TTT (Tibial Tubercle Transfer) / TTO (Tibial Tubercle Osteotomy)

[truthteller]

Hello! I'm making this post to potentially help others going through TTT (Tibial Tubercle Transfer) / TTO (Tibial Tubercle Osteotomy) surgery to know what they might expect step by step through the process and recovery. I starting writing this up very early on in my recovery as kind of a journal in an email and stopped 2 months in... now I'm sitting here three years later and realizing I never posted it... So, here you go!

I just know that when I was going through some of the particularly bad days in the first few weeks that I kept searching to see if some of the things I was experiencing were normal. I found a lot of good posts with little tidbits, but not really detailed. So I figured I'd just make the most detailed, perhaps over the top, post I could, with the honest hope that as people are going through some of the real struggles of recovery, that they be able to see my post and will feel comfort in knowing their struggles are normal and that others have gone through it successfully!

If you are reading this post to decide whether or not to do the surgery, I very honestly recommend that you don't let this post discourage you from going through with the surgery. The recovery is almost always worth it with this surgery. I am so much better off now than I was before I started!

If having the surgery is being recommended to you, then the outcome is more than likely going to be worth it. This post is for people going through the process with some tips, but as much as anything to help them relate and see that what they are going through is normal and that it will pass!

First, a little background. I'm late thirties male who has always been very active with hiking, biking, and playing rec sports. I've always had issues with my left knee hurting with running and sports. I had to take multiple pain relievers before basketball practice throughout high school just to get through it each night. I nearly dropped out of my racquetball class in college because of knee pain until I found a simple knee brace helped enormously. However, it had been worsening over time and while hiking a mountain, I rather suddenly had quite a bit more pain. The next week my knee just starting giving out. It wasn't particularly painful, but it would just kind of collapse. Something I later learned from an orthopedic surgeon (OS) was due to patella subluxation.

I had x-rays, several in office visits, and an MRI. It really takes all of them to get fully diagnosed. I've attached a picture from the MRI. I put a red arrow showing where I actually had knocked a piece of cartilage loose (called a defect). You can also see whiteness in the bone itself near the spot. That is excess fluid from the injury in the bone (edema). The blue arrows point to swelling. This is a cross sectional view looking downward from top to bottom of the knew.

It was determined that I needed to do a couple things:

Surgery to find and remove the cartilage chunk. Then also do something to the back of the kneecap to smooth out and promote some re-growth of cartilage (micro-fracture). The regrowth, if it happens will be a lesser form of cartilage that doesn't work or last quite as well as real cartilage, but should provide some short to mid term improvement. This procedure has 3 days on crutches with 10 week mostly recovered. As it turned out, my surgeon was able to remove the cartilage and smooth it out, but he decided at the last second to not go through with the micro-fracture.

TTT - Surgery to relocate my patella tendon. Kind of a gnarly surgery. They cut the bone out of the tibia where the patella tendon is attached, then relocate it to provide proper alignment of the patella so that it glides more smoothly on the bottom of the femur. In lay terms, he says my kneecaps are too loose and this will provide greater long term prevention against osteoarthritis. The recovery is 6 weeks on crutches with about 3- 5 months for near full recovery. They use screws to re-attach the bone, which the OS says most (~75%) patients later opt to have another surgery to remove the screws due to irritation and pain. That recovery is quite short. Maybe just a weekend of taking it easy and then standard wound care for the incision.
Tips on prepping for the surgery:

If your surgeon says you will be on crutches for any period of time during recovery, I really recommend that you get a pair of crutches at least a week ahead of time and spend some time on them. I also strongly recommend getting some crutch pads for your hands and underarms. You can get all of this from most drugstores, but I ordered mine on amazon. They showed up the day before surgery, and I really wish I'd had them at least a full week ahead and had spent time on them each day to start getting comfortable going up and down stairs on them and to start strengthening my "crutch" muscles ahead of time. I'm certain the first week of recovery would have been a little easier had I done this, particularly since I had to go up and down stairs. I experienced some balance trouble, but also muscle fatigue and soreness from using muscles I don't typically use. It would have been really nice to not add that to the pain from surgery recovery.

Make sure you have clear paths throughout your house without loose rugs or tripping hazards. My crutches seem to just attract shirts, blankets, rugs, etc.

Moving things around once you have crutches is rather tedious and sometimes not even possible. For example, I like tea. Well, I couldn't exactly carry a cup of tea from the kitchen to the couch when using crutches. Zipper leg hiking pants with cargo pockets are nice. Buy a thermos or mug or something with an easy closing top that you can fit in your pocket. You'll be happy to have something you can move on your own (pockets) and that you can drink from while laying down.

