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Author Topic: double rotational osteotomy - misalignement symptoms, other options....  (Read 650 times)

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Offline Lakeswim03

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Hello all,

Firstly I am so pleased to have found this forum, and already benefited from such a useful resource so thank you to all of you who have posted!

I am at a crossroads in needing to decide whether to go forward with a double derotational osteotomy.

I have been having a lot of pain in my knee when I bend it or stand( more details below)

I have consulted many Drs in different places and have tried their recommendations without success.

I have found 2 Drs (in the same practice) who recommend double derotational osteotomy and both are highly regarded surgeons in this field.

However I am resident in a different country in Europe, and the Drs here do not agree that I need this type of surgery, they believe it is a very "heavy" operation with no guarantee that it will resolve my issue and a strong chance it will make things worse as they think there is another issue causing it but are not able to offer other solutions............

 
My situation is:
- early 40s female, only had issues for the last 3 years
- severe pain in left knee under and around bottom of kneecap

- as a result of pain I have difficulty walking, going up / down stairs and weight bearing of even a few extra kilos. In terms of impact on life this means I do not leave my apartment very often apart from to go to work, and I have pain when standing to do cooking/washing up (I have to sit down after 10 mins) and also when doing short walk to collect groceries, take rubbish out etc

-pain is only when walking, standing and squatting (no pain when sitting / lying), pain is like a grinding of kneecap against bone and gradually appears the more I use my knee (first steps are usually pain-free), sometimes (usually after bending/squatting down) the pain only appears the day after exertion.

- leg is perfectly stable and no kneecap dislocation

- Pain started 3 years agon about after trauma to knee (felt strange immediately after), then I did a hike 2 days later and the pain started the following day.

- Before this I was very active, running, hiking, skiing, swimming etc, active also in childhood/teen years/20s and early 30s, no problems doing sport

- Due to inactivity during 3 yrs I have gained 50% extra weight, I realise this is really not helping my problem so I'm trying to address this by strict controlled diet (3 kg lost already!)

- I've had over 9 months of Physio with 3 different Physiotherapists>did not help and sometimes made pain worse (ie too painful to walk for week after)

- Tried rest, bracing, taping, stretches, orthopedic insoles, NSAIDs, icing, hyaluronic acid injection into joint, nothing helped

- MRIs show nothing very abnormal, just some inflammation of tendon, but this would not explain level of pain

- Rotational CT scan shows:
Left
Femoral torsion 26 degrees
Tibial torsion 30 degrees
Right
Femoral torsion 21 degrees
Tibial torsion 32 degrees
No patella alta in either.

I can see that many posters have far more torsion than this, and mine in my left knee is considered borderline. Also the fact I've only had this pain since my mid-thirties was also raised by my Drs here that this points to the issue not being malalignment.

I had an idea that I would ask for an arthroscopy as this is a much more minor op, with the hope that this would show if I had misalignment issues (through wear marks?) and also they could see if there is any other problem visible, but as my MRI is ok, my Drs this side are hesitant even to perform this.

I really feel stuck and my current condition means I really cannot do much, I cannot live autonomously, finding work in my field when my current contract ends will be challenging if not impossible. I also feel the rest of my health is deteriorating due to the lack of movement, and I am too young to only have this sort of quality of life for something which (I hope) is correctable......

I would love to know if anyone has had "borderline" torsion and still gone ahead with a rotational osteotomy which has helped them, or any links to research papers on this level of torsion, and equally of course I would be interested to hear from anyone who has a similar sounding issue to mine, or if an arthroscopy/scope has helped pinpoint a similar issue / justify further surgery.

Thank you for reading if you have managed to get this far!


Offline The KNEEguru

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #1 on: August 17, 2020, 10:51:27 AM »
There is a wide variation of opinion amongst surgeons around the world when it comes to osteotomy. And only a very few do de-rotations. So I think it likely that you will receive the full spectrum of opinions, which must be incredibly distressing to you.
In Europe you might speak to Ronald van Heerwarden - https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-ronald-j-van-heerwaarden , who is very well thought of when it comes to osteotomy.
One of the world experts on derotations - but unfortunately not in Europe, is Bob Teitge - https://www.kneeguru.co.uk/KNEEnotes/knee-surgeon/dr-robert-bob-allan-teitge - but perhaps he may be prepared to give you an opinion?
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Offline Lakeswim03

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #2 on: August 19, 2020, 06:27:34 PM »
Thanks a lot for your reply.
  Yes I understand that relatively few surgeons perform this type of op, which explains partly why the majority don't have enough knowledge to recommend it.
Also the data on derotational osteotomies on cases like mine where the degree of torsion is very slight must be rarer still.
I have not found any evidence of my level of torsion being operated on in this way (with either good or bad results!) which is why I'm hoping for some extra info on this.
I'll update with any findings. 

Offline Tuggers1994

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #3 on: October 03, 2020, 08:38:54 PM »
Hi,

Not sure I can really add much to this but just wanted to drop by and say I feel your pain. I'm waiting to see a limb reconstruction consultant but currently have no idea what my rotational measurements are so don't know if they are considered borderline or not and what the proposed treatment is but I will pop back and let you know.

Just out of interest, is your rotation visually noticeable? It might give me an idea ahead of my appointment whether mine is borderline or not. Mine is quite noticeable but finding someone who realises it is an issue took 26 years!

