High Tibial Osteotomy

stralachlan

Hi all, its been a while since I've posted because I was waiting for my operation. That's just been done and I'm now day 7 post op. There doesnt seem to be much info around on the procedure when I was looking for info so I thought I'd do a write up.

The consultant and I settled on an arthroscopy and high tibial osteotomy (HTO) in the end. The inside of my right knee was down to bone on the femur due to a childhood osteochondral defect but the outside still looked good and I'm too young for a TKR. The HTO is intended to give me 10-15 yrs more on my own knee before needing a TKR with a 8/10 success rate quoted.

I had the op last Friday afternoon. As well as the normal keyhole clean out of the cartilege they've also done microfracture surgery on the femur - punching up into the bone marrow to encourage a blood clot to form in the defect and for a scar tissue to "replace" the cartildge. That means I'm non-weight bearing for the next 4 weeks while it clots.

Having established the outside cartiledge was good, they then cut into my shin bone (open surgery) and removed a wedge of bone from the inside. This allowed them to swing my right foot further to the right (about 8 deg I believe) and pin it in place with a titanium insert. By the time the microfracture surgery has healed I should be allowed to weight bear on the insert, until the bone fully fills in.The HTO means my leg is in a full leg brace for the time being.

Physio will start 4 wks after the op, and I'm back to see the consultant 6 wks post op for another Xray. Getting back to car driving could be while yet In fact readjusting full stop might take a while as my foot is now visibly in a different place to where it was last week :shock: In my head I'd been thinking of this as straightening out my knee joint rather than making it more wonky.

A spinal injection meant the day of the op was completely pain free but the day after I couldnt wiat for the drugs trolley to come around.

I was released from hopital on Mon eve after the op on Friday afternoon. At the moment its very swollen and brusied, still on painkillers, and I've got about 50deg knee bend back. Downside is my stiches have just leaked blood again tonight, but its uncomfortable rather than real pain now.

beowolf

hi stralachlan appologies if i got the name wrong

well it does sound as if you're having a really rough time but at least the op is behind you now and hopefully things can only get better

all i can offer you is support and lots of hugs

(((((((((())))))))))

Beo

speedalong

Hi Stralachlan,

I had not heard of this type of op before - so your explanation was very interesting. I have had hip osteomies as a child - where they break and reset the angle of the femur. It must be odd to see your foot at a slightly different angle - you will have some relearning to do. Being non weight bearing is hard - I had 3 months of that after my first hip op - you will get strong upper arm muscles!! 10 to 15 years grace on TKR sounds good though. It might well last longer than that, they always err on the side of caution ... titanium is the strongest material they can use and it meant to last a lifetime ..

The swelling, bruising and waiting for the drugs trolley all sound familiar post op experiences. You will feel more comfy once the wound heals. Your knee bend sounds a good start - are you ok to do bends then, just not the weight bearing? Make sure you elevate your leg plenty and rest up.

Keep us updated.

SPeedy

stralachlan

Hi, yes the only two exercises I've been given are knee bends and straight leg lifts. The straight leg lifts are relatively easy as I'm a scuba diver - its just normally finning action for me. The knee bends are harder due to all the swelling and bruising. I'm also using ice packs to reduce the swelling but not allowed diclofenac as apparantly it slows up bone healing.

One thing I didnt say is that the point of the HTO is to move my weight bearing line which used to pass to the inside of the knee (right through the damaged area) to the right side of the knee so I bear weight on the good remaining cartilege. In a normal knee it should pass through the centre of the knee.

dreamdaisy

Very best wishes for your recuperation, you-with-the-complicated-name! One other person on here has osteochondritis dissecans, I hope she spots your thread, as your condition sounds similar to hers: you are a rare bunch I believe! Keep in touch over the next four weeks, we might be able to provide a diversion, you never know. Good luck. DD

frogmorton

Oh my God Stralachlan

That ounds an incredibkle procedure!

Isnt it amazing what they can do now?

I hope you are not in too much pain? are you sleeping ok? No you are right we have not heard of this procedure at all so it is very interesting to hear about.

You take very good care and do keep us up to date

Love

Toni xx

dorcas

Hi Stralachlan

WoW :shock: that's some procedure...

fascinating though and the fact that you'll write up the experience.. on here?... will be so helpful for anyone else who might go have to go through the same op.

I hope that you've got good pain meds now and that you've got someone looking after you?

please let us know how you are day by day; we are a very nosey lot.

seriously though we want to support you!

Iris xx
(is that a Hebridean name you've got there?...... see! I told you I was nosey. :oops: )

marion1952

Hi Stralachan

Just to say the description of your op was very interesting to read..

