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Author Topic: Open Wedge & Derotational Tibia Osteotomy of a former Mountaineer - Oct. 23, '19  (Read 479 times)

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Offline kczech

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Hello everyone, first post here but I've read the complete diaries of some that have undergone a similar procedure, which has been invaluable to me in preparing for my own surgery.

A little background before I get into the nitty-gritty. Skip the brackets if you're only interested in the relevant diagnosis and surgical plans.

{
I'm a 25 y/o male who has been extremely active over the past 7+ years. During that time, I've summited the tallest 10 peaks TX, 35 of 58 14ers in CO, a hand full of the highest peaks in NM, AZ, CA, and UT, have done numerous 50+ mile backpacking trips through the Grand Canyon, and did my best to maintain running 20 - 35 miles a week, all while finishing a degree in Physics and working part-time for the National Park Service.

In celebration of the completion of my degree and the end of my NPS job, (which was tied to my being a student) I set out to hike 150 miles across the Grand Canyon, the furthest one can go along the established east-west trails. I had been training and prepared both mentally and physically for this for almost 6 months, and I felt invincible as I looked over the edge of the canyon the day I began my trek. That couldn't have been further from the truth, unfortunately. After about 3 days (~40 miles) of feeling great, I started to feel a dull pain in the lateral part of my right knee, which quickly became unbearable. At that point, I had another ~25 miles to the closest exit point and panic begin to set it. The next 48 hours were the most excruciating of my life. I could not bend my knee without experiencing a sharp 10/10 pain, I had to make a 2 mile side trip to the river to get water as the drainages were dry, and it had snowed ~4 inches the night before I finally made it out of the canyon, which made the final push all the more miserable. But I made it out, and I was thankful to be alive.

Upon returning home, my orthopedic surgeon (OS) quickly diagnosed it has IT Band Syndrome (ITBS) and said I just overdid it. A few weeks rest, a bit of PT, and I should be good to go again. Great! Two months later, my PT instructed me to try an easy hike, during which time I experienced the same excruciating pain again, not only in my right leg, but in the left now too. Had an MRI done that  same day and it showing a great deal of inflammation between the IT Band and the lateral femoral condyle. More PT, a second & third opinion, a dedicated strength training regimen over the past 4 months, and it only seemed to get worse, as I started experiencing pain along the medial side too now (MRI showed contusion/degeneration of the meniscus in the L knee, but no tears). I finally found a physical therapist that was genuinely interested in getting to the cause of my pain, as conventional ITBS therapy was clearly not working, and he pointed out that I have external tibial torsion (ETT). Say what? But it was as clear as day once it was brought to my attention. I brought it to the attention of the most recent OS and they dismissed it and said I should just have IT band release surgery, as I was "too old" to undergo a derotational osteotomy. I had surgery scheduled and all of the sudden the surgeon's office called and said he wouldn't perform the surgery and provided no explanation as to why, only that he was "very busy". That was when I felt like I hit rock bottom. At the ripe old age of 25, I wasn't ready to give up the one thing that made my life feel like it was worth living, but I was starting to think I might have to.
}

Scouring the internet for anything or anyone that may be able to help, I came across an article about "Miserable Malalignment", which described a number of symptoms of ETT, including ITBS and medial meniscus pain. That sounded familiar. Further research led me to a blog post by Dr. Mark Sanders of the Sanders Clinic in Houston, TX, who seemed to have success in treating various types of "Miserable Malalignment". It seems a number of his patients are members of this site as well, and I am indebted to their willingness to share their stories and their confidence in Dr. Sanders. I called and set up an appointment and his office was more than willing to accommodate out-of-town patients. Luckily I have family in Houston, which makes it a lot easier, so I set off on the grueling 13-hour drive across TX the day before my appointment. I had an EOS X-ray done at TCH and met with him shortly after, where he quickly identified my ETT and that I apparently have a varus deformity as well. To get a more accurate assessment of the ETT angle, they set up an MRI rotational study the same day, and I met with him again the following day. The study showed the torsion angle to be >40į on both sides, which made me a candidate for surgery. I was in shock as to the extent of the deformities, but I composed myself long enough to get through the meeting and asked as many questions as I could come up with, eventually agreeing to go ahead with the surgery.