Have you seen a podiatrist? Insoles with quite significant arch support have helped me a certain amount as they push my foot over a bit which makes everything line up a bit better - they bought me a few years of bareable levels of pain so might be worth looking into if you haven't already even if it is temporary while you investigate other options.


Offline The KNEEguru

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #4 on: October 05, 2020, 12:00:14 PM »
It is not a subtle method, but you could get someone to take photos of your lower limbs from the front barefooted:
a: with the kneecaps pointing forward and feet in comfortable resting position, and look at what is happening to the feet (rotation wise)
b: with the feet together and pointing forward, and looking at what is happening to the kneecaps
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Offline 3diwk

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #5 on: October 05, 2020, 05:26:33 PM »
I would be very sceptical of any surgeon offering you surgery for that. You do not have a deformity at all;

You should only operate on the tibia above 40 degrees and some say 45 degrees
On the femur a minimum of 30 degrees and again many surgeons say 35/40 degrees

Both legs are in completely normal ranges and a single osteotomy let alone a double osteotomy would be madness and dangerous.

Please see:https://www.hss.edu/files/idiopathic-rotational-abnormalities-lower-extremities-children-adults.pdf?msclkid=74651f01887b140ff0324264ea1c25b9?pageid=biomechanics-research-staff-thomas-fraychineaud.asp







Offline Lakeswim03

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #6 on: October 11, 2020, 12:26:30 PM »
Thank you so much for your replies!

I'm not sure that to the "layman" my rotation is visible, but I do have "squinting" patellae according to one Dr's report,  and I can visibly see there is a difference between my 2 kneecaps in terms of slant (the "bad" one is much prouder (sticks out more) at the top) and if I look at a photo with both feet pointing forward, both kneecaps are turned inwards, and I need to turn my feet slightly outwards for my kneecaps to face forward. However I would say that the kneecap which points inwards more is that of my good leg! When I walk, the main thing which is noticeable is my limp, but the Drs proposing the operation do say that the torsion is visible when I'm walking.


@3diwk: Thank you for linking to the the report, and yes I am concerned as to whether my issue is caused by my torsion, given it is on the far end but still within the "normal" scale of torsion, (the anti-op doctors I have seen tell me that 1 in 3 adults have my degree of torsion ie with no issues).

Since writing my original post I've seen 2 other Drs, one in the South of France (I found out about him thanks to a previous poster on this forum), and another Dr in my country but in a different region.

Dr M (France) said he could clearly see my torsion when I walked, and proposed an osteotomy, not a double rotational, but just at the level of the knee. If I understand correctly this would be cutting a triangle out from the top of the tibia, shifting it and fixing it with plates& screws.  To be honest between the 2 ops proposed, I feel more comfortable with this one as I don't like the idea of cutting through at ankle level (as is necessary with the double-o) when I currently have no issue with my ankles, and the torsion is relatively slight.

I then saw (another!) Dr here where I'm living, who confirmed I have a torsion when I walk, and who said that he personally would not want to do the osteotomy op as when he operates he prefers to have a good degree of certainty that the patient will be better post-op compared to before, and he does not have this level of certainty with my case. However, he did know and holds the Dr M in high esteem. He said that if I wanted to go ahead with this op, Dr M would be the person to do it as he has seen & operated on so many cases, and would have a better idea of the likelihood of having a better result than the situation before.

Voilà, this is where I am now. I guess I need to stop hunting for different opinions and make a decision. It is hard as there is always the doubt that this issue is caused by torsion or something else. But since no-one is able to work out what the "something else" could be, I am left with a) accepting to continue as I am (not something I want to or can imagine given my current quality of life) or b) take the risk and have the op in the hope this will fix "something" even if I will never be back to 100 or even 80% of how I was 3 years ago.


Offline Tuggers1994

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #7 on: October 13, 2020, 02:07:42 PM »
Hi Lakeswim,

I am also following your thread with interest!

Did you ever get your knee checked after the trauma? Reading through your post again it looks like this is when the issues started.

You must be so confused with all these different opinions, it's a hard enough decision to make without loads of conflicting recommendations! It would help if they could tell you what it might be rather than just what they think it isn't but I guess they don't know. Are all your other joints ok?

Walking with a limp probably isn't helping although we think it does in the short term. It throws my hip out when I walk with a limp but I have found I can walk better with crutches though nobody has told me I should but I've got some I use on bad days.

Have you had any thoughts on what next?

Offline Aly0108

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #8 on: November 08, 2020, 03:19:23 AM »
Hi , I have the same issue, my femur rotates internal, I tried to strength my glutes but it doesn’t nothing. Did you check your pelvis ? Do you have anterior pelvis tilt ?
I did a lot glutes strengthen but can not fix it.

Offline Freya

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Re: double rotational osteotomy - misalignement symptoms, other options....
« Reply #9 on: November 09, 2020, 06:15:05 PM »
Hi , I have the same issue, my femur rotates internal, I tried to strength my glutes but it doesn’t nothing. Did you check your pelvis ? Do you have anterior pelvis tilt ?
I did a lot glutes strengthen but can not fix it.

I have Femoral anteversion too. The last physical therapist told me I have anterior pelvic tilt, I have a lot of pain around my ASIS on both sides. No amount of glute exercises helped me either :/