Glad to hear that it all went well. Non-weight bearing is tricky but it will be worth it in the end.

Marion

stralachlan

Day 8

Hi all, thanks for your interest.

Well I was going to go for a pub lunch today (no drinking of course :oops: ) but instead ended up going back to the minor injuries clinic as I was concerned at the amount of fluid seeping from the wound which started yesterday. Anyway, i've been reassured its not infected and to just change the dressing as necessary.

As for pain, I got my best nights sleep last night ironically, and I think the thigh swelling has gone down a bit. Yesterday I dropped from 30mg codeine (2 tablets 4 times a day) down to 10mg codeine, plus paracetemol. I can just feel a low level but bearable throbbing so I'm going to continue on that dosage for the next few days.

Am I rare? Osteochondritis dissecans isnt unheard of, but there dont seem to be many around. A lot of the nurses on the osteo ward didnt seem familiar with the leg brace. But spookily my older brother had the same problem as a kid so it must be genetic.

As for the name Stralachlan, its a place in Argyll, sometimes spelt Strathlachlan. Lachlan is a local name meaning from the land of the lochs (ie the Norsemen) and a Strath is a wooded valley. I'm from Clan Mac na Caerd (Macnokaird) who were workers on the Clan McLachlan estate in Stralachlan.

stralachlan

Day 25 - Update

Well the wound continued to seep, and when the District Nurse saw it on Day 12 when she came to tidy up the stitches she decided to come back every other day to redress it. Last Monday she took a swab and on Friday I had it confirmed by the GP that I did have a staph infection and he put me on a course of Flucloxacillin antibiotics.

So then it all kicked off as my GP phoned the hospital - my consultant wasnt working that day, and the rest of his team were in some long operation all afternoon at Southmead hospital. As I live in between two hospitals about 15mins from each they decided to ask me to go to Frenchay hopital's A&E dept to get the incision checked over.

Sadly it appears that Frenchay didnt tell the team at Southmead the entire truth about the seniority of the doc I saw at A&E - I had certainly seen a different person to the name given to Southmead hospital. Not suprisingly my consultant's team were then a little reluctant to believe anything Frenchay told them, so I was asked to go in later Fri eve to have it seen by them as well.

1 GP visit and 2 hospital trips later it was starting to feel slightly farcical! Anyway they convinced themselves it wasnt a bone infection and I didnt need to be readmitted, so I was asked to come back again on Monday morning to see the head honcho for a check up.

That was yesterday, I'm still in the clear but have been put on a second broader specturm antibiotic as well, amoxicillin. The wound has finally stopped seeping so I'm hoping it'll look better on Thurs when the District Nurse comes back to redress it. And I'm back to the consultant again next Monday for another check up.

So all in all its been a busy couple of weeks. And I've just been signed off work for another month.

And I've just bought a bath board so I can finally use my shower which is over the bath 8)

dreamdaisy

Strewth! I guess infection is always a risk after any form of procedure but poor you, two different hospitals involved! It's good news that you are on the mend now, another month off work seems sensible to me to ensure that you are a) fully healed and b) fully fit for the return to the fray. I wish you well. DD

speedalong

Damn and blast - an infection! Does sound like the antibiotics are working. Is it sore?

Have you tried out the bath board?

Is your mobility still improving?

Speedy

dorcas

Post op wound infections are really nasty things :shock: :shock:

I'm glad that the docs have now put you on stronger antibiotics.... especially if they think it's a bone infection... did I pick that up right?

please keep an eye on things and if you have heat, swelling, redness, loss of movement or feel 'fluey' contact the hospital again. I had a wound infection too post op TWR and the orthos had me come in every second day to be seen.... they were very 'twitchy' about it and warned me to immediately report any of the above symptoms... hence me passing their advice on to you!

hope it all settles again for you... and you get back on track with your recovery.

please let us know?

Iris xx

stralachlan

Hi all, at the moment the docs think its just a skin infection and doesnt go as deep as the bone, which is why they havent readmitted me. 'Twitchy' is exactly how I would describe them though

The downside is that all the antibiotics have upset my guts a bit.

I've got the District Nurse in tomorrow so I'll see how its progressing then, but it appears to have stopped seeping. It has been tender to touch, and there's an area of 'slough' which needs removing by debridement - not looking forward to tomorrow much as I suspect this might hurt

Then physio on Friday so I'm expecting to be told to start putting weight on my leg which will be another milestone crossed. And I'm back to see my consultant on Monday for a check up again.

