Surgery after TTT tibial tubercle transfer

Hi Patty,

Good to hear from you.

The second surgeon basically said the same as the first, but explained it better.

The surgery would be the hamstring graft from the inner side of the kneecap to the bone beneath (as detailed before). Plus low femoral osteotomy wedge (larger wedge opening to inside of leg - from two full thickness cuts - to reduce Q angle) combined with inward rotation (so that my whole leg won't go outwards as far from the hip - I apparently have ~120 degrees rotation of my leg from the hip joint where most people apparently have about 90 degrees - this is in addition to specific knee joint pathology including knee tracking), plus a high tibial rotation inwards (making the double osteotomy) - single full thickness cut through the tibia before it splits into tibia and fibia, because otherwise my foot and lower leg would point outwards because of the femoral rotation.

The second surgeon believed I needed all of the above (in one operation, and probably also removing the screws from the TTT at the same time). His reasoning is the graft won't do it on it's own, because of my loose ligaments (and therefore more elastic collagen), because the graft will stretch and weaken over a relatively short period of time (this is also his explanation of why the TTT became ineffective over time). His reasoning that the double osteotomy with rotation on its own won't work is just because my kneecap is too unstable, and even with the alignment better, it will still be loose and likely to redislocate. If the low femoral osteotomy was done without rotation, then I wouldn't also need the high tibial osteotomy, but the surgeon believes it needs the rotation as well as the wedge to reduce the chances of my leg position (whole leg from hip, rather than position of upper to lower leg or forces on knee joint itself) being "out" and therefore increasing risk of my kneecap then going out. Hard to explain, but it made sense when he said it.

He estimates I would be on crutches (presume with immobiliser brace) for three months, but depending on my pain and mobility etc, at the absolute earliest I may be able to return to work after two weeks (if someone can get me in and I don't have to get up much etc).

He also doesn't believe there is any great urgency.

I am still not sure yet about having the surgery - but at least there is consensus between the two surgeons. It is still a big operation, and they could get the alignment wrong etc ("eyeball job") and it would still be the first surgeon doing it, and he has only done one similar operation which was on a child. It should be covered cost wise by insurance, provided they accept, and I haven't begun down that road yet (want to make sure I want to go through with it first). And I haven't discussed possibility of operation with work yet (they know about my knee etc, just not possibility of op; I want to be sure I am having the operation, and have some timeframes before approaching work). Still have nothing in writing (supposed to have letters from each surgeon and doctor and physio).

I am not anxious, just not yet at a decision. I know whatever eventuates I will be alright, I will not be devastated, God will continue to be with me.

The knee has been pretty good, we had holidays and drove lots, and it handled sitting for long periods better than I expected. I was very careful, wore my brace lots and didn't take risks. I did have near dislocation walking into a petrol station (stumbled on uneven floor at entry). Pain has been low. Still lots of cracking and movement etc as normal. Virtually no swelling most of the time. Muscles wasted more from holiday, trying to rebuild...

How are you? How are your knees, and how are you generally?

Hope all is going well.

Take care,

Liana

Hi Patty,

Thanks for posting back.

I looked at both the sites and found the article. I had seen the different types of knee surgery one before - but looked at with different eyes this time, but I'd never been to the Ortho supersite - the article was very interesting.

Thank you for your opinion about the surgery. I'm still not sure, but will see the other surgeon before making any decisions. It is reassuring to know that you sought several opinions. I was really surprised this surgeon suggested I get another opinion - I've never had any doctor or surgeon say that to me before; it made me feel like I had "permission" to seek another opinion.

I did not consider getting a second opinion for the first surgery. I did end up with a second opinion, in that I was a public patient and kept getting the surgery put off because of waiting lists, eventually the central wait list bureau offered to transfer me to a different surgeon in a different area to have the surgery done much more quickly, and this second surgeon did my surgery. It was the registrar of the first surgeon, not the head surgeon himself, that had suggested, pushed for and explained the surgery, even though the head surgeon would have performed it. I am very greatful to that registrar, because I had previously just been told, for years, that nothing could be done. That registrar was the first to actually ask about my history of dislocations not just the particular one I was presenting with at the time.

