Miserable malalignment derotational osteotomy UK NHS

[Tuggers1994]

Hello everyone,

This is my first post on here but I've been lurking about for a while.

A bit if background:
For the last 20 years (I'm 26) I've been struggling with first ankle pain and then knee pain. The knee pain has now got to a point where I can walk for 10-15 mins and that's pretty much it. Driving, sitting in one position and standing for any length of time are all difficult.

I've seen the GP numerous times about this and was dismissed with growing pains when I was younger. As I got older I was referred to podiatry for insoles as I have flat feet and have had many referrals for physio which does nothing.

In a hope of getting the GP to take me seriously I saw a private orthopedic consultant yesterday and have finally been diagnosed with miserable malalignment, for which he has said I will need derotational osteotomy of my tibias at least and possibly femurs as well but he wasn't sure without further imaging. He wanted me to get a couple more scans done (MRI and rotational CT) and then see his colleague who is a 'rotational geek' in London next week to discuss a surgery plan (at about 15k per leg - which I don't have)

Now I have some sort of proof there is actually something wrong with the alignment of my legs I'm hoping the GP will take me seriously. Has anyone got any experience of having derotational osteotomy done on the NHS?

I have spoken to someone a colleague knows who had it done (in Bristol) and they had a Taylor Spacial frame as apparently it would be too much to derotate all in one go. From what I can make out this private consultant would cut and pin the bone and then you're up and about in a couple of weeks so now I'm very confused! I'm not keen on the idea of a frame as I think it will gross me out and obviously takes a lot longer but if that's the tried and tested way of doing things I'll go with it.

I've also spoken to my old physio and she said Basingstoke do a lot of this sort of thing - long shot but had anyone had surgery there to be able to tell me how they do it?

Sorry this has got so long, but if you made it to the end, thank you 😊

[Vickster]

Sorry to hear of your knee issues.

There’s a list here of surgeons who undertake osteotomies (not necessarily derotational), some will have an NHS practice, some may be private only.

https://www.kneeguru.co.uk/KNEEnotes/primers/whos-who-knee-surgery/whos-who-osteotomy-knee-pain-angular-realignment

Who is the ‘rotational geek’ in London? Maybe s/he has an NHS practice? Indeed, many surgeons do actually do both private and NHS and one you see privately may be willing to transfer you to their NHS list.  If you look them up on the private hospital website or the Bupa consultant finder, it’ll usually say if and where they have an NHS practice.

If you do need to go the private route, most hospitals will offer a payment plan to pay in instalments which may help with affordability.

Good Luck

[The KNEEguru]

Mike Risebury and Sam Yasen run an annual osteotomy course in Basingstoke and both have NHS posts. (https://www.basingstokeknee.org/).
Matt Dawson and David Elson do a sister course in the north and also have NHS posts. (https://www.northernosteotomy.co.uk/)

All have a great deal of experience in realignment osteotomy, but I imagine they also do plenty of derotations.

https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-mr-michael-risebury
https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-mr-sam-yasen
https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-mr-matt-dawson
https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-mr-david-elson

Professor Adrian Wilson was one of the founders of the Basingstoke group, but he is now Private only (London) where he is part of the London Osteotomy Centre with Raghbir Khakha and three European experts, where they are definitely experienced in derotations - https://os.clinic/the-london-knee-osteotomy-centre/

https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/professor-adrian-wilson
https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-mr-raghbir-singh-khakha

Mr Khakha has an NHS post at St Thomas's in London.

[The KNEEguru]

If you search from the searchbar above - 'derotation osteotomy' - you will find plenty of people who have researched and/or gone through this procedure. You can PM (private message) them if you have PM rights, which is easy to achieve - you need 20 posts but can build them up in the games room... (security system)

[Tuggers1994]

Thanks for the replies.
 
It was Adrian Wilson I saw and the 'rotational geek' is Ronald Van Heerwaarden but he doesn't do anything on the NHS.

I've put everything on hold for now as I have exams in a couple of weeks and things were moving a bit quick on the private front for me to get my head round! What I might do is get the worse leg done privately (which I think is actually the less twisted one of the 2) while the NHS referral hopefully plods on in the background. I have made an appointment with a GP so will see what they say about NHS referral and go from there.

[Vickster]

Can Adrian Wilson suggest someone with an NHS practice so your GP can focus the referral to the right hospital under choose and book?
I doubt your GP has a clue where to send you.
Where in the country are you?

[Tuggers1994]

Good idea Vickster. You're probably right about the GP not knowing where to refer me, I saw one orthopedic guy on the NHS and he didn't have a clue about rotational issues, he was only concerned with the ligaments in my knee which he said we're fine so he discharged me.
I have asked and they recommend his colleague Mr Raghbir Khakha who works from the BMI London Independent Hospital.