The bath board is excellent - I tried it yesterday and I dont have to worry about climbing in and out the bath. I can just sit down and swing my legs over. Plus I can stay seated while having the shower. Its perfect.

bailey27

Hi
Good to see someone else on here having had the same as me. (well not good but you know what i mean)
I had this surgery done about 10-11 weeks ago. Mine was slighty different as they actually removed the bone which my patella tendon is attached and pinned it over with screws to change angle going through knee as i too have cartlide good on the one side but not the other. My knee caps were wearing down because of this which is whythey wanted to change the angle of the knee. Still having a few problems in that the bones ave still not healed and my surgeon said he would of liked to see them healing by now but isnt too concerned as there is some improvement and the screw and bones have stayed in alignment. I dont have much pain anymore and things are improving. I too had a lot of weeping and ended up going to out of hours GP as thought it was infected. I still have a full leg brace on (Donjoy) and go back in 4 weeks where it will hopefully have healed a bit me and it can come off.
The additional good thing i have noticed so far that my leg is 3/4 the size of other and so my clothes feel looser on the one side even though the brace is on there.
Hope everything goes well for yu. PM is you wanted any other advice about it as i am sure you will ups and down days as i did.

stralachlan

Hi Bailey27,

I got the impression from my consultant they might do about 10 HTOs a year so they are not that common, but not incredibly rare either. Certainly they had someone else in the week after me and they said 2 in 2 weeks was very unusual.

I was also told by my physio that my consultant likes to see people weight bearing at wk4, but that the only other consultant that does them at my hospital waits til wk12 and admits he's being ultra cautious. So its a bit like black magic i think, rather than hard & fast science.

I havent seen any post op xray's yet so I dont know how much its healed. Have to wait & see how painful it is on friday when I start putting weight on it.

I've got a full leg brace on too (Bregg) but my consultant wants me to start weaning myself off of it. My leg is wasting away too - its suprising how quickly it happens, but that will come back in time with a bit of exercise once this is all over. Being non-weight bearing makes it worse.

I've got a scuba diving conference and black tie dinner to go to on the 16th Oct - that should give me some exercise!

bailey27

Hi,
I was on toe touch weight bearing from the day after surgery. I was full weight bearing at 8 weeks but with crutches and now 10-11 weeks on i am full weight bearing without crutches but with the full leg brace. I always ask the radiographer person if i can see them after they have done it and some are mostly willing to show you. It is unbelievable when you see it. I saw mine recently and there is pretty much a black gap between the 2 pieces of bone. It has started to get lighter in areas but mostly stlill just pure black between most of it apart from the screws. It is impressive to look at. My surgeon said he wants to see the gap getting lighter which will show it is healing. He mine wasnt as he would hopef for at this stage but is on the right path so cant grumble really.
How is your pain? I know mine was terrible for first couple of weeks.
When you start to walk just remember to be careful, you dont want anything to loosen up in your leg and set you back. Even though i have brace on I often am walking and all of a sudden it will just give way without any notice which I guess is why the brace is on because to support.
How many degrees movmement do you have?
I hae been at 90 for about 4 weeks and a further 4. I started off pretty much straight and had it increased to 45 degrees after 4 weeks then 90 degrees 8 weeks post op.
I am noticing the further along it is getting that i am unable to straighten my leg fully and found i could straighten more when i came out of surgery. Probably because the patella tendon is not as flexible now, will have to check at physio.
How old are you if you dont mind me saking? Have they said next op be knee replacement?

stralachlan

Hiya,

I'm 37. We havent really discussed next steps in too much detail - waiting to see if this works first, but I've certainly been given the impression that once the cartilege wears out on the outside of the knee, or if this isnt successful, I'll be looking at a TKR. I think the real question is when will I have to have one, not if. I know my surgeon was planning the incision location with a TKR in mind, bearing in mind this is already my 2nd knee op. Assuming I live that long, I'm kinda expecting a TKR and at least one revision in the future.

I was quite lucky with knee bend, had 50deg when I left hospital, and am now at 90 deg (which is hitting the stops on the brace). It still hurts a bit to fully straighten it - i get these odd kind of muscle twitches when I do that. If yours involved the knee cap it might be more swollen than mine and stopping you get the same bend.

When I say non-weight bearing I'm allowed to toe touch but there's no weight going through it. That's pretty much pain free. I suspect putting partial weight on it is going to hurt, certainly on the couple of times my crutch has slipped on wet floor its been painful, we'll have to see. I'll update on Friday after physio.