I'm scheduled for surgery on September 4th, which seemed like enough time to come to terms with it, but I find myself still struggling with the anxiety of it all. After reading through a number of diaries, I thought that it might be helpful to start one of my own as I prepare. I plan on updating this after my pre-op consultation with Dr Sanders on the 3rd, and as often as I can post-op. I don't think anyone can beat @crankerchick though! It was extremely reassuring to read such an in-depth account of the experiences of a past patient. Hopefully this helps someone else down the line too.

Thank you for taking the time to read this far. I look forward to updating this.

UPDATE: I ended up having to postpone the surgery because of a few family and personal issues that came up. I'm now scheduled for pre-op on October 21st, and surgery on October 23rd.
« Last Edit: October 24, 2019, 04:25:39 PM by kczech »
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline kczech

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First update post op:

According the Dr Sanders, the surgery went well. My left tibia was corrected internally by 20į, resulting in a torsion of about 24į, and my 4į varus was corrected to about -1į or -2į (Valgus). The difference when compared to the uncorrected right leg is striking. He also performed an MPFL imbrication, which tightens this ligament by folding it over on itself and sewing together. I opted for this as opposed to a full reconstruction.

One thing I knew about but wasnít quite aware of the extent was the wearing down of the cartilage behind my kneecap, particularly on the medial side, which was due to repeated partial subluxation. Hopefully the tighter MPFL and new tibial alignment will prevent this from happening again and spare the remainder of my chondral cartilage.

Pain was surprisingly minimal after waking up due to the nerve block. I was sent home about 3 hours after the surgery was over, which seemed crazy to me but itís nice to be in a familiar bed. This was until around 8pm when the nerve block started to wear off and the pain became much more intense. Post-op instructions from the hospital nurse we to stay in bed, and only take half an Oxy every 6 hours until tomorrow (today), which conflicted with the instructions given by Sandersí office. Right about the time we were reaching out to him, he calls to check on me and thatís the first thing I asked. He wasnít happy that the nurse gave us conflicting information and instructed me to get on the medication schedule immediately. Sure enough, little to no pain within 15 minutes of taking everything (OxyCodine, gabapentin, tramadol, Tylenol, and baby aspirin).

The most difficult thing so far has been getting up to pee. The residual effects of the anesthesia make it hard initiate flow and I have to constantly push and hold my breath to get anything out, even though I feel the urge to go more than I ever have before. Hopefully this getting easier over the coming days.

Another effect of the anesthesia has been numbness in my hands, particularly my first 3 fingers. Itís made it hard to hold onto things, especially the small pills and my phone. But itís finally a bit better today.

Iíve been laying with my left leg up at 90į since around 12pm yesterday (other than we I get up to pee) with constant ice and the Venapro cuffs on each leg to prevent blood clots. Iím supposed to straighten it out tomorrow with only a small support below my ankle. ďCannonballĒ exercises should start tomorrow too, which will likely be painful but Iím excited to start moving my leg again.

Iíll update tomorrow after I switch position.
« Last Edit: October 28, 2019, 03:41:38 AM by kczech »
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline kczech

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Todayís been a rough day.

I started laying with my leg straight with a small support underneath my ankle so the knee isnít touching the bed. This is fairly painful so far and I find it difficult to get comfortable in this position. Iíve also started to develop pain below the incision along the anterior and lateral part of my ankle/lower calf. I think this is from the new position of my leg pulling on the muscles and nerves. I asked the doctor about it earlier and he said itís nothing to worry about, just gotta deal with it for now.

Also started doing the cannonball exercises (knees to the chest, keeping calves down), which arenít as bad as I expected. Just taking them slow and I can feel a bit of pain along the incision as I bend the knee, but not much pain within the leg/knee itself. I almost have full range of motion as compared to the other leg.

