Hello NACG, thanks to your great blog. It has been very useful for those undergoing HTO and iBalance in particular. I would like to add my story and some tips of HTO w/ iBalance that I recently underwent on my left knee at GUH, done by Dr.K.
I am a 41 year old male. I became conscious of my bowlegs in my teens but never thought that would cause any issue until I noticed that my left leg progressively became more bowed over the years and started having gait and balance issues in the last 10 years. 5 years ago I had a sharp pain at the patella-femoral articular joint line that triggered a subconscious gait change and ligamental laxity as a result which in turn contributed to more bowing and gait/balance problem. I could no longer pivot and turn without taking subconscious help from the right (good) leg. The knee would feel strength-less and the knee down (tibia) would feel as if it is a foreign body part (possibly from laxity in the ligaments inside and outside of my knee…all of which probably developed as a result of progressive bowing). The left leg would feel slightly shorter than the right due to “excessive” bowing. The left side of pelvis dropped a bit and rotated as a compensatory response. Since right leg took upper hand, the spine also curved slightly at the lumbar/cervical region towards right. So, when sitting or even laying in bed I feel my body is shifted to the right and more pressure under right pelvic/gluteal area. All of these changes started having an effect on the quality of my life. Workout (esp Swimming and yoga) would keep things from getting worse. But, a few days without workout would bring back the terrible imbalance and gait issues. The knees themselves are OK, no sign of cartilage wear or inflammation. But, if I look closely on the left knee in the xray, the medial compartment is slightly narrow than the lateral side, indicating a beginning of wear due to bowness.
I found out about iBalance from your blog and liked the idea of keeping the implant flush to the bone without prominence. Since the wedge implant is not real bone, my only concern is on its longevity (>10 years). Though no need to take it out, Dr.K said it can still be removed and filled with other bio compatible material.
In addition to HTO, I had knee “chondroplasty” where the cartilage surface is shaved/smoothed to help knee be healthy long term. So, I got 3 keyholes in addition to osteotomy opening line of approx 7.5cm (3in). I am not sure if chondroplasty is needed for each patient but sounds appropriate. But, it prolongs the recovery time.
The procedure lasted little more than an hour and I probably woke up from anesthesia after 2-3 hours in the post-op recovery room. The pain level was not much (4-6 out of 10) as nerve block is still active and some pain meds were being administered through IV. I did not have any nausea and not hungry (possibly due to IV saline) but was very thirsty. One of my nostrils and throat area was irritated probably due to a tube used during the procedure. I stayed in the recovery room for about 6 hours before being admitted (had to wait for a room to become available). The throat pain would go up the next day but subsided after getting a shot of antibiotic through IV. I was discharged on day 2 post-op after pain is under control with the right kind of meds. On the day of discharge, the onsite physical and occupational therapists went through PT exercises and how to move around and carry out some basic chores. I was given a cryo/ice cuff (polar care brand) which was very helpful and convenient to use to reduce swelling and inflammation. Instead of actual ice, we could use small water bottles kept under freezer (idea from my PT office). After few weeks, as I lessened its use, I switched to gel packs (large size to cover lower half of leg) sold online for more ease and convenience.
Its has been 11 weeks since my surgery. Healing and recovery going well (as per books).
Srinivas-after-HTO-iBalance (10 week post-op)
srinivas-after-HTO-iBalance long film xray (8wk post-op)
Srinivas-before-HTO (the pic is in the mirror, so the operated leg is the one on the left)
Srinivas-before-HTO (showing angle measurements)
Below are some of my experiences and tips/recommendations.
After the procedure, do get admitted to the hospital to get an handle on the pain management. The pain level after nerve block wears off shoots up dramatically and you should get the right pain meds (and dosage) figured out. As I rarely take pain meds in my life, a 10mg oxycodine was too much for me (made me extra drowsy and sweaty). I settled with Percocet (5mg oxycodine + 325 acetaminophen) and MS contine (morphine). I did not see any help from morphine, so I stopped it in the first week itself and slowly decreased the frequency on percocet and stopped it after 2 weeks. I took it once in a while at night when pain goes up to get me drowsiness but I found that it was not helpful in putting me to restful sleep and usually made me feel tired in the next morning. It was a difficult time between 2 and 4 weeks in getting good sleep.
Do not underestimate the effect of pain meds (esp narcotics). In order to “stay ahead of pain” we are encouraged to take them more frequently. But, need to manage and take precautions of its side effects. During the first few days or weeks, use walker instead of crutches (unless you used them before and good at it). During my discharge, I became drowsy (due to pain meds) for a split second and accidentally put excessive weight on my operated leg when trying to get into the car, as I was using crutches and could not balance myself. I think my ankle took the hit and surrounding soft tissue became swollen with pain after a day. The case manager said they usually order crutches for patients of this type of procedure. She also indicated that the crutches are not run separately through insurance and would be part of hospital overall bill. So, upon my request, she could order the walker through my insurance (which pays for only one not both). Walker has been my friend for 3-4 weeks (huge help in the toilet and bath).
Another side effect of narcotic/morphine based pain meds is severe constipation. Start on stool softener (dulcolax) and/or laxative (miralax) from day one (yes, day one). You may not expect bowel movement for 2-3 days until they start working. I never had any constipation issues in the past and foolishly stayed away from them while at the hospital. The first bowel movement (after 3 days!) was a terrible one. I immediately started on dulcolax (in AM) and miralax (in PM) and stayed on it until I weaned off of pain meds.
