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Author Topic: Second opinion: Fulkerson or LR?  (Read 167 times)

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Offline bcerella

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Second opinion: Fulkerson or LR?
« on: June 29, 2020, 06:31:43 PM »
Iíve had PFS since I was 16, and the pain has finally become so bad that I canít go for a walk without a lot of pain. I saw an ortho surgeon who recommended a Fulkerson osteotomy, and - although I dread the rehab - I was comfortable with his explanation of how it would help me. Since itís such a big surgery I paid out of pocket for a second opinion... the second surgeon recommended a bilateral lateral release instead. He says that since my TT TG numbers are 18.9 and 19.3, they donít warrant the osteotomy. The idea of taking care of both knees simultaneously with a shorter recovery is very tempting, but Iíve read that the LR isnít predictably successful. Whatís your experience been?
« Last Edit: July 10, 2020, 10:48:14 AM by bcerella »

Offline Vickster

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Offline Brandon123

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Re: Second opinion: Fulkerson or LR?
« Reply #2 on: June 30, 2020, 02:43:58 PM »
Fulkerson osteotomy is a big surgery, but I would not consider bilateral lateral release as minor either. Also, if a bilateral lateral release goes wrong, it will be very problematic. See this recent thread on LR for more info:

https://www.kneeguru.co.uk/KNEEtalk/index.php?topic=77981.0

As both alternatives could be categorized as a bit "risky" procedures, my advice would be - if you can afford it somehow - to seek out a third opinion by a patellofemoral expert, for example someone on this list:

https://www.kneeguru.co.uk/KNEEnotes/primers/whos-who-knee-surgery/whos-who-patellofemoral-surgery

Tell the third doctor that you have been given these two options and don't know what to do. It will be money very wisely invested. Even if you need to borrow or sell something, it would still be my no. 1 advice in this situation.

Good luck and let us know how everything develop! 
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline bcerella

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Re: Second opinion: Fulkerson or LR?
« Reply #3 on: July 01, 2020, 09:42:16 AM »
@Brandon123: Good idea, and thanks for the list. I was able to get an appointment to see Italyís leading PF surgeon this Friday. Weíll see what he says!
« Last Edit: July 01, 2020, 09:44:15 AM by bcerella »

Offline Brandon123

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Re: Second opinion: Fulkerson or LR?
« Reply #4 on: July 01, 2020, 10:33:00 AM »
@Brandon123: Good idea, and thanks for the list. I was able to get an appointment to see Italyís leading PF surgeon this Friday. Weíll see what he says!

Sounds great, let us know what he says!
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline bcerella

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Re: Second opinion: Fulkerson or LR?
« Reply #5 on: July 03, 2020, 05:10:48 PM »
UPDATE:

Per Brandon123ís suggestion to find an expert, I saw Dr. Zaffagnini today. He (literally) wrote the book on patellofemoral pain (https://www.springer.com/gp/book/9783642054235) and you could tell. He was so knowledgeable, took his time with me and explained why I should do this and not this - he was GREAT.

In more detail:

Dr. Z noted that I have significant trochlear dysplasia - essentially flat. A lateral release wouldnít work because thereís no groove for the patella to engage in. What groove there *is* is too high to be useful.

He recommended that I start conservative (physical therapy, swimming, synvisc, stem cell therapy) and move to surgery when those things stop working or prove ineffectual. Some of those things Iíve already done; Iím checking with insurance to find out what else would be covered.

When itís time for surgery, he recommended tibial tubercle medialisation with ďvastus medialus obliqus advancement plastyĒ to strengthen the insertion of the VM quad.

 He was appalled that one surgeon recommended bilateral LR - he said that would release the patella but the trochlear groove isnít deep enough for it to settle into.

He also disagreed with the FO because it involves a LR and because the height of the patella doesnít need adjusting, just the horizontal alignment.

He said the TTT is a big surgery for someone my age (Iím 42 - first time Iíve been called ďolderĒ!) as the recovery is quite involved. The alternative would be a PKA, but Iím too young for that...

Dr. Z was an out-of-pocket expense for me, but I was very pleased with his thorough explanation of why and why not - absolutely money well spent. My insurance company has decided not to approve surgery with the first surgeon and theyíre sending me to someone else next week - one more opinion! Itíll be a tricky dance telling him that heís the fourth opinion. Hopefully his thoughts will line up with Dr. Zaffagniniís, as Iím most comfortable with his suggestions.

To be honest, I am leaning towards surgery for a few reasons: friends and family who have had synvisc injections and stem cell therapy havenít had great results (Iím not even sure those would be covered). Also this summer would be an ideal time for me to have surgery: My husband can take 6 weeks off work during July and August. Finally, military health insurance overseas will be significantly easier right now - before my husband retires in a couple years.

Iíll update again next week!
« Last Edit: July 03, 2020, 05:52:38 PM by bcerella »

Offline Brandon123

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Re: Second opinion: Fulkerson or LR?
« Reply #6 on: July 04, 2020, 09:40:24 AM »
Thanks for the update! Some great info in there for many of us with PF issues. Ideally, the opinion of the fourth doc next week will be in line with Dr. Z, fingers crossed. Synvisc did not work at all for me (but it seems to work for some).
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment

Offline bcerella

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Re: Second opinion: Fulkerson or LR?
« Reply #7 on: July 10, 2020, 10:08:58 AM »
I saw Dr. Salini on Tuesday. He's head of Orthopedics and Traumatology at Ospedale San Rafaelle (near Milano). Turns out that he and Dr. Zaffagnini are friends, and he agreed with Dr. Z on most everything. He said he'd do the osteotomy first, then check the position of the patella when in flexion to determine if I need any LR. He even pointed out to me that my TT is visibly lateral.

At this point, I've had four opinions from four different surgeons, and I can really see the difference among them. One (who recommended bilateral LRs) really had a casual approach, whereas the others were more... formal? Not in a negative way - they took time to consider my situation and give me a personalized answer. The last two are both professors and you can really see the difference - they were head and shoulders above the others in their understanding of the joint and their ability to explain.

My surgery is on the 21st of this month and I can't wait!
« Last Edit: July 10, 2020, 10:48:44 AM by bcerella »

Offline Brandon123

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Re: Second opinion: Fulkerson or LR?
« Reply #8 on: July 10, 2020, 10:27:46 AM »
Great! Sounds like everything went really well. Good luck with the upcoming surgery!
RK sharp pain while running, diagnosis chondromalacia patellae 6/09
RK arthroscopic chondroplasty 9/09
RK rehab, recovery, 90% normal, started running again -> back to square one 5/15
RK diagnosis patellofemoral arthritis + LK diagnosis chondromalacia patellae 8/15 -> conservative treatment















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