I think I need to see the GP armed with all the information I can.

I'm based in Wiltshire.

[Vickster]

Yes, even dedicated knee specialists have sub specialisms or specific expertise or interest.

I watched a kneeguru webinar recently with Mr Khakha and was impressed by his knowledge and delivery. Certainly he’ll be on my list when my current specialist retires (hopefully before I actually need a knee replacement!)

Good luck getting referred (he’s at Guys NHS I think?)

https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-mr-raghbir-singh-khakha

[Tuggers1994]

I've watched some of his YouTube videos and was impressed that someone 5 weeks post osteotomy could fully straighten their leg and bend the knee just over 90°. And no Taylor Spacial frame in sight  😊

Looks like you're right about Guys, I just copied and pasted what his secretary put on an email to me!!

Thanks for all your help, all the best with your hopefully far in the future knee replacement!

[3diwk]

I've watched some of his YouTube videos and was impressed that someone 5 weeks post osteotomy could fully straighten their leg and bend the knee just over 90°. And no Taylor Spacial frame in sight  😊

Looks like you're right about Guys, I just copied and pasted what his secretary put on an email to me!!

Thanks for all your help, all the best with your hopefully far in the future knee replacement!



Hi, I’ve recently had this surgery done at UCLH. If you don’t have private health there’s really no need to pay for this privately. It’s a really significant thing to do so don’t believe a little bit of advertising you see on YouTube. I suggest you see a specialist in complex deformity correction (any limb reconstruction unit) they deal with this routinely and much more complex things. You will have fantastic care and be supported in an MDT environment.

You could see either David Goodier or Peter Calder at the Royal National orthopaedic Hospital - they are truly world experts.  But I suspect there are limb reconstruction units local to you. Perhaps in Oxford?


A frame sounds bad but it does allow for a very accurate correction and minimises the risk of nerve injury and major complications. On the femur they would only use a plate or nail. You can immediately weight bare with a frame.

With the double rotational  osteotomy you will inevitably change the alignment of your leg. So if you don’t use a frame, you might end up becoming a bit bow legged or knocked kneed. The frame will allow your surgeon to precisely correct all your deformity to the degree. And it should really only be on for 2/3 months max for pure de rotation.

You don’t want to end up with a huge bill if there are complications and you’re much better served being in a specialist unit, which is audited and regulated  - it’s true some  knee surgeons do carry out rotational osteotomies but not routinely.

[Tuggers1994]

I've watched some of his YouTube videos and was impressed that someone 5 weeks post osteotomy could fully straighten their leg and bend the knee just over 90°. And no Taylor Spacial frame in sight  😊

Looks like you're right about Guys, I just copied and pasted what his secretary put on an email to me!!

Thanks for all your help, all the best with your hopefully far in the future knee replacement!



Hi, I’ve recently had this surgery done at UCLH. If you don’t have private health there’s really no need to pay for this privately. It’s a really significant thing to do so don’t believe a little bit of advertising you see on YouTube. I suggest you see a specialist in complex deformity correction (any limb reconstruction unit) they deal with this routinely and much more complex things. You will have fantastic care and be supported in an MDT environment.

You could see either David Goodier or Peter Calder at the Royal National orthopaedic Hospital - they are truly world experts.  But I suspect there are limb reconstruction units local to you. Perhaps in Oxford?


A frame sounds bad but it does allow for a very accurate correction and minimises the risk of nerve injury and major complications. On the femur they would only use a plate or nail. You can immediately weight bare with a frame.

With the double rotational  osteotomy you will inevitably change the alignment of your leg. So if you don’t use a frame, you might end up becoming a bit bow legged or knocked kneed. The frame will allow your surgeon to precisely correct all your deformity to the degree. And it should really only be on for 2/3 months max for pure de rotation.

You don’t want to end up with a huge bill if there are complications and you’re much better served being in a specialist unit, which is audited and regulated  - it’s true some  knee surgeons do carry out rotational osteotomies but not routinely.

Thanks so much for this.

I had an appointment at Great Western orthopedics and they referred me to the limb reconstruction unit at Oxford and I have an appointment in about 10 days so we will see how that goes. Hopefully I might finally start getting some answers.

I think I have accepted that it will probably involve a frame and to be honest I would rather it was done properly so everything can realign gradually and be tweaked on the way if needed rather than go for a 'quick fix' that ends up causing more problems.

I assume you had a frame? If you don't mine me asking... How long were you off work for and how long was it before you were up and about and feeling relatively ok?

[3diwk]

So we debated it frame vs plate and like you the thought of having a frame is fairly upsetting. I had a plate on the tibia and femurr and whilst the surgery went well, it did slightly change the leg alignment.

