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Author Topic: Double derotational osteotomy of the femur and tibia  (Read 4816 times)

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Offline Jean Pepito

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Double derotational osteotomy of the femur and tibia
« on: March 15, 2014, 10:01:24 PM »
Hi everyone !

After many others, this is now my turn to report on my derotational osteotomy surgery !!

Before anything, I would like to thanks the KG community for all the support and information received in the last year : it has helped me make the right decisions about my operation and gain more confidence as I started this surgical journey. I would like to extend special thanks to DrMark and Crankerchick for their insightful answers to my many (technical) questions about the procedure. Thanks also to Wenikio and Crankerchick for all the information shared in your post-op diaries : reading your posts has been very inspiring !!

So, let’s update on my surgery.

I was operated on february 11, in Montpellier, South of France. The procedure was a double derotation osteotomy of the right tibia and femur, associated with a lenghtening of the lateral retinaculum and Pridie drillings to repair the cartilage of my kneecap.

The surgery lasted about 5 hours and went on well : no stress, no pain. When I woke up, I even had to ask twice if I had actually been operated, because I felt virtually no pain at all in my operated leg, which was a pretty strange feeling after such a heavy procedure…

My pre-op background :  I am a 39 year old male, suffering from chronic bilateral patellofemoral pain since my late teens. No patellar instability, but developing chondromalacia (soft cartilage) and chondropathies in both kneecaps. At the begining my symptoms were mild, and all they did was to restrict my ability to practice the sports that demanded too much from my kneecaps (running, skiing…). With time, the symptoms have worsened, but the underlying reason for my PF syndrome remained undiagnosed despite my consultation of many physicians and O.S.

In the fall of 2012, I went through a « crisis period » and decided to research about my condition on internet. After a few weeks, I came across several medical publications that made me realise my PF syndrom was the result of a congenital maltorsion problem. I came across the KG website, read patient testimonies, and tons of medical publications, which all pointed to a single treatment option : a heavy procedure called  derotational osteotomy. I started to travel and consult the best and most knowledgeable O.S about this procedure, in Argentina (where I was staying in the fall of 2012) then in my home country France, and in the Netherlands.

I actually live in Paris, so I did travel 750 km to get to Montpellier and have my surgery done in the hands of Prof. M.  I chose to be operated in his hands because I believe he has by far the most extensive experience in France as far as derotational osteotomies are concerned : he has performed this surgery successfully since 1986 and boasts more than 200 cases operated. When I consulted with him, it was obvious that he knew more about this surgery than most other OS I had consulted with. Interestingly, he did not need to look at my CT scan to tell what were my femoral anteversion and tibial torsion angles : he just looked at my legs, my walk, he assessed my hip rotation range and he then guessed what my angles were with the same precision as the CT scan !!! 

As I understand, the surgical sequence was as follows :
-   Femoral external rotation osteotomy of about 15° performed in the intertrochanteric zone (pre-op anteversion angle : 31°)
-   Lengthening of the lateral retinaculum
-   Pridie drillings in the lateral patellar facet to repair two contained fulll thickness chondral defects
-   Tibial tuberosity osteotomy
-   Fibular osteotomy
-   Tibial internal derotation osteotomy of about 25° performed proximally (pre-op tibial torsion 46°)

My experience of the surgery :
As already mentioned, my biggest surprise was the absence of any pain following this procedure. I did feel weak and tired, because I had lost quite a lot of blood (not enough however to warrant a blood transfusion), but my operated leg was almost pain free. If I had to rate my pain level on a scale of 0 to 10, as surprising as it my seem, I would say it was a 0 most of the time. It is only when I started to proceed with more active rehab at about 2 weeks post-op that I started to experience mild pain / discomfort on some occasions (very tolerable however).

I don’t know why I had so little pain, but I know for sure that other people have been less lucky than me. I almost never used my Patient Controlled Analgesia (PCA) during my week at the hospital. Maybe only a couple of times to relieve discomfort in my back that resulted from my lying in a bed for several days in a row, but that’s it.

My leg did swell for a couple of days (oedema), between days 2 and 4  post-op ,with no obvious explanation for it, but it resolved spontaneously.

I had 8 drains in my legs to avoid the formation of hematoma. That is a lot, and I believe as in many other situations it can be described as a « trade-off ». As I understand, more drains theoretically means more risks of infection, but on the other hand it avoids the risk of hematoma. Maybe is it one of the reasons why my O.S never experienced any compartment syndrome when performing this surgery.

My rehab protocol : focused on Continuous Passive Motion (CPM) machine in my first week at hospital + isometric contraction of the quads. Then I moved to a rehab center where I started to add more active exercises : walking with crutches, Range Of Motion (ROM) and strengthening exercises with physiotherapist.. My stitches were removed in the fourth week post-op and I can say I have very nice scars. The tibial scar in particular is very discrete (hardly visible). Since the healing of the scars is OK, I will start rehab in the pool early next week.
Being in a clinic / rehab center makes the recovery process more easy and comfortable. Everything is at hand and it is a very protective environment (at least in the clinic where I am !!). My O.S suggested that I should ideally stay for a total of 10-11 weeks in the rehab center.

