly something to discuss with him next time I see him.  Thank you.

Offline muscle20

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Re: HTO or PKR in left medial knee ... advice
« Reply #3 on: January 12, 2013, 10:08:23 PM »
similar issues of grade 4 medial OA. i am 51 and have done 30 yrs of competative bodybuilding and powerlifting(to british level). this was after a compound fracture of the right ankle at 21(competative rower at the time) and being told id need a ankle fusion and not do any sport again.first 6 months after clean out and scope stopped gym work. big mistake. saw physio and he told me get to the gym and work through it to a comfortable level. 2 yrs on muscle tone back but reduced bulk and the pain is annoying but not painfull. cant desribe it any other way. no nsaid or painkillers. keep it moving and working seems to be the key.
considered synvisc but seems to work better at grade 2 level. maybe the muscle support is what keeps me going as the physio and os cant beleive im biding my time.

Offline WonkeyDonkey

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Re: HTO or PKR in left medial knee ... advice
« Reply #4 on: January 14, 2013, 02:18:26 PM »
Hi

A PKR does not re align the knee in any way, it just replaces the worn out parts. This could last you 10 + years all being well, and then you would probably need a revision TKR.  A HTO is design to re align the weight bearing through the knee and give you time prior to any replacements.

Due to your age many OS' won't offer a TKR as you are classed as too young (makes a change when you get to 50 to be too young!)

I have had a HTO and feel it was the right option for me as I have grade 4 OA in the medial part of my left knee. I no longer have the OA pain that I did have, no longer take pain killers or anti inflammatries, and can do more activities than I could do prior to the HTO. If you want to read my post op diary here is the link.....

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

Read the articles on HTO and PKR in the informaion section, you may find them useful.

WD


Offline mmrocker13

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Re: HTO or PKR in left medial knee ... advice
« Reply #5 on: January 14, 2013, 04:45:05 PM »
I would go with the osteotomy, for sure. It allows you to stay active, and keep your own parts. Honestly, the recovery is not that bad, and well worth it.

I had a DFO, so a longer recovery than HTO in general...and then had a complication that basically doubled it, and I would do it again (even WITH that issue) again in a heartbeat. Absolutely a no brainer for me. I was able to run and ride better than I had in decades. Obviously I'm hoping for 10-25+ years out of it, but even if I only get 5, STILL worth it.

Have you tried an unloader brace? It can simulate the effect of an osteotomy, and is a good thing to try beforehand.
89: Pat. dislocation, lat. meniscus tear, femoral OCD lesion
89: debridement, chondroplasty, lateral partial menisectomy
02: partial lat. menisc., debride
02: mfx
09: subtotal menisc., debride, c'plasty
10: scope/debride
10: varus DFO
13: HWR
15: total menisc., debride, c'plasty, notchplasty

Offline JOW_103

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Re: HTO or PKR in left medial knee ... advice
« Reply #6 on: January 14, 2013, 07:19:54 PM »
@mmrocker13 - I do have an unloader knee brace and sometimes where it.  I find that I don't get a lot of relief using it.  OS thinks it's because my knee ligaments are so tight that it really doesn't have a lot of effect.

@wonkeydonkey - I have read your post-op diary.  Very informative and thank you for sharing your story.  Just trying to rationalize in my head of going through a long recovery to only do it again 10 years later with either a PKR or TKR. Definitely leaning towards the HTO.

Did either of you try SynviscOne before your surgeries?  Did it do anything?  If I'm going to end up with surgery anyway, rather skip the injection, have the HTO and start the recovery process rather than waiting another 6 weeks to find out the injection didn't work.

Offline mmrocker13

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Re: HTO or PKR in left medial knee ... advice
« Reply #7 on: January 15, 2013, 12:05:53 AM »
I did not do the injections prior to my DFO. Had I done them years earlier, it might have been worth it, but by the time I went with the DFO, it was sort of past the point of being beneficial--I was in my early 30s, the injections are a short term solution, and you can't do them forever, and I wasn't going to give up being active.

If you want the full details on on my recovery, I have a journal in the changing forces throughout the joint section (http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=50020.0), but like I said...I really didn't think it was that bad. I wasn't running races the next day or anything, but at 7 months post op, I was walking unassisted, and spent a week in the Boundary Waters camping (although I didn't carry gear on the portages). At 9 months post-op, I took a trip to France and Italy (walking at least 2-3 miles a day, often 5+), and also did a 40 mile mountain bike race (albeit slowly and leisurely). I missed one  full season of racing, then had a very laid back season, and the following season after that I was better than I had been in years. Maybe I'm just used to pain, suffereing, and rehab, and have some screwed up perspective...but it wasn't as bad as I'd feared.