Numbness in my hands is completely gone thankfully. Peeing has also gotten easier, but itís still been almost 3 days since Iíve had a bowel movement. I know I need to keep eating, but I feel bloated. Popped a few stool softeners and a laxative earlier so hopefully those help. Riveting stuff here!
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline kczech

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Yesterday sucked (day 4). I stopped taking the Oxy to help with the constipation and woke up feeling decent, but then started feeling achy everywhere (flu-like) and the laxatives kicked in full force. Was in pain most of the time resting and didnít eat very much either because my digestive system felt like it was in chaos. I also noticed a small amount a blood coming through the medial part of knee after doing cannonball stretches. Pulling back my stockings showed 5 needle-sized holes outside the bandages that were bleeding. No idea why they were there but will ask doc.

Today (day 5) started off the same too. But after eating and moving around a bit more, I feel a lot better. The primary source of pain now seems to be the in the lateral part of my ankle around the malleolus, especially in dorsiflexion. Not sure yet exactly whatís causing this. Hopefully Doc will have some answers tomorrow. Follow up appointment in the morning then flying back home tomorrow night. Looking forward to being back home but dreading the logistics of air travel in my current state.
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline Ron22

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Hope your appt. went well.  I posted here quite a bit a long time ago.  I've had just about everything done over the yrs.  Have to update my profile as I am now up to an even dozen surgeries.  Four yrs of college football and then 15 yrs or 30 seasons (Fall and Spring) of Division 1 Rugby.  They told me to stop playing all sports after my freshman yr of college.  I have no regrets but cannot get the knee and hip replaced due to the ancient vascular surgeries where they just yanked out the long pulmonary veins (2 of those bad boys).  I'm pretty familiar with your surgery and others.  I'd be happy to answer any questions you might have.  I had good surgeons who did like to explain in even further detail than usual and I have absorbed a lot of knowledge over the yrs and am always willing to share whatever I can if anyone needs any first hand experiences.

Best of luck and feel free to PM me or post.  Hang in there.
« Last Edit: Today at 07:00:00 AM by Ron22 »
Surgery #1 ACL/LR/Mdl Mesniscus
Surgery #2 Vascular Repair
Surgery#3 ACL/Ltl Mesniscus/MCL
Surgery#4 Vascular Repair
Surgery#5 Maquet/Bone Graft/Screw/LR/ACL
Arthritis/Knee/Hip
Necrosis/Hip
PFS/Chronomalacia
RSD
Vascular Issues
All on Right Leg

Offline kczech

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It's been a rough few days since my last post. Follow up appt on Oct. 28: removed my dressings, took X-rays, and started partial weight bearing per doc's orders. The wound is sickening to look at (although I was told it was healing well) and there are a number of black, blue, and yellow areas from my thigh down to my ankle. Most are not painful though and should disappear in the coming weeks. X-rays look pretty gnarly too. I knew it wouldn't be pretty, but I was surprised as to the amount of step-off. The back of the distal segment protrudes about 8mm from the proximal segment because of the irregular shape of the tibia when rotated flush with the tubercle. Doc says it's nothing to worry about functionally, so I'll take his word for it. I had been carrying the leg on crutches up to that point so it was frightening when we instructed me to start putting weight on it, but it wasn't as bad as I had expected. It was (and still is) just difficult to go through the ambulatory process with one foot pointing in a different direction. The lack of dorsiflexion is a big factor, as it was something I never fully developed with my feet pointing out for so long. Lastly, a scope of my patellofemoral compartment showed abrasions along the trochlear groove and significant deterioration of the cartilage on the medial facet. Nothing to be done about that for now, but hopefully the new alignment will help.