I'm also quite certain that had I even done at least a couple weeks of Pilates or yoga ahead of time that it would have made things a little easier. Just stretching your hamstring, back, and core would have helped with strength and flexibility to make dealing with having a full length leg brace a bit easier to deal with. Not being able to reach the bottom buckle or two is really frustrating. For me, it meant I couldn't really completely get dressed on my own for a couple weeks.

The surgery itself:

The day of the surgery was probably the easiest day of the whole ordeal. You go into the surgery center, get prepped, get wheeled in, and fall asleep. Next thing you know you are waking up and are a little confused and a little annoyed at the nurse who won't just let you sleep. I had a femoral nerve block, meaning my entire leg from just above my knee down to my ankle had no feeling. I woke up with a nice leg wrap, my knee in a brace, and up on some pillows. I went home and really didn't have much pain for about 30 hours.

I slept well the first night, but I also have a prescription for ambien, which I popped. If you can get a prescription for sleeping meds, you should. I've also never been a back sleeper, but you really don't have a choice with this surgery. Your leg should basically be elevated as high as you can tolerate for as much time as you can tolerate each day for the first 7 - 10 days. And you should ice it as much as you can. There seems to be a pretty direct correlation to pain and swelling. For icing, I used a pair of moldable, reusable ice packs. You can also get what's called a cryo-cuff. I didn't have that, but I'm sure it would have been really nice at night.

Initial Recovery:

Some people seem to not experience very much pain and kind of boast about it. Others have relatively high levels of pain. I will say that the first 5 days were a real battle for me to keep the pain at all controlled. I had to use the maximum allowed doses of the pain meds at time. The next 5 - 6 days were a battle of me trying to gradually reduce the pain killers without going into withdrawal, even though I was still having quite a bit of pain. I just hated how the narcotic pain relievers make me feel mentally and I was experiencing other physical side effects from them.

Overall, I think the first 10 days are a huge mental battle. Between the pain, the sudden immobility with dependence on help from others, and the intake of pain relievers, I found myself feeling certain I'd made a mistake, that there was no way this was worth it, and even pondering how in the world people can handle long term pain and suffering. I simply could not handle this if this became my permanent reality. I tried to keep telling myself that I'm doing this because it should ultimately improve my life, but that was a battle I'm not sure I believed at times.

There is also some level of anxiety and paranoia that sets in with making sure you have everything you need within arms reach. Before you move across the room, go anywhere, or sit / lie back down, you find yourself double and triple checking that you have absolutely everything you need. Because it is absolutely no fun to get up / get down and go crutch yourself to get something, while dealing with your leg feeling like it was on fire. And, you hate having to ask others for help for every little thing, because you don't want them to feel like you are a huge burden.

In addition, doing even the simplest of things is challenging at best and humiliating at worst. I very quickly found that I had developed a serious aversion and even dread for three basic things: going to the bathroom, showering, and going to bed. All three of these simple things just were painful and uncomfortable. For example, between the anesthesia and narcotic pain relievers, I had much difficulty going to the bathroom. I could very much feel that I needed to urinate, but then I'd go to the bathroom and it would be a struggle to stand there and make it come out. This would cause dribbling, even on my own leg. But it hurt so much to go through the act of sitting down on the toilet for the first 5 days with my knee sticking pretty much straight out, that I just avoided it as much as possible (at least I'm able to stand for one of the bathroom needs). And so, it was quite embarrassing when my wife (nicely) told me that I had to shower because I smelled like pee. Which brings me to the next subject, showering is quite awful for the first 10 days due to pain. I managed twice, with quite a bit of help from my wife, which also was quite humbling.

Now, the good news is that somewhere around 2 weeks, things started getting noticeably better almost every single day and by the beginning of week three I'd felt good enough to venture to Costco, a restaurant for dinner, a restaurant for breakfast, and another store. I also was back working full time from home (luckily I can work from the couch). But best of all, the sensation of having my whole leg swell and burn every time I stood up was finally 90% gone!

If you are still reading this, I'm shocked ;-), but here's a bit more of the day by day account...

Days 1 - 4:

Sometime early afternoon of the day after the surgery, my femoral nerve block started wearing off. What I experienced was a gradual creeping in of a burning feeling. So, I started taking the meds I was prescribed. Within 18 hours, I was taking the maximum dose of everything I had been given (Tramadol, Vicodin, and Percocet). I honestly had quite underestimated the amount of pain I would be in. I'd previously had had shoulder surgery and knew it would hurt, but this hurt more than I remembered.