I know my trochlea groove, at least in my left (problematic) knee, is very shallow, I don't know what a "normal" angle is - but my left is now 141 (right 132) degrees. You can see from the X-ray (and CT) that it is shallow. The depth is also very short (5mm left, 8mm right), so the underside of the kneecap would be struggling to engage well even if the trochlear groove was perfect. The CT scans I had done in 1999 (2 months after very severe dislocation, 5 months before TTT operation) had trochlear depth for left 7mm, right 8mm and angle left 136 degrees, right 135 degrees. I know the groove and depth were considered shallow then. Over the last 5 and a half years my right has stayed about the same, and my left has got 5 degrees flatter and 2mm shallower. Not a huge change, but I'm not yet 35 and I wonder if it will continue. I guess the 2mm could be purely from cartillage wear... (Not really a comforting thought, as cartillage is pretty thin and pain will increase the less there is...)

I don't know my Q angle. I am aware it is much larger than normal, but I don't have "normal" figures. I remember reading an article on the internet, maybe two years ago now, that had how to calculate the angle and normal figures. Can't remember where it was from but I might do some searching and see what I can come up with. Any measurement I would take would obviously be very rough, but I guess better than nothing.

While we're on pathology... I also have quite loose ligaments generally. Very apparent in both my knees, but possibly most obvious in my back. I can easily lay my head against my legs when I bend over and touch my toes, and , if I work to it (which I don't anymore because I know it's not good for my back), I could put either elbow on the top of my foot, I can still very easily put my hands flat in front or behind my feet on the floor, palms up or down, with my elbows bent. I have not had any back problems. My ligamentous laxity was something the surgeon was concerned about before the TTT, but decided all my other pathology was classic (if extreme) indications for TTT. I did have lateral release done simultaneously - which I understand is sometimes contraindicated in patients with loose ligaments too.

More pathology... My kneecaps are quite small. My kneecaps ride fairly high - not extreme. My kneecaps can be moved at rest up and down as well as sideways considerable amounts with ease. They also j-track heaps. My legs also hyper-extend, my left used to always hyper-extend much more than the right, it doesn't as much now (did not get full movement back after 2003 dislocation - full as far as "normal" goes, but less than what I had before). Left now heal about 2cm (3/4 of inch) off flat surface with foot up, right nearly 3cm (1 and 1/4 inch). I think my left was over 4cm (1 and 1/2 inch) before.

My feet and ankles are pretty good, I don't have flat feet and my feet are not too prone. I wear orthotics (actually they're knid of double orthotics - a standard hard orthotic, with an extra foam type orthotic underneath to make really tilted) in an effort to continue to build the VMO, and to overcompensate for the tracking of my knee. (My VMO is still quite wasted despite years of physio and exercise. My physio theorised this may be due to nerve damage to the VMO area, probably from my 99 dislocation, I also basically have no foot reflex in that foot, which is connected to the same nerve bundle.)

I have seen my physio since I saw the first surgeon and he thinks the double osteotomy may be a combination of a high tibial osteotomy (proximal tibial osteotomy) and a low femoral osteotomy (distal femoral osteotomy). My physio said he would be surprised if it wasn't wedges being taken out of at least the tibia. He does know of these two procedures being done together, but not with concurrently with the other one - that you referred to as a proximal realignment. I put a lot of stock in my physio because he is really good, has great knowledge, keeps up to date (also does talk back shows occasionally etc), has seen me for a long time, understands my knees more than anyone, listens and explains things well. He is also now studying to become a doctor, while still treating patients and managing his practise in two locations with several physios under him; he is a great physio.

Terminology is a bit of a pain, because it seems to be used differently here (Australia) or no name is given until the day of the operation when you sign away to say you accept risk and responsibility if anything goes wrong. (Do they do that in America? I assume you are in America??)

The "minor" operation is I guess a type of proximal realignment, but I'm not sure whether it is the same as what was referred to in the knee hip pain article. The article referred to tightening, loosening, splicing or interweaving the existing structures to change the forces and tracking in the knee. The surgeon talked about removing a section of my hamstring and anchoring one end to the top of the inner side of my knee cap, and the other end to the underlying inner side of the bone (I assume onto the medial condyle of the femur?). There is not normally a structure (taut or loose) that holds the kneecap in this way. It could be that the surgeon was simplifying the surgery to explain, but that was the impression I got. When I go back, after seeing the other surgeon, I will have to ask lots of questions, and try to get a really clear idea of exactly what is being proposed.