I am now in my 5th week post-op and my feeling is everything at this stage is going in the right direction : my ROM is good, strength is building back in my leg, my stamina is good, I sleep well…

I will have an X-ray check and consultation with my O.S on Wednesday next week, so I will know for sure how things are progressing and I will update on this basis.



« Last Edit: March 23, 2014, 07:43:06 PM by Jean Pepito »
2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #1 on: March 23, 2014, 07:51:36 PM »
I consulted with my O.S last wednesday, who was very positive on my recovery so far (so am I!!). :)

The X-Rays at 5 weeks post-op show good consolidation. I have good range of motion (passive knee flexion around 130°) and muscles are getting back in shape. No pain at all (i stopped medications and icing several days ago). I can now go for long walks on my crutches (45 min is OK).

At present,  I put about 30% of my body weight on the operated leg, but I will start to increase from next week till I reach full body weight in four weeks time.

2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #2 on: March 25, 2014, 09:49:53 PM »
I ditched the knee brace yesterday. I feel every day brings its progress...

A few pics below showing my femoral and tibial scars 4 weeks post-op.  I am quite impressed how discrete are the scars after only four weeks (especially the tibial scar)!
« Last Edit: March 25, 2014, 09:52:11 PM by Jean Pepito »
2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Rose C

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Re: Double derotational osteotomy of the femur and tibia
« Reply #3 on: April 02, 2014, 09:38:46 PM »
How are you feeling???

I read your entire post!!

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #4 on: April 02, 2014, 10:38:23 PM »
I feel good, thank you! :)

I am now at 7 weeks post-op. I can now put around 60% of my body weight on my operated leg.
Rehab is progressing well. Walking and exercising in the pool withought crutches is particularly helpful to get back in shape. I started 2 weeks ago with water above the sternum, now I walk with water up to the navel.

My knee is still a bit swollen from the operation, but it is mild and quite normal at this time as I understand.

I have no pain on the sites where the derotation osteotomies where performed (hip and proximal tibia). The part that is most sensitive is the patelar tendon (probably due to the tibial tuberosity transfer): I do feel some pain when I do unassisted leg extensions, so I am still careful with this at present. But my physiotherapist says it is normal for me at this time, considering the surgery I have been through.

I am planned to stay another 3 weeks at the rehab center, then I will move back home and get back to work 100% (after I ditch the crutches). I have started to work a few hours everyday thanks to my laptop and internet connection (I do an office work and most of my job can be done on a remote-basis).

2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #5 on: April 05, 2014, 08:55:18 PM »
Almost 2 months post-op. I have tried to identify more precisely the pain that I have below the kneecap. It seems to be the portion of the patelar tendon just below the kneecap. The knee is a bit swollen and often warmer at this place.

Walking is just fine and straight leg raises are OK as long as I maintain the knee in a really straight position. But I do feel pain when I do either of the two movements in a seated position:

1. Leg extensions (from a bent leg position). The pain arises in the last degrees of leg extensions.

2. Leg flexion (from an extended leg position), but only when there is no other resistance to the movement other than that exerted by my quads. When my physiotherapist makes resistance whith his hands against my leg flexion, then I feel absolutely no pain. When I do the movement alone, it becomes painful. My physiotherapist believes that in this situation, I make an active contraction of the quads to resist gravity and slow down the leg flexion movement (otherwise the leg would fall!). This quad contraction would exert pressure on the patella and probably create tension on the patelar tendon.

I don't know how normal it is to feel this way at close to 2 months post-op. Has anyone experienced such thing? I am not overly concerned at this stage. The fact that I still have a swollen knee makes me believe that my knee is still in the process of recovering from the disruption created by surgery. So I'll wait and see. I will ask my O.S on the 23rd of April when my next consultation is scheduled.

For those interested, below are two aditional pictures, pre-op and post-op. The difference betwen the right operated leg and the left leg is quite visible.
« Last Edit: April 05, 2014, 08:59:17 PM by Jean Pepito »
2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #6 on: June 19, 2014, 09:39:59 PM »
I am now past the four month mark.

My bones are healing well.

I am getting better and better.  I ditched on crutch more than one month ago.
I still use one for comfort when I go outside, but I don't need it at home or for short distance walk.

I stopped physio after leaving the rehab center at two months and half post-op. I feel that exercising would not make my healing faster as I have  already recovered good mobility and strength in my leg.

My limiting factor is in the kneecap. It is still fragilized from the operation. My OS says I have pain where I had chondral lesions and they still need time to heal. As a matter of fact, my OS did a shaving of my patellar surface and Pridie drillings through the chondral lesions to help them heal.

My OS said it could take up to 6 months for the cartilage to heal. We will see how I feel in September.

For now, I am limited as far as physical activities are concerned. My OS said I could try swimming or biking on a level ground. But getting back to the dance floors (I am fond of tango dancing...) is still beyong my current abilities. I can do slight knee flexions as in normal walking, but I cannot do much more, because it is too much pressure on the kneecap. Going up the stairs is OK, going down is possible only with crutch.