Is your leg noticeably wonky now? That was surprise to me - I wasnt expecting it to be so obvious :shock:

bailey27

Hi
My leg does feel weird now. It looks straighter than before the op in that my knee doesnt bend inwards when walking. the problem i have now is that where they moved the bones in my knee i now walk on the outside of my foot and feel my ankle is going to rll over. I have had surgery on my ankle in the past and so hoping it wont come to more surgery. I have to see podiatrist soon so will have to see how that goes. As i am full weight bearing now i find it odd when walking especially trying to increse pace as i feel i have no control over my leg at all. I guess that will improve as it gets stronger. Your progress sounds fab especially with the range of movement you have. good luck for friday and let me know how you go. My physio is reluctant to push too hard becasue of the arthritis and doesnt want to flare up any other joints whilst working on the knee so will be interesting to know another physio's opinion,

elainebadknee

Hi Stralachlan
Im not sure but i think i may be the person DD was meaning whenshe said someone else on here had Oesteochondritis Dissecans. I have had it since age of 18 when had first loose body taken out of left knee, followed by about 3 or 4 others between ages of 19-27 and arthroscopies...Got told back then would need TKR at age of 40. I reached that age and up until then had it relaitvey fine, i mean leg would go bad (as i put it) and collapse for about 2 weeks every year but would always come good again...So last June my dad had TKR and i was helping him exercise daily when i nticed leg hurting lots and thought it was one of my annual spells but it never got better, just progressively worse, with me now having a BB and walking stick as cannot walk far at all, only about 100yrds.....Saw consultant who did an arthroscopy in March 2010 and they skimmed knee also, its made it worse and he refused to treat me any further, ruling me out at TKR age 41 and basically hit a brick wall with him as i do exercises and hydro once a week...Had to in the end seek 2nd opinon at Wrightington ( i live in Lake District) and he is considering a half knee but i only saw him a month ago and its not final decision yet.
I will admit i dont really understand your procedure and im not sure exactly what a half knee would ential, surgerywise....It sounds very hi-tech your treatment what with the titanium insert and taking a piece of bone out of your shin bone....
I will say you sound loads fitter than me, being a scuba diver instructor, i am overwieght but as i cant exercise a lot i cant really alter that situation much.....
I do want surgery but admit im scared shitless as the only bigger surgery i have had (and its not big really) was the loose boodies removals...Also dad was very ill after hid TKR as he lost a lot of blood during his op, they didnt tell him and he was weak for quite some time....So after seeing that and expecting him to reocver as he's as fit as a fiddle for his age, i was shocked and started to state i wouldnt go through that is it frightened me....Im also scared of having an epidural, the thought of it makes me squirm as im needle phobic and have difficulty getting even blood taken...

Its nice to hear of another sufferer as dont come across anyone else who has what i have and while your story may differ to mine it appears that you at age 37, need surgery and it just confirms to me that the surgeons who refuse us for being too young are wrong to do so....It seems you being active and me being overwieght has brought almost the same conclusion - the knee need attention cometh late 30's, up to 40+...

Good luck with the continuing recovery.....

Elainex

stralachlan

End of Wk 4

Hi Elaine,

It sounds like a similar story. I too went through good patches & bad patches in my twenties with my knee, and over the last two years have put on about 2 stone in weight as my walking distance has reduced. I got to the point where I could cycle the 2 miles to work more easily than I could walk the 300yds from the back of the car park - that took some explaining to colleagues! I felt like I was in a downward spiral which I needed this op to break out of.

I would certainly ask about an osteotomy, but I beleive its only an option if one side is still good. If you've had multiple loose bodies that may not be the case. A good picture is here which may help to explain what they've done.
http://www.orthspec.com/osteotomy.htm

My consultant Mr James Murray at the Avon Orthopaedic Centre has written a research paper on osteochondritis dissecans. It might be worth suggesting to your consultant that he speaks to Mr Murray.

The spinal injection wasnt as bad as I thought, you cant see it happening, and I felt some pressure, but no worse than having a drip in your hand, probably better. I presume you could ask for the old style GA if you really dont want a spinal.

I've just been given the green light to start partial weight bearing, and some physio exercises to do. I'm back again in 2 wks for an Xray to see how healing is progressing, and might be allowed to drive after that if my weight bearing is good enough. I'm expecting to have the leg brace off then too.

Its too early to say if its been successful yet, but the advantage is that it doesnt interfere with the bone around the knee area. Its not the 1st TKR which is the problem, but once that wears out you may need one or two revisions to get through the rest of your life, and the bone they have left to work with gets less & less each time. This HTO hopefully gets me the same length of time as a TKR but without the bone loss in the knee, and without the danger of any loss of functionality like knee bend.