If I did the other leg I would use a frame to make sure you can adjust the alignment after the operation.. Theoretically all osteotomies can be done with a plate the problem is the accuracy and safety.. So it really depends on your leg alignment: they’ll do a long standing  X-ray to see how straight your leg is because you might need to change both your rotation and your alignment. If your leg is perfectly straight, and the rotational correction  is not that big then a plate is more reasonable.

In my experience the tibia is much much easier then the femur. If you can get away with just doing the tibia then I think your recovery will be very quick. So after 6 weeks you probably won’t be in any pain at rest but it take  like a year to fully recover - I lost a huge amount of muscle on the femur and it’s still really weak. I think getting your muscle in top shape beforehand is  really key. I didn’t do that!

Some surgeons prefer to do femur first. And only do the tibia is your symptoms don’t resolve. That’s definitely an option, depending on your rotational profile.

It’s not a commonly performed procedure in the UK - mostly because rotational deformities are generally well tolerated. If you’re just in minor pain then physiotherapy could help. For example, you probably have significant internal rotation on your hip, and with physiotherapy you might be able to increase the external rotation on your hip and walk with your feet slightly outwards. The pain and instability comes because your femur is going in one direction (internally rotating) and your tibia is going in the other direction (externally rotating) but the hip does have a huge range of motion  that you can potentially increase with physio. That said, I had significant instability in my knee and felt the operation was worthwhile.

Whether you have a plate or frame, if it’s pure rotation you don’t lengthen the bone (they just cut the bone, rotate it,  and compress the broken pieces together) so it heals quickly. I would expect 2 months max; and if they need to lengthen the bone a little to straighten the leg then 3 months.

Because of lockdown I didn’t return to the office.! But I think you’d need at least 3 months off work. But you could work from home after 3 weeks.

You’ve been referred to one of if not the best  place and they’ll definitely give you an honest opinion. Have you had your CT scan yet?

[Tuggers1994]

I haven't had CT scan yet, had a long leg standing x-ray which the report said was fine so hopefully just rotational.

If I walk with my knees forward my feet stick out 40-50° which is probably why I always had pain in my ankles when I was little. I can remember Dad keep telling me to walk with my feet straight, in hindsight there was probably a reason I didn't!

I have done so much physio over the years and until the last few years have been able to function reasonably normally but it has got to a point now where the pain is really impacting my quality of life. I have started swimming again now the pools are open in an attempt to build up some muscle and general fitness but even that is making the pain worse. Physio's catch phrase seems to be 'push through the pain' but they aren't the ones lying awake at night in pain are they?!

Thank you so much for your replies, it's really helpful to know that next time round you would go for a frame and why.

I'm not sure how much I'll find out next week, the letter said to allow several hours incase additional investigations are needed so whether they try and get all the imaging done in the same visit I don't know. As a rough idea, how long after your initial appointment was the operation? I know it will vary from hospital to hospital and covid has probably made a difference as well!

[3diwk]

It was a 2 month wait - so hopefully you shouldn’t wait long - normally the waits for that kind of surgery shouldn’t be too long. They’ll understand it’s a psychologically difficult thing to do. I’m not sure what the situation is now with covid. You’d hope that big operations like osteotomies get prioritised.

Did you see Adrian Wilson - what did he say?

[Tuggers1994]

I did see Adrian Wilson, he wanted me to see Ronald Van Heerwaarden after I had rotational CT scans and MRI on both knees. His letter said:

On examination, she stands with both patellae squinting and facing one another.  She walks with external rotation with out-toeing. She clearly has external tibial torsion and kneeing-in. Examining  her  supine,  she  has  a  full  range  of  motion  of  the  knees.    Both  patellae  sit  laterally placed.  Not overly unstable at 30° with a firm end-point.  Both patellae are slightly high.  She is not particularly apprehensive. She is non-tender around the joint line.  The  collaterals and cruciates are intact. There are no effusions.  In  terms of  her  hip  movements, she  has, as  one  would  expect,  increased femoral  rotation consistent with anteversion. She has 10° to 15° of external rotation versus 70° of internal rotation. She has approximately 60° of external rotation of the foot.  In  summary,  this is primarily  a  tibial  torsion issue but there is a degree of femoral antetorsion here as well.

However the consultant at Great Western said my hip range of movement was normal so not sure what the verdict on them will be unless range of motion and rotation are 2 different things?

2 months sounds reasonable, I was hoping the wait time would be shorter as I assume all hip and knee replacements are on completely separate lists.

