Hello from Srinivas (11 week HTO-iBalance post-op)

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).

C360_2016-01-02-12-11-00-546

Srinivas-after-HTO-iBalance (10 week post-op)

Srinivas-LongLegXray-20151222-GUH-DrK-8weekPostOp

srinivas-after-HTO-iBalance long film xray (8wk post-op)

 

CAM03138-1

Srinivas-before-HTO (the pic is in the mirror, so the operated leg is the one on the left)

Srinivas-LongLegXRay-20150825-Georgetown-Dr.K-AngleMeasurement

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.

 

Photo from Sarah

I’ve gotten a bunch of requests for photos of my legs. This shot was taken a while ago, but it does give a good idea of what they look like today. My scars are basically 3-inch white lines extending down the inside of my shin from my knees. I’ll post more shots when I get a chance.

Hope everyone is doing great and enjoying the end of winter/beginning of spring where those seasons mean something. It’s been a long hard winter here in New York City, weather-wise!

Two Legs

Update from PJ

Hello everyone! I know this post is so very long overdue. It’s been 14 months since my first HTO and 11 since my second. As many other HTO patients reported in the past, once walking resumes, life gets busy again and posting gets put on the back burner.
I had been planning to post for several months that things were going great! I returned to work in August of 2013 and was thoroughly enjoying wearing boots, skirts and skinny pants! Then around December, I began having pain in my left knee (the most recent surgery leg). I had started a new job that required a lot more time on my feet, so at first I just chalked it up to my legs needing to adjust to the new physical level.
By January, the pain was increasing (sharp, stabbing pains) and I scheduled an appt. with my surgeon to have an x-ray taken. The x-ray showed everything to be in place (Arthrex wedge, screws, etc) and stable. There was very little bone growth however compared to my right knee which was only 3 months ahead in the healing process. The slow bone growth was not a big concern at this time as it is not uncommon for each leg to heal at a different rate even after the same procedure.
My surgeon believed I was likely suffering from a small stress fracture (which often don’t show up in standard x-rays). He said that those can sometimes happen when the muscles around the knee are weak (which happens after this surgery) and the bones are taking more impact with each step. He suggested that we could have a bone scan done to be sure, or just give it a few more weeks to heal (stress fractures take between 6-8 weeks to heal) and I was at about 5 weeks at this point. I opted to wait it out as the treatment plan wouldn’t change by knowing for sure anyways. I went back on pain meds to be able to tolerate walking (which is ok to do with a stress fracture).
Fast forward another 3 weeks or so and the pain worsened. I decided to do the bone scan which showed something was definitely wrong in my knee. The surgeon then ordered a CT scan so they can see detailed cross section x-rays of my leg to determine exactly what was happening.
After all of this, it turns out the new bone completely stopped growing and had turned to mush. The pain I was feeling was the Arthrex wedge and screws shifting slightly as there was no bone growth for increased structural support. When new bone fails to grow, it is called “non-union”.
Non-Union apparently happens in 10% of cases after HTO. Most of the time it will happen in patients that are smokers, drinkers, drug users, etc. When all of those things are ruled out, as in my case, the patient falls into the 2% category of “they just don’t know why it happens”.
With that being said, I now have to go back in to surgery (this coming Monday) to have bone grafted from my hip and placed in my tibia to stimulate new bone growth. Some people from Arthrex will be present during my surgery as they want to determine if this has anything to do with their device. There is a 90% chance this will work. If not, we try again. My surgeon will go in through the same incision as before (only a smaller opening this time). I will be able to walk right away and will need 1-2 wks for recovery. The worst part of this procedure will be the pain from having taken bone from my hip bone.
So, that is my update. Not what I was hoping for 1 year after surgeries, but not much I can do about it. On a positive note, my right leg feels like a champ and has lots of new bone growth. I’m so happy with the way my legs look and the way I feel in clothes. Now if I can just get the bone in my left leg to grow to get this pain to go away! Wish me luck…I will try to post updates for you all.