If it doesnt work I'm not too keen to have a TKR yet, might put it off for longer. Fingers crossed though the HTO works

elainebadknee

Hi Stralachlan

Yes i get what you mean re cylcing but not being able to walk...My condition at present means minimal walking, trouble getting up from settee, no kneeling whatsover, bending even to put on underwear is unbearable and in the car well sometimes i dont make the gear chnage but i cant replace car as no funds.
As i believe it, it is my medial side that is worse damaged but its not certain yet as local suregon was so obstructive that he didnt pass on all my notes from arthoscopy to Wigan so still waiting for another app, 2nd week in November hopefully.
Im afraid you havent convinced me re the epidural...The fact you say it wasnt as bad, you felt something pressure and i have never had a drip put in so i deffo think its GA for me....
I will mention your Mr Murray at next app, thanks also for link...

I hope your physio goes well and you continue to flourish

Elaine

stralachlan

End of wk 7:

Time for a quick update, I'm making slow but steady progress back to unaided walking, down to one crutch on safe surfaces now, and have pretty much stopped using the leg brace. I just have to remember that I really can bend the knee.

I went along to a scuba diving conference the weekend before last, and a black tie gala dinner, all dressed up in posh frock complete with leg brace and crutches. It was a hoot, and a really good break from being at home. Some good friends looked after me, and ferried drinks from the bar. Sadly I couldnt drink too much in case I got a bit too wobbly on the crutches :oops: My back & arms were killing on the Monday though!

I went to the gym for the first time this Tues at physio. I did 9 mins on the exercise bike with no resistance, the wobble board and some little steps. It was quite painful the yesterday, but I was back on the bike again today for 5 mins so I'll see if its improving and getting used to the shock of being worked

However, my knee cap keeps slipping out of place and jamming the joint which is effing painful. I've been told its because my quad muscles arent strong enough at present to keep it located properly, but I dont remember this happening on my last knee op, so I'm a little worried its because of the realignment. Has anyone else experienced this post op, and did it improve with physio?

edward61

Hello,
I am 49 and had a very similar procedure to you at southmead hospital one week ago. Had my dressing changed yesterday and everything looks ok. Taking Ibuprofen and paracetamol at the moment and the pain is not too bad. The night time is the worst,the only way I can get to sleep is put pillows under my knee which I am not sure is the best thing for healing!
I am on crutches,partial weight bearing but done very little yet due to pain and swelling.
Please let me know how you are,and any advice would be helpful.

dreamdaisy

Hi edward61, I hope all is as well as it can be with you today. I haven't had the op that you have, I have had two open synovectomies on my left knee and found that I too had to sleep with a pillow underneath it, in the early days of recovery, asd my knee would not lie flat. It doesn't now, either, but this is a good few years on from the ops and the arthritis has worsened. If your knee feels more comfortable with the support then that is important: check with your surgeon tho if you are not sure. I wish you well. DD

stralachlan

Hi Edward,

Do you have Mr Murray as your consultant? I've been seeing his Knee Fellow Aneel Ansari more as he's doing a study on osteotomies trying to write a paper on selecting the right weight bearing point.

Yes - I found sleeping with a pillow under my knee far more comfortable. Have they told you 4 wks before weight bearing? Keep going with leg lifts and knee bends as much as you can, little & often, and keep your foot moving - it'll help the rehab no end. Other than that there is really not much more you can do at this point.

I was still taking codeine to sleep for the first few weeks when I got home, go and see your GP if you need something stronger as there is no point in suffering all night.

Once I was allowed to weight bear that's when the real work starts in physio. I'm was allowed to drive after week 7 once I could emergency brake, and was signed back to work then too (office job sat on my bum all day). By that point I was just about down to one crutch at home, still 2 crutches for long distance. I could also do steps without crutches, and just about leading with both legs but slowly.

I'm at the 3 month point on Friday. My physio appointments have just dropped from twice a week down to once a fortnight on the understanding that I'm going to a gym or swimming every other day. The 2 physios in Southmead are nice, although all physios are bullies (dont tell them this as they'll just make you do more work!!!)

I've learnt to hate the wobble board, and also find the cross trainer a bit scary as it gets faster & faster somehow! My gym routine is now
- 5-10 mins exercise bike
- 3 mins forward, 3 mins reverse on the cross trainer
- 5 mins stepper
- 5 mins rower
and I can manage 30 lengths swimming on a good day. So its suprising when you look back and see how much more you've managed to acheive each week. I've still got a limp, but it gets better each week. Walking 'long' distances is still very tiring. (Long counts as the distance from the AOC entrance to outpatients!)

After Xmas I'm hoping to persuade a diving doc that I'm safe to be let back in the water to go scuba diving. I want to get back out to Egypt for a week in Feb - go swimming with those Oceanic Whitetips, it'll have more trouble biting my leg off!!!

If you have any other questions ask away

Mary