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Author Topic: Open Wedge & Derotational Tibia Osteotomy of a former Mountaineer: 10-19 & 2-20  (Read 4781 times)

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Offline RGB

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Hi Kczech. I speak from a position of no knowledge but considerable personal experience. I counsel careful thought before getting into the whole cartilage repair process, especially for the patella and trochlea, unless you're young and feeling lucky. I spent a 7 years of trying one thing and then another, strictly following rehab protocols, hoping for the best and having those hopes dashed. You can find my posts if you search. I've ended up with a PFJR and it's fantastic - not quite a natural knee but pretty good. For someone in their mid 50s and older with serious isolated patellofemoral issues that's what my evidence base of one indicates to be the best option. You have a lot of other stuff going on with your knees so this may not apply to you. I did a lot of research before trying various other procedures and they all looked promising at the time. However, in hindsight I don't believe any of the current cartilage repair options is sufficiently developed/successful to warrant the investment. I'm not talking about money but time, energy and hope. Feel free to ignore me - others have been luckier than I was, and I have no medical training. Good luck though - it's a tough problem to have.

Offline kczech

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Hi RGB, thank you for your message. Itís definitely not something I take lightly and Iím aware of the mixed results with cartilage repair on the patella. Thatís one of the reasons Iíve decided to go see someone who has arguably the best success rate for addressing these types of defects.

Iím definitely not planning to jump right into it. Iím still recovering from the last surgery and Iíd like to see what happens once Iíve had a chance to build my strength back up. For the time being, Iím just planning to talk to Dr Minas to get a sense of where my cartilage is at right now and what might become of it if I delayed treating it or tried to return to higher levels of activity. That is my ultimate goal and if itís not possible given where things sit right now, I donít really see another option. Iím not quite ready to call it quits and give up hope of returning to climbing at this point.

Iím sorry to hear that cartilage repair didnít work out for you. Youíre not the first Iíve heard from that has cautioned against it because of their experiences. Iím glad to hear youíre doing well with a PFJR though. I will see if I can find your posts about it. Best wishes!
L Tibia derotational & medial open wedge osteotomy + medial imbrication: Oct. '19 (failed)
R Tibia derotational & medial open wedge osteotomy: Feb. '20
L&R diagnostic scope, lysis adhesions, chondroplasty, & ITB lengthening: July '20
L hardware removal & partial medial release: Nov. '20

Offline kczech

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14 weeks post-op 2

I had an MRI and a CT scan done on my left leg a few weeks ago. They showed significant scarring behind Hoffaís fat pad, medial compartment (thatís new) and PF chondromalacia, and damage to the lateral part of the quad tendon (likely from the arthroscopic incision from the last surgery). These all seem to mostly line up with the worsening issues Iím having. Since my last post, Iíve also lost the ability to actively extend my leg. It feels like it gets stuck around 45į of flexion due to pain and restriction underneath my patella. If I relax my quad, it can be moved manually though, albeit with a fairly prominent and uncomfortable ďclunkĒ. The lateral IT band pain is also back intermittently, so back to square one on that too it seems.

About 2 weeks ago, I started to notice a very dull pain in the lateral compartment of my right knee, which I assumed was just my knee getting used to the load distribution from my new 2į valgus alignment. A few days later, it suddenly became very sharp right beneath the anterior lateral joint line during a sort walk and I had to hobble back home. My physical therapist did a McMurrayís and Apleyís test and they were seemingly positive, which would indicate a lateral meniscus tear. I have an MRI next week to see if thatís the case. Before this happened, my right leg was actually doing pretty well.

Iím not going to physical therapy any more now because Iím still extremely limited on the types of things I can do, and what I can do Iíve been doing at home as often as the pain allows. Sometimes this means not getting off the couch for a day or two, and sometimes I can do straight leg raises, stretching, and other simple floor and balancing exercises for a few days in a row.

Iím at the point now where Iím beginning to regret going through with these surgeries. It seems like all the new issues coming up are direct and/or indirect results of them, the issue that started this whole ordeal is back, and Iím possibly looking at several more surgeries to get back to at least being able to walk comfortably again, let alone do any of the things I used to. One thingís for sure, I will never walk through the office doors of Dr Mark Sanders again.

Iíve had two virtual visits with Dr Minas so far and I am impressed by his thoroughness and general demeanor. Iím scheduled for arthroscopic surgery on both knees with him in mid-July to remove scar tissue, asses my cartilage (with a possibly biopsy for MACI), and fix anything else that might be amenable at the time. We also discussed the possible need to redo the osteotomy on my left leg at a later date because itís still at 5į of varus and now I have medial compartment damage.
L Tibia derotational & medial open wedge osteotomy + medial imbrication: Oct. '19 (failed)
R Tibia derotational & medial open wedge osteotomy: Feb. '20
L&R diagnostic scope, lysis adhesions, chondroplasty, & ITB lengthening: July '20
L hardware removal & partial medial release: Nov. '20

Offline kczech

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Been a while since I updated this, but I wanted to do one more post to close it out.

Since my last post, Iíve had 2 surgeries with Dr Minas, gotten dozens of opinions from other doctors across the country, and Iím currently scheduled for another ďbig surgeryĒ with Dr Minas and Dr Dror Paley working together on a fairly complex revision osteotomy.