Look at it this way: if you have the HTO, eventually it wears out. So you spend a couple months recovering, then resume your life. 10 years later, you need a PKR. If you have the PKR now and spend a couple months recovering, 10 years or so later, you'll need a revision. So you'll probably have multiple procedures down the line regardless--the only difference being at least this way, you go into that procedure 10 years from now in far better shape, since you're still deling with your original equipment. PKR to TKR and revisions are finite--so it's best to forestall them and go into them with as much of your own parts as possible.
89: Pat. dislocation, lat. meniscus tear, femoral OCD lesion
89: debridement, chondroplasty, lateral partial menisectomy
02: partial lat. menisc., debride
02: mfx
09: subtotal menisc., debride, c'plasty
10: scope/debride
10: varus DFO
13: HWR
15: total menisc., debride, c'plasty, notchplasty

Offline JOW_103

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Re: HTO or PKR in left medial knee ... advice
« Reply #8 on: January 15, 2013, 04:57:55 AM »
@mmrocker13 - Thanks for the reply.  I read your blog and your post-op diary.  Thanks for sharing your experiences.  Did you have another surgery to remove the osteotomy hardware?.  If you did, how soon after you healed did they do that?  What was the recovery time for that procedure?

I just bought a 2013 Harley Davidson motorcycle so I'm really bummed that I'm going to miss a third of my very short riding season here in Massachusetts.  Trying to figure out the best time to do all this and preserve as much riding time as I can.

Offline Adobec

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Re: HTO or PKR in left medial knee ... advice
« Reply #9 on: January 15, 2013, 05:24:59 AM »
My doctor was talking to me a while ago about the osteotomy (at the time it was an option, now it isn't, unfortunately). Anyway, he said that a colleague of his, who performs PKR's, opted to have the HTO at age 51.  He will then have the PKR 10? Years down the road.  Good luck with your decision.  I would definitely go with the HTO.

Ps- I did orthovisc injections, they didn't help at all.
1991 - R ACL patellar tendon, med. meniscus removed (50%)
2002 - R ACL revision, cadaver, lat. meniscus removed (50%)
2011 - L ACL patellar tendon, med. and lat. meniscus REPAIR. 
3/2012 - L Medial meniscectomy (didn't heal from 2011), microfracture
11/6/12  - L TTT (maquet). Micro fully healed

Offline mmrocker13

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Re: HTO or PKR in left medial knee ... advice
« Reply #10 on: January 15, 2013, 06:33:27 PM »
@mmrocker13 - Thanks for the reply.  I read your blog and your post-op diary.  Thanks for sharing your experiences.  Did you have another surgery to remove the osteotomy hardware?.  If you did, how soon after you healed did they do that?  What was the recovery time for that procedure?

I just bought a 2013 Harley Davidson motorcycle so I'm really bummed that I'm going to miss a third of my very short riding season here in Massachusetts.  Trying to figure out the best time to do all this and preserve as much riding time as I can.

I live in Minnesota...so I hear you on missing out on the every short nice weather season :-)

I did have my hardware out (last week, in fact). I would NOT have asked to have it done, nor would my surgeon have done it, if it had not been affecting me adversely. My IT band--which was scarred (they cut it to do the DFO)--would hang up on the anterior edge of the plate. I could live with pain, but it made for poor functioning and was limiting my running and riding. In general, though, they prefer to leave it in (and I totally would have preferred to as well). I had to wait 36 months (the time varies--they are cautious with a femur and a plate) to have it out. I will be on crutches for at least a month. I've updated my DFO diary with the report following this last procedure--there is also a journal in the post-op diary section (and pictures!).
89: Pat. dislocation, lat. meniscus tear, femoral OCD lesion
89: debridement, chondroplasty, lateral partial menisectomy
02: partial lat. menisc., debride
02: mfx
09: subtotal menisc., debride, c'plasty
10: scope/debride
10: varus DFO
13: HWR
15: total menisc., debride, c'plasty, notchplasty

Offline WonkeyDonkey

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Re: HTO or PKR in left medial knee ... advice
« Reply #11 on: January 17, 2013, 02:19:19 PM »
I didn't do any injections prior to my HTO, basically my OS had done an arthroscopy, long leg x-rays, etc and this was the way forward.

Having had a HTO and done the physio recovery, for me personally I would recommend the osteotomy, although I do not have any hardware to be taken out later on. I have an iBalance implant which is a relatively new idea.

Link attached to view it.....

https://www.arthrex.com/innovations/index.cfm?adid=42

http://www.orthoillustrated.com/

I would suggest that you ask your OS how many osteotomies he has done, so you can find someone who has experience in this op. Ask lots of questions, and make sure you understand what is going to happen and how your recovery is handled. A good OS will always answer your questions.

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

WD