2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #7 on: June 22, 2014, 10:12:20 PM »
My X-rays at 100 days post-op
2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #8 on: October 12, 2014, 10:06:26 PM »
8 months post-op.

I continue to make steady progress though recovery is certainly slower than what I had hoped for before the operation.

I still cannot fully extend the leg in the air from bent position when I am seated as it creates too much pressure on the patella. But I have gained a few more degrees. Only 15-20° missing to full extension.

I danced a few tangos end of August. It was a bit awkward because I could hardly flex the operated leg. Also, I would feel some discomfort at my tibia and femur. I do not know if it was for the hardware or the for the bone still consolidating.

In early september the X-rays showed very good consolidation, both femur and tibia. My OS was quite happy with my progress. He believes the chondral lesions in my patella will eventual heal.

I did walk a lot last month during a business trip to New York. Some days I would walk up to 1 hour and half or two hours spread through the day. That was OK at the moment, but when I was back to Paris, I felt as a reaction some pain at the tibia, maybe the tiberosity. And I had to take back the crutch for a few days. Pain is gone now, but I have not tried to walk as much since then.

I have started to do stationary bike at home, trying to do twice 15 min per day as advised by my OS. No pain to report. Next consultation with my OS in February at 1 year post-op.



2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #9 on: March 08, 2015, 06:32:48 AM »
13 months post-op

My leg keeps progressing. I can now virtually walk unlimited distance, I can bike or swim also without problem. I had the occasion to swim for 2 hours in a row several times, without problem.
Running is still not possible because of my knee. Jumping on my operated leg is also very difficult. 

My knee is slowly progressing however. Now I can fully extend the leg from a bent position. It makes significant noise (cracking) in the knee but it is now painful. My OS says the cause for this noise is the fibrocartilage formation that resulted from the Pridie drillings in my patella. He also says i should not worry about this noise.

I have now more ability to load my patella : I can now flex my operated leg while bearing weight on it. Much easier now to put on my socks!!!

I hope the progression will continue. I was a bit disappointed last month because I had the feeling that things had not improved materially between month 9 and month 12 post op. But now I can see that at month 13 post op, I am still making significant progress.
2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings

Offline Leena20

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Re: Double derotational osteotomy of the femur and tibia
« Reply #10 on: June 25, 2015, 10:30:37 AM »
Hi Jean
I just found out that the angles for my right leg are 40 degrees for both the femur and tibia. The left leg is not quite as bad, doesnt hurt much, and after two tendon debridements on it I am happy to leave it be and hope that no more problems occur with it. I am pretty committed to getting my right knee done but sounds like a big op! How long did it take for you to get back to work? I think I would have the femur and tibia done at the same time but the femur would be rotated down at the knee cap end not at the hip. Not sure if this makes things quicker or slower but seems to be how my OS works. Are you overall glad to have had the surgery done? Thanks!

Offline Jean Pepito

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Re: Double derotational osteotomy of the femur and tibia
« Reply #11 on: June 25, 2015, 11:02:29 AM »
Hi Leena.

I went back to work after 2 months and half, but thanks to internet I did start to work about 5 or 6 hours per day from about 1 month and half post-op, while I was at the rehab center.
I could honestly have gone back to work a bit earlier if I had wanted, but I was still on crutches and I followed the indications of my surgeon. I could also possibly have skipped the rehab center, but it was more comfortable to be there at least for the 5 or 6 first weeks.

I am overall glad to have had the surgery. Very happy about the osteotomy for realignment : my right leg is now perfectly straight. No complication. That said, my kneecap cartilage seems to have a bit suffered from the cartilage surgery that was done at the same time (shaving+pridie drillings). It is still progressing a bit, but my kneecap is overall more sensitive than before when I try to indulge in demanding activities (running, dancing...). I cannot be sure 100% because there were many procedures done in on surgical setting, but intellectually I believe the osteotomies were a great success, while the cartilage surgery probably did more harm that good. This cartilage surgery was not discussed with my OS pre-op, he took the decision to do it intra-op, when he saw my chondral defects. For my left leg, I am thinking, subject to my OS opinion, to have the same osteotomies done, but no cartilage surgery.
As regards daily activities, walking, walking and down stairs, cycling, etc : I can do what I want. I bet that thanks to the realignment my knee will be more resilient in the long term.

The femoral osteotomy can be done at the femur (like I did) or above the knee : from the litterature, it  seems that both way can yield good results and no procedure has been proved better. Each way has its pros and cons. Each surgeon has its own preferences. I think the most important is to do the procedure with an OS who has done the surgery many times.
2012 Diagnosed with torsional malalignment
2013 CT scan : Femoral AV 36° (L) and 31° (R) Tibial torsion 37° (L) and 46° (R)
2013 : Arthro-scan : Bilateral patellar chondromalacia
2014 :derotation osteotomy of the right femur and tibia + TTT + lengthening of lateral retinaculum + Pridie drillings















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