The only other meds given was aspirin for 14 days, which I was allowed to stop after 10 days after suture removal. I was alarmed at the development of reddish brown bruises all over my leg (mostly posterior) in the first week. I was told by nurse that it was due to Aspirin and possibly from the use of Tourniquet around upper thigh during the procedure to limit blood loss. The bruises stopped expanding after 2 weeks and fully disappeared by 4th week.
Expect mild fever for several weeks (below 100 degree fever until 3-4 weeks is not abnormal). I had over 101 fever on the second at home and it went down slowly over several days. I would get sporadic 99.x temp every day for up to 5 to 6 weeks! The nurse said no need to take antibiotics just for this mild temp unless other indications warrant.
Do continue to use the wind inhaler to keep lungs active, at least for 2-3 weeks post-op. In medical field, after surgery, they use 4 W’s to help determine (or avoid) the cause of any infection and temp spike. It stands for Wind (lungs related when not getting enough air intake after bed rest, Water (Urinary related infection), Wound (the wound site getting infected), and finally *What* else (needs blood work I guess).
Use of walker or crutches may result in calluses on hands. As I was glued to the walker for about 3-4 weeks (just because it is very stable), I developed pain in the hands. From 4th week as I started using crutches and alternating with it helped curb the progress of the pain, possibly due to different angle of pressure from holding it.
This is important. Do discuss the degree of correction with your surgeon. Any correction of 10 degrees or over has a potential for error and make you feel out of shape after (hopefully until you are used to it). The leg length will increase but slightly (could be up to 1/4 inch or more). Make sure that both you and surgeon are in agreement. This involves knowing some technical stuff on the geometry aspects used in this type of procedures. There is a nice PDF online from Univ of Buffalo (actually prepared for ortho residents and fellows) that helps you understand this stuff. A bit of Math geometry background helps.
My leg may have been slightly over-corrected and feel knock-kneed on my operated leg (visually exaggerated when putting both legs together where the right leg is bowed). It feels how it is like to be on the other side of deformity. Not sure if it will get corrected itself as my weight bearing becomes normal. Looking at the standing long leg xray taken 8 week post-op, I feel that over-correction may be between 1 to 2 degrees. I hope that this feeling would go away as my body adjusts to the new geometry and when leg feels normal. I have concavity in the proximal tibia which may be contributing to the impression more so near the knee.
I did not shower for 10 days until my sutures are removed (BTW, it was painful). Just settled with wiping with hot wet towel, and washing face and hands. For shower I used a thick plastic sleeve sold at CVS pharmacy. Its mouth is very tight and feels like a tourniquet at the thigh after fully covering the leg. But, it really worked well to keep the site dry and not let a single drop of water in.
I started outside physical therapy in the 3rd week post-op. The PT would follow the script given at discharge time. It was shocking to see the amount of loss of muscle tone in just few days after the procedure. It will take 6 months, sometime up to an year I was told, to get it all back. As some noted, it helps to start strong and bulky so the loss of muscle does not appear as much.
I started trying full weight bearing in the 6th week, but still held onto one crutch for prolonged walking or standing. Initially I noticed strange sharp and tingling sensation in the foot when walking with full weight. I think it may have lasted couple weeks. Now I do not feel it any more. I stopped using crutches by 9th week and my walk is slowly getting better though still limping. Now I am able to go up and down the steps with one foot at a time (though sometimes I try with full weight on the operated leg). I think running is far away for me. Due to change in anatomy, my pelvic girdle went sore (including some back pain) the first week I started walking without crutches. The pain is high in the morning out of bed since muscles were resting before. I still have some pain all through the day near iliac crest.
Between weeks 5 and 8, once I started doing more PT with increase in weight bearing, the wound line had tiny spots with swelling which eventually would rupture and let accumulated liquid matter out. I would just clean with alcohol wipe and applied topical antibiotic cream. Both doc and PT indicated that it may be due to breakage in the inner absorbable sutures and would heal again. It would have been a cause for concern if the swelling had expanded beyond the wound line. Now (11th week), I think the wound site is healed completely and do not expect any swelling or rupture.
The entire knee site feels warmer than the rest of the leg. The extent of warmth has gone down since 8th week, but I can tell that it is still slightly warmer than other knee. The swelling is still present when compared to the other leg, and goes up after prolonged walking or standing (more than an hour). It is absolutely essential to do icing and leg raises in initial weeks to have a greater impact and result. I feel the need to continue them at least once a day before going to bed (I use multiple pillows under my leg).
The lateral side of the wound line is still numb and the area near tibial tuberosity feels semi raw when touched with a slight press. Per doc, the numbness may remain for a very long time (could be up to 2 years!) but should not interfere with any leg function except sensation.
On ROM (Range of Motion), I can flex close to 140 degrees, but not yet bring it close to the thigh. My ankle went through many phases of pain as it slowly adjusted to the new angle of tibia. At present I am still getting pain in the medial tendon of the joint when doing flexing during lunge. I include ankle and feet when icing.
For up to 10 weeks, I had excessive dryness and peeling of the skin from knee down all the way to my foot. The shedding of the skin stopped after 10th week and now it looks completely clear of any skin peeling.
It is a long post, but overdue as I got busier going back to work at the end of 9 weeks. Thanks and all the best.