The first surgery with Dr Minas in July 2020 was a bilateral arthroscopy to asses my cartilage for possible MACI and clean out scar tissue. Following that surgery, Dr Minas stated the articular surfaces in both knees were actually fairly healthy, aside from a 1.5cm^2 Grade 2 lesion on my left medial trochlea, and a 1cm^2 grade 1 lesion on my right MFC. Dr Minas did not think either of theses warranted taking a biopsy for MACI, which was good news. There was a lot of scar tissue cleaned out of my left knee, which made things feel a bit better at first, but it was shortly lived. We discussed my residual malalignment, and agreed to wait another few months before making any decisions to correct it.

Two months after, I was still having aggressive and painful crepitus, and any loaded flexion activity was still impossible, so there was no functional improvement. Consulting with Dr Minas again via zoom, he wanted to have a second look and we agreed to take the hardware out of my left tibia to see what kind of effect that would have. Upon seeing him in person again, he noted that my left patella had no lateral mobility, and limited mobility overall. After reviewing my previous surgical history in more detail, he concluded that the MPFL imbrication done by Dr Sanders was done unnecessarily, and stated that it was an overall ďbad surgeryĒ. The overly tight MPFL causes my patella to track medially and results in increased contact pressure on the medial facet of my PF joint, which is only exacerbating the medial lesion we already know is there. During the surgery, he said he would try to release some of this tightness, but admitted a medial release is a very uncommon procedure, and that a total MPFL reconstruction may be necessary in the future, along with a tubercle osteotomy.

While I was in Florida, I also consulted with Dr Paley for his opinion on my previous surgeries with Dr Sanders. He said he had never seen anything like the surgery Dr Sanders performed, and explained how he would have corrected my initial deformities. He ordered new X-rays and measured a number of different things on them and during the exam. He described what he saw as a ďmalunionĒ and explained that the rotational correction was over corrected by about 10į, my varus was made slightly worse because of what was likely an unintended medial translation at the osteotomy site, my PPTA (posterior proximal tibia angle, aka posterior tibial slope) was changed from 82į to 91į, and my left leg was longer by about 12mm. He also noted the same ďhypomobilityĒ in my patella that Dr Minas described. His recommendation was to proceed with the surgery Dr Minas was scheduled to perform, he would stop in during to look while my knee was open, and we could come up with a more comprehensive plan during our next consultation.

After my surgery with Dr Minas, he explained that the hardware was removed without complications, and there was some additional scar tissue removed from my PF joint. In manipulating my knee during the surgery, he noted that my patella tracked medially in the groove, and there was increased contact pressure overall in higher flexion. He did not end up releasing any of the medial soft tissues, and he decided during the surgery that a tubercle osteotomy and a ďsoft tissue balancingĒ was necessary at a later date to centralize my extensor mechanism. When pressed about the need to correct all the other metrics we knew were off, he admitted thatís not something he could do, but he would discuss with Dr Paley a possible collaboration on a future procedure.

Since that surgery did not yield any improvements, I consulted with both Dr Minas and Paley again to express my desire to move forward with the larger realignment procedure we had discussed. Here is my understanding of how it will be done:

Dr Minas is going to perform the tubercle osteotomy and flip up the bone fragment and my patella tendon so that Dr Paley will have unobstructed access to the prior osteotomy site. He will then cut along the previous osteotomy, and remove 10mm of bone from the distal segment to correct my leg length, externally rotate it slightly to undo the overcorrection, laterally translate it 12mm, open a small medial wedge, and open an 8į anterior wedge to restore my tibial slope. Once that is fixed in place with a new medial plate, Dr Minas will reattach my tubercle slightly medially from the original position, and attempt to balance the soft tissue restraints to restore my patellar mobility. Heíll also be removing the hardware from my right tibia and doing another lysis of adhesions on my right knee.

That all sounds like a lot, so I asked Dr Paley how each of those different metrics is achieved. He said it was ďgood carpentryĒ, and didnít offer much more of an explanation than that. Iím aware of his skill and reputation in the field but I was hoping for something a bit more concrete. Iíve resolved to just put my faith in him regardless, as I donít see any other option, and Iím told by multiple doctors that he is the best in the world at this kinda thing. One option presented to me by another doctor was to correct everything gradually with an external fixator, then go back and do the tubercle osteotomy. When I explained that I had seen Dr Paley and he offered to do everything at the same time internally, that doctor said he was aware of the work Dr Paley does and he recommended I do the surgery with him, as Dr Paley is the best in the world at that kinda thing. I have heard something similar from other doctors who are familiar with Dr Paleyís work too, so that is somewhat reassuring.

According to Dr Paley, my initial rotational deformity was an easy fix, and my varus probably didnít need correcting in the first place. Now my situation had been made immensely more complicated by Dr Sandersí failed and unconventional attempt to correct both.

Iíll close it out with this. Dr Sanders is an extremely unconventional surgeon who holds a number of controversial opinions regarding patella-femoral mechanics, and performs deformity correction osteotomies unlike anyone else who attempts them. He claims to know more than he does and is extremely arrogant, unjustifiably so. If youíre reading this and considering having surgery with him, donít. He ruined my life and I completely regret ever having made contact with him. Iíll be lucky if I can ever walk without pain again, let alone do any of the things that previously gave my life meaning.
« Last Edit: February 12, 2021, 01:45:43 AM by kczech »
L Tibia derotational & medial open wedge osteotomy + medial imbrication: Oct. '19 (failed)
R Tibia derotational & medial open wedge osteotomy: Feb. '20
L&R diagnostic scope, lysis adhesions, chondroplasty, & ITB lengthening: July '20
L hardware removal & partial medial release: Nov. '20