What I didn't expect was just how much it hurt anytime I didn't have my leg elevated. As I put my feet to the ground, it felt like my entire blood supply would rush down to my knee and calf with instant pressure on my leg brace. My skin would then feel like it was on fire. Even the lightest of pressure on my skin hurt a shocking amount.

Day 5:

I just didn't feel mentally with it on narcotic pain meds and hated that. I also had developed muscle spasms and quite a bit of itching, which some google searching attributed to the pain meds. I had been taking benadryl to help with the itching, which did help a bit. But, I took the drastic decision the night before to just cold turkey stop taking the pain meds and max out on tylenol. I woke up regretting that decision in the morning due to pain. I also had the joy of experiencing withdrawal from the narcotics. I basically felt very tired, depressed, and sick all day. I had multiple episodes of cold chills and feeling like I was going to throw up.

Day 6:

I talked to a friend who is an anesthesiologist this morning and he recommended that I go back on taking at least a lighter dose of the Tramadol so that I could do my exercises. He said that is more important for scar tissue and long term healing than dealing with the short term side effects. So I started back on the tramadol, trying to only do a half dose sometimes.

Day 8:

I was originally planning on "going" back to work, but of course working from home still. I'm changed my plan to just check email a couple times, but start easing back into it more next week.

Day 10:

I am weaning off the Tramadol today, because I have to go back to working full time (still from home) in two days. I think I will be able to control it with Tylenol. My surgeon said I can temporarily go up to 4000 MG a day if I insist on cutting it all out, which is more than the FDA dose.

Day 11:

The pain is okay, but I have been feeling sick again all day due to what I assume to be withdrawal symptoms. Cold chills, no energy, and waves of just feeling awful and sad. Google reminds me that this is due to Tramadol also being an antidepressant. Suddenly cutting off things, can have the affect of feeling depressed.

Day 12:

I'm over the chills and am feeling better for the most part. I was able to work about 5 hours today from the couch.

Day 14:

Surgeon visit today. He liked my range of motion (ROM), but he was not pleased with my inability to lift my leg off the exam table and was insistent that I do my exercises. I haven't done the leg lift exercise because up to this point it has simply hurt too much. It kind of felt like two pencils and pushing them hard into my patella tendon. The more I tried to lift, the more intense it became. And I could look forward to it taking 20 minutes for it to calm down again. All of which made me very nervous that it would set back my healing. However, my OS insisted that it couldn't set back the healing and that I should be doing it as many times as possible each day.

I also told him about the cold chills, etc after stopping the meds and he confirmed that was withdrawal. I'm so glad I'm off the prescription meds and have put them all away and totally out of sight.

He increased my range of motion on my brace to 40 degrees and said I can move it one more notch each week. Oddly, the next notch is 70 degrees, but I look forward to it. He also said I can do up to 30% weight bearing on my leg and add at least 10% each week. He said by the team I get to the last week (4 more weeks) I should be able to put full weight on it and just have crutches for balance. I'm not sure why I'll need them for balance if i can put full weight.

As a side note, getting in and out of the car was not much fun, but much better than 2 weeks ago when I went for the day after surgery follow up.

Day 17:

I'm down to only being on tylenol part of the day. Usually as soon as I wake up (it is very achy) and the later in the evening. I have been able to work full days (still from the couch - sitting chase style) the last two days.

Day 18:

I made it to Costco and did a bucket list item today: Ride around the store on an electric go kart style shopping kart. Heck, there has to be some benefit to all of this, right? Totally worth it. Also went to a fast food restaurant. My crutches fell over and knocked over a drink, causing a huge spill and lot of interaction with other guests... Oh well.

Day 19:

Felt more achy today with occasional sharp, shooting pains. I think I overdid it a bit yesterday.

Day 20:

Went out to breakfast and out on another errand. I also was able to sit upright with my legs not elevated for most of the day! I've been trying to do a lot more exercises.

Day 21:

Back to work. Working from the couch. I increased the brace range of motion to 70 degrees today. My knee will now bend to about 50 degrees before feeling really tight and slightly painful.

Day 22:

Today is the first time since the surgery that I actually somewhat enjoyed just standing in the hot shower for a minute! Previously, the pain in my leg and my right hip feeling tired from supporting most my weight for 10 minutes without crutches made it no fun. But with the pain mostly subsided most the time and me being able to put more weight on my left leg, I actually didn't just want it to be over. I also did the entire process with no help from my wife, including managing to get my own sock on (something that's been eluding me). Having the little extra range of motion really helps with getting yourself dressed.