I'll keep you posted. (But I am going to have to reduce my posts - they take too long to write - it's a public holiday here today and my husband is working, but nearly half the day is gone and I've accomplished little of what I had planned. C'e la vie.)

Thanks again, I really appreciate it.

Liana.

Hi Liana,

Good to hear from you. It sounds like your OS wants to do a proximal realignment this time. I would certainly do this before I proceded with the double osteotomy. The proximal realignments are less invasive than a TTT and do have a shorter rehab time (in most cases). If you go to Kneehippain.com you can read about the proximal realignment. There is also a good article at OrthoSupersite.com That discusses when a proximal realignment vs a distal realignment should be done. It is entitled Surgical Options for Patellar Instability Depend on Pathology. It is by Dr. John Fulkerson, a highly respected patella-femoral specialist. You will have to register at the site but it only takes a few minutes and it is free.

What is your Q angle after the TTT? Do you know what a normal depth for the trochlear groove is?

I always think that a 2nd, 3rd.....opinion is a good idea. I went to 5 different OS's before I made the decision to have the TTTs. Best of luck to you! Keep me posted on your decision and how you are doing!

Take care,
Patty

Hi Patty

Thank you for responding to my post.

I see an orthopaedic surgeon tomorrow (will be first time I have seen this one); I'm not sure what surgery he may propose.

The tubercle is still united well to the bone, but the kneecap is "normally" tracking way way off where it should be. I also have cartillage damage to left knee, but pain is manageable. There may also be nerve damage to the left knee.

My last scans had patellar tilt angle relaxed right 10 deg, left 0 deg; tensed right 77 deg left 180 deg.
Congruence angle relaxed right 27 deg, left 28 deg; tensed could not be calculated because of extreme position.

[Femoral trochlear depth right 8mm, left 5mm; femoral trochlear angle right 132 deg, left 141 deg;
tubercle lateralisation right 12mm, left 14mm.]

"Comment: there is severe bilateral subluxation and tilt. It was notable that the left patellar dislocates on quads contraction." ie the position my left kneecap currently takes when I fully tense my left leg is sufficient to qualify as a full dislocation, and position of both my knees as subluxed (I have never had medical intervention on my right knee, and the right has not dislocated for maybe 15 years, and never as badly as the left).

The referring doctor (sports physician but not surgeon) who ordered the recent scans thought maybe redoing the TTT and some tightening of inner structures (not specified) and I s'pose doing the LR again too, I'm not really fussed about the LR - don't think it will make much difference. My physiotherapist hopes it won't just be moving the tibial tubercle further across, because he doesn't think that will be at all effective. My physio thinks HTO may be more helpful, a high tibial osteotome where a wedge shape chunk (full thickness) is removed from your shin bone, to reduce the Q angle (quadruceps angle, basically upper to lower leg), maybe in conjunction with other procedures.

I'm not sure and don't really relish the thought of any further surgery - but I feel a bit like a time-bomb waiting for my knee to dislocate severely with everything that that brings. I am aware that surgery done now may restrict options for further surgery down the track. General consensus seems to be I "need" surgery (because of severity), no other options, just matter of what type. I am very interested to hear what the surgeon will say tomorrow...

Thank you for suggesting kneeguru, I have just read several postings on kneeguru that talk about failed TTTs and limited lifespans of TTTs; very interesting and enlightening. However, most of these are to do with failure defined as pain (from weightbearing on a different part of the kneecap), not to do with actual maltracking and dislocation. My primary objective in this surgery is to prevent future major dislocations; general pain from maltracking is not the main issue. (Though a pain free knee, post rehab, would be a major bonus.)

Would love to hear back from you. I will endeavour to update to this post whatever surgery may be proposed.

Thanks

Liana

Is there anyone out there who has had further surgery AFTER having a TTT?

If so, what kind of surgery did you subsequently have, how long ago, and how successful was it?

I had TTT (and LR) done in 2000, and am now looking at further surgery because of further dislocations and tracking problems. (Recent CT scans woeful.) I have a long history of dislocations etc.

Liana.