Airport and plane ride sucked, not much else to mention there. Iím also not a fan of being pushed around in a wheelchairÖ

First day home was good after moving things around and making other living accommodations. That night though, I had an accident and fell while getting out of bed. Combination of factors: I was lightheaded getting up, my crutches were further away than they should have been, and I really had to pee. I donít think it was that bad of a fall, as I landed on my good side and was only about half way bent over, but itís hard to remember exactly what happened as sheer terror took over. Called Doc the next day and he didnít think it was enough to knock anything loose, but I had xrays done just to be sure. Based on those, he still doesnít think I did any harm, which is a relief, but I still have new pains that developed after which makes me paranoid.

The most annoying new pain is a pulling sensation in the lateral part of my thigh, which seems to start on the lateral prominence of my patella (more of a stinging) and extends upwards through the area of the ilitotibial tract. Hard to say if itís the IT band, the vastus lateralis, or whatever else. Itís painful to the touch and pulls when walking (trailing in extension) and in full flexion. Iíve also developed pain around the proximal part of the plate when too much weight is put on it or sometimes when moving against gravity.

Despite all these new pains, Iím still keeping up with my exercises (cannonballs, working ROM, etc) and partial weight bearing as tolerated when walking. I know itís only been 9 days, but I was hoping to be past the point of developing new pains so I would only have to focus on managing existing ones. The long road to recovery continuesÖ



Ron22, thank you for your message and for the well wishes. I am sorry to hear about your situation and I hope you have found a solution that works for you. As I donít have the ability to send messages yet, Iíll post a few questions I have here. Do you have any experience with plate fixation or with this type of surgery yourself? And would you expect there to be any future issues/complications with bony step off, such as the kind that is presented when rotating the proximal tibia on itself?
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline kczech

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Finally an entry that isnít all doom and gloom! Past 2 days have been what I would consider good days, in contrast to the recent string of bad ones. I started going on daily walks a few days ago and today I managed to make it all the way around the block! I can feel my pace quickening too. I was definitely in pain by the time I got home, but after some ice and a pain pill, I felt much better. Iíve also been doing a number of easy exercises given to me by my physical therapist, and theyíve been getting easier day by day. Above all, the pain is finally at a level where I can ďexistĒ in relative comfort without doping up.

Sleeping is still somewhat difficult though, even with sleeping pills. I often wake up 3 or 4 times and find it difficult to go back to sleep. I managed to sleep in later today and itís amazing how much better I feel. Hopefully this keeps getting better too.

Lateral thigh pain/tightness is still there but seems to be getting somewhat better. The more I look at it, it seems to correlate with surface discoloration. Biggest annoyance right now is the pain behind my knee that causes numbness in my foot when laying down, although I did manage to find a combination of foam supports that eliminates the pressure behind my knee. My right (nonsurgical) knee is starting to bother me again too, I imagine because Iíve been relying on it a lot recently. That pain in minimal compared to the other leg, but is annoying nonetheless.
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline kczech

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Good days are never without bad ones it seems.

I think I overdid it with the walking and I may have been doing too much weight bearing. I feel like I need to push myself to keep making progress, especially on good days when my confidence is higher, but then I'm reminded by the pain that's it only been about 2 weeks since I had my tibia cut in half and reattached. I'm not a patient person by nature, but this whole ordeal seems to be a lesson in that.

The primary pain I'm experiencing now is around the plate. It's a dull ache most of the time, but increases as I do too much walking. I think it was the day after my last post that I stopped going on daily walks so as not to exacerbate the issue. As an alternative to walking over the past few days, I've been using a stationary bike with variable resistance, which I think will be my primary form of exercise for the time being, in addition to the leg raises, extensions, etc. I started doing more walking again yesterday, but stopped as soon as it became painful after a few minutes. Now that the swelling is mostly gone, I can easily feel the outline of the plate, and it is tender to the touch as well.

The pain/discomfort behind my leg at the osteotomy site is still there too. There is a slight, sharp pain in full extension and most lying positions seem to put too much pressure on the area of the bony step off, which causes pain at the site and the rest of my leg to go numb. The couch in my living room has cushions with a space right behind my knee when lying down, so that's where I spend most of my resting time. Otherwise I have to put together a number of foam cutouts we've made for support, which is a pain in the...