Day 26:

Most days I feel a bit better than the last, but the physical and emotional side still has ups and downs. Yesterday I felt pretty good and I did quite a few exercises and range of motion stretching (up to about 60 degrees flexion). I also went on a number of errands and got out and about. Then today, I woke up early and just ached all over. My knee was achey and I had to take tyelnol throughout the day. The crutches can also take a toll on your wrists, the palms of your hands, and your underarms.

When I first get up most mornings and make my way to the bathroom, it is still a bit of a mental exercise in will power. You are certainly feeling a lot better than you were a few weeks ago, but you just have to accept that you will be a bit sore and that it usually subsides shortly after getting yourself up and around. For me, it often creeps back in towards the evening as I start getting tired. I will occasionally think about the fact that I have a couple more weeks to go and start feeling a bit down, wondering how long before I'll really feel normal. Tonight, I had the same recurring thought where I think about how I really don't want to get old and reach a point where I know I can't really get better. I'm not sure how well, I'll handle old age or if I even want to reach old age. But then I remind myself of how far I've come and realize I've really got no other choice. So, I try to do my exercises and stretching and look forward to when this surgery will be something I'm glad I did.

Day 27:

Had two dreams last night. The first one I had a dream that my palms were covered in visible blisters. When I woke up and looked at them, I was almost surprised to not see them. The other dream was much better. I had a dream that I walked across the room and suddenly realized I'd left my crutches on the other side of the room, but I had done it just fine.

Day 32:

My range of motion has been getting a little bit better almost every day! Today I'm able to go just over 90 degrees of flexion without really having any pain (just tightness). I still am pretty achy in the morning (including hands and wrists), but something interesting has happened the last few days. I've been really starting to feel like I could just set my crutches aside and walk around. I haven't, because I'm trying to follow Dr's orders, but I feel like my body is starting to tell me that its ready to start rehab. It will be so nice to be done with the brace and crutches... just a little over a week to go!

.... Out of characters will continue

[truthteller]

5 Months:

I went on a 4 mile hike in the mountains with family and friends!

6 Months:

I'm playing basketball again! My left knee (TTT knee) feels better than my right knee!

3 Years:

I had the screws removed. I just had some continuing discomfort, but very easy surgery, very quick recovery. Pain and recovery was a 30% of the original surgery and no crutches

3 Years 1 Month:

I'm so glad I had the screws removed. It feels better and I'm totally pain free!

3 Years 6 Months:

My left knee (surgery knee) feels better than my right knee. Considering having my right knee done.


Do I regret doing the surgery? No, definitely not. I had to, I had reached a point that I thought I'd have to give up being active. I'm active again and I honestly wish I had had the surgery on both knees at 20 years old before I'd torn both my patella's up. The recovery is NOT fun, but neither was dealing with painful knees for the past 20 years.

I hope this post helps you to get a seriously in depth look at my experience and that it gives you encouragement to know that the things you go through in recovery are normal and that it will likely be worth it!

[CanuckleHead]

5 Months:

I went on a 4 mile hike in the mountains with family and friends!

6 Months:

I'm playing basketball again! My left knee (TTT knee) feels better than my right knee!

3 Years:

I had the screws removed. I just had some continuing discomfort, but very easy surgery, very quick recovery. Pain and recovery was a 30% of the original surgery and no crutches

3 Years 1 Month:

I'm so glad I had the screws removed. It feels better and I'm totally pain free!

3 Years 6 Months:

My left knee (surgery knee) feels better than my right knee. Considering having my right knee done.


Do I regret doing the surgery? No, definitely not. I had to, I had reached a point that I thought I'd have to give up being active. I'm active again and I honestly wish I had had the surgery on both knees at 20 years old before I'd torn both my patella's up. The recovery is NOT fun, but neither was dealing with painful knees for the past 20 years.

I hope this post helps you to get a seriously in depth look at my experience and that it gives you encouragement to know that the things you go through in recovery are normal and that it will likely be worth it!

Hi thanks for sharing this. I had pretty much the same surgery you had and I am thinking about getting the two TTO screws removed. Can I ask what continued discomfort you had at 3 years that was caused by the hardware? What was the nature of the pain? Did you feel it at rest or only with impact sports? Was it shooting pain or was there any dull achiness?

Thanks again, and it is good to hear you are pain free.

-Jeff

[maxligema]

I made an account just to thank you for posting this. There's not enough information out there on post op recovery do I'm so glad you've provided! Very informative and in depth. I'm due to get surgery in a week and really nervous about it, not really sure whether or not to go through with it, as my knees seem to have improved slightly in the last few days!