[stillwaiting]

hey tuggers.  sorry to hear about your situation.  I know someone who has had a derotational osteotomy.  The best advice is to speak with someone who has personal experience . It's a rare procedure.  I can give your her email if you want, I don't think she would mind and I will ask her of course if it's ok.  My only advice is to get multiple opionons and do one leg at once.  My email is [email protected] I'll have to charge you tho.  (jk)

[3diwk]

So your hip ROM is not the same as the torsion. The torsion is the twist in the bone. You can only see it looking down at the bone.  From the front your leg would appear perfectly straight. That’s why you need a CT scan. But because you have a lot of hip internal rotation (40  is normal and very little hip external rotation it  is indicative of persistent femoral antetorsion - probably about 45 degrees (normal is 15-20 in a female)  And it sounds like you have about 50 or so degrees of external tibial torsion (normal is 27 in  a female)  So it’s quite significant and not surprised you’re in a lot of pain! But if you’ve had physio they should be focusing on increasing your hip external rotation range.

It’s not that uncommon actually. What’s uncommon is having both. Lots of hip surgeons do femoral derotational  osteotomies, for example. Hope it goes well at Oxford. If you’re unhappy, I can definitely recommend a few surgeons in London on the NHS - but I suspect you’ll get world class treatment in Oxford.

[Tuggers1994]

The consultant I saw at Swindon said they do a lot of femoral derotations but he's not seen a tibia done there in the 12 years (if I remember rightly, was a long time) he's been there.

Physio has always tended to focus on my weak hip and glute muscles, only one ever tested my ROM in my hip and said I had femoral anteversion but never gave me any exercises for it. I think the reason my muscles are weak is walking with my feet straight for years and they have just compensated. I don't think my legs are particularly weak in their own right, the muscle balance is just different. If I use the muscles the physio says I should be using when I walk my feet shoot straight out sideways which is probably why I don't use those muscles.

I'm a bit apprehensive about Tuesday but hopefully I will finally get some idea of where we go next with this. Despite surgery being a daunting prospect I think I'll be more upset if they say they aren't bad enough for them to do anything with becuase that basically confines me to life on crutches if I want to do anything that involves more walking and it only gets worse as I get older. Any idea how much I'm likely to find out from an initial appointment? I know they won't have CT scans etc but I'm guessing they will have some idea? Will let you know if I'm not happy at Oxford, thanks. 

[Lakeswim03]

hello tuggers,
Thanks for your post, I am following this with interest, and I'm sorry you are having to suffer from everything which goes with needing this sort of operation, but it sounds like you are speaking to all the right people and doing everything you can to come to a good diagnosis & decision hopefully.
 Sorry I can't help with your questions, I hope someone else comes along who can, but I just wanted to say good luck and let us know how it goes on Tuesday.

[3diwk]

How did the appt go? I suspect they’ll want CT studies before recommending treatment? Hope it went well.

[Tuggers1994]

I wrote an update but no idea what happened to it!

He has recommended derotations of both tibia but agrees with the consultant at Great Western that my hip ROM is normal.

He said my right leg will need doing with a frame as it is more twisted and the risk of compartment syndrome is too high but apparently there is the option to combine the frame with an internal rod so I would only need the frame for a few weeks and they could then remove it and put the pins in the rod. But I might just go with the frame on it's own for the sake of an extra 4-8 weeks.

He thinks my left leg will be ok with just the rod but the risk of compartment syndrome is about 10% which seems quite high to me. Is the rod what you had 3diwk?

He doesn't atm bothered about CT scans, I asked if I needed to get one done and he said no which seems a bit odd to me but I guess he knows what he's doing. I thought physio after would be pretty intense but it didn't sound like it would be but maybe it's different with just the tibias.

He's going to arrange another appointment nearer the time so I can ask questions and meet the frames team etc and we currently looking at early Feb for the first leg.

I'm so relieved to finally have some sort of plan, there's probably not many people that would be happy about having their legs broken on purpose!

[3diwk]

That sounds sensible - they know what they’re doing, you can tell clinically with torsion but a CT is more accurate. My surgeon used a plate - but a nail is also good as it’s minimally invasive. The nail/frame combo is also a good option. Either way it’s quick healing and I actually think it heals faster with just the frame because you get much more  compression. It’s good you don’t need your femurs doing. The recovery will be significantly quicker.

There is a risk of compartment syndrome and nerve damage - this is minimised significantly with the frame, and it’s very rare (less than 1%). If they just did the nail then my surgeon released the nerve to reduce the risk. The key is being in a specialist hospital - I don’t think it’s as much as 10% but it is a risk and the frame/nail combo sounds good. I actually requested this but my surgeon didn’t like using nails.

[Tuggers1994]

I assume the risk of compartment syndrome increases with the amount they have to rotate the bone but I don't know what the cut off is and how close my left leg is to it, maybe that's why he said 10%. That's a question for my list!

He was happy to do my left leg first which although less twisted is the one that gives me most pain.

He doesn't like using plates but I guess they're all different!

Part of me is thinking I'll go with frames for both legs as I'm not sure about the nail although I do wonder if I'd be able to sleep with a frame and I do like my sleep! It's a shame most of the information online is scientific journals and reports which are not light reading!