I hope this is something that will resolve with time, although I don't see how given that the prominence on the distal segment isn't going to go away. I had the opportunity to look at a few other X-rays from patients who had the same (or similar) thing done, and their distal step off is nowhere near as prominent as mine. This may be due to a number of factors, but the result in my case is unexpected nonetheless. This is the one outcome of the surgery I am disappointed in at this point, but I will do my best to be optimistic that it doesn't result in any functional deficiency later on. I've attached an image of a lateral xray that shows the step off I'm talking about. If anyone cares to provide an opinion and reasoning as to wether or not this is problematic, I would greatly appreciate it.

As far as things that have gotten better, the lateral pain/tightness is almost gone, along with the bruising that seemed to be causing it. Just a minor pain along the lateral part of my patella that remains. Bruising/discoloration overall has improved quite a bit, and ROM is now just about identical to the other leg.


The "views" count on this keeps going up quite a bit every time I check, which is somewhat unexpected given how inactive this site has been recently. If you've read this far, thank you for your interest and feel free to leave a comment if you'd like :)
« Last Edit: November 10, 2019, 04:45:33 PM by kczech »
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary

Offline crankerchick

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    • Derotation osteotomy & TTT Post-op diary
Itís too early to be disappointed and worried about what will and wonít resolve. Some of the improvements Iíve had over time are measured in years. Most in months. Few in weeks. Week to week improvements, especially in the beginning, weíre more related to initial surgical pain and the deep bone pain (if that makes sense). Iím not saying this ďbony step offĒ will improve, Iím just saying try to stay focused on the small goals and ďwinsĒ rather than the big ones. Youíll go batty and stay depressed otherwise.

Iím curious Docís thoughts on walking versus cycling. Itís been a while for me but when I had my surgery, it was all about the cycling. I lived for the bike. It kept me from getting stiff and it always felt better afterward, even if during the ride if it was hard. Being stiff hurt so much more, especially when time came to move again.
« Last Edit: November 11, 2019, 03:09:06 AM 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

Offline crankerchick

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    • Derotation osteotomy & TTT Post-op diary
Is it possible with healing over time there will be some bony build up to fill in the step somewhat?
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

Offline kczech

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Crankerchick, you are right. Looking back, there have been so many things that have gotten better or resolved completely since day 1, but I have been reluctant to acknowledge them in the face of current issues or pains. That's something I probably need to get better at for my own sanity!

Perhaps the word "disappointed" was a bit strong. It's just one of those things I remember having a small freak-out over the first time I saw it in an xray because it was something I was worried about beforehand and I was expecting it to be fairly minimal based on other xrays I had seen. It seems to me like sharp or larger bony prominences are generally problematic, especially when there wasn't one there before and in areas where there are nerves, tendons, etc. Doc did not think it would be an issue, but I was skeptical based on my own preconceptions. My skepticism may very well be unfounded though, and I hope it is. I'm just a worrywart and admittedly, I'm stubborn. It is likely there will be some fill-in around the step, but it will clearly remain prominent. Maybe once the sharp edge is gone it will become less of an issue though. In any case, I'll do my best not to dwell on this one issue. I appreciate your response and your viewpoint :) and glad to see your profile revived!

Doc had me start weight bearing during our post-op appointment only 5 days after surgery and said to stop "carrying" my leg, and to try to stay as active as I could tolerate. He didn't even mention the bike but it's something I asked about recently and he said it was a good alternative if I was unable to do much walking. The reason it became an issue for me is I was trying to put too much weight on it. Should've only been doing around 20-30 pounds, but I never bothered to check on a scale and I was probably doing 40-50+ at times. No wonder it hurt...
« Last Edit: Today at 05:12:36 AM by kczech »
L. Tibia derotational and medial open wedge osteotomy - Oct. 23, '19

"It is not the mountain we conquer, but ourselves." -Edmund Hillary















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