LEFT IMAGE: left leg Aug. 2013 RIGHT IMAGE: left leg Jan. 2014.  Bright white bone mass has diminished.

LEFT IMAGE: left leg Aug. 2013
RIGHT IMAGE: left leg Jan. 2014. Bright white bone mass has diminished.

LEFT IMAGE: rt leg Aug. 2013 RIGHT IMAGE: rt leg Jan. 2014. Lots of new bone growth!

LEFT IMAGE: rt leg Aug. 2013
RIGHT IMAGE: rt leg Jan. 2014.
Lots of new bone growth!

Legs together.  No space between knees!

Legs together. No space between knees!

After two HTO surgeries

After two HTO surgeries


PT on left leg. Leg lifts with ankle weight. July 2013 (3 months post surgery)

PT on left leg. Leg lifts with ankle weight. July 2013 (3 months post surgery)

Pictures of Corrected Legs

Here are a couple of photos of my legs — taken in a mirror. 

Leg on right operated on Feb. 2014, leg on left operated on Sept. 13. Still some swelling on most recent leg.

Leg on right operated on Feb. 2014, leg on left operated on Sept. 13. Still some swelling on most recent leg.

Straight

I am very happy with the appearance and so grateful that my nightmare is over. I think I am one of the oldest contributors — if not THE oldest– on this site so far — and believe me, I have had many decades on unhappiness because of something that was decided in the womb.

I can remember one particularly cruel little girl at school, jeering at me and telling me that I’d be “stuck with those legs — all your life”. Sadly, I had come to accept that she was right. Today, I am very happy to prove her wrong. I could not be happier with my “new” legs and am looking forward to regaining strength and getting back to normal, and on with life. I hope that one day soon, legs are not something I think about very much.

Day 4

Image

Day 4

Its day 4 after my HTO and I am going home today – woohoo! Have been in really good shape for the past couple of days pain wise (even though day two was a little trying until the nurses got my pain control right) and as I had the allograft the whole operation has been a thousand times less painful than my first HTO where the graft was taken from my hip. Life was even better when the nurses reduced my Oxycontin and Oxynorm from 20mg to 10mg and I could actually function properly. I am, lets say, a sturdy bloke but these two reduced me to a gibbering wreck and I am thankful I am off them and on Paracetamol and codeine when needed. I can only wonder what horrors people who are addicted to those drugs are running from.

According to the surgeon I have had a 14 degree correction (although there was a complication in that there was a fracture at the closed end of the wedge which can occur) and he is delighted with the allograft wedge and fixation. As I have mentioned before, the operation I have had involves an amazing piece of technology called Orthpilot which uses transmitters attached to the femur and shin bone. These transmitters are connected by infra red to the main computer which track the movement of the leg and allows the surgeon to set the leg with great accuracy.

Image (Copyright acknowledged)

I know that this system is not in wide use but if you can have it then make sure you do. In the UK it’s an additional £1800.00 charge to the insurance company and they may complain but if the surgeon says he/she needs it then so be it. The dry crepe bandage  will be taken off before I go home and even now I can engage my quads and push down through the knee without pain.

ImageImage

My legs before the second HTO (left). Difficult to see but I am looking straight down at my legs and the ‘normal’ leg (HTO in November 2013) is on the right. Not sure if you can see the way the left leg curves? This has now been corrected, but to what extent is unclear. Will only know when the ‘gift wrapping’ comes off!! You can just see the scar on my right knee (just on the left where my knees join) from the orthpilot transmitter inserted into my femur.

First Follow-up with Surgeon on 2nd HTO (Right Rotational)

Well, I met my surgeon on Friday and had x-rays taken. Bone growth is showing nicely. He was very surprised at how well I am doing. I already have more than 90 degrees range of motion and can do leg raises. He gave me the OK to start physio in earnest and put as much weight on my operated leg as I can tolerate.  I also got the ok to ditch the brace, take a bath vs. a shower — which I love to do — go swimming in a public pool if the mood takes me, and even drive! My operated leg is my driving leg (automatic car), though he recommended staying off the highway and being sure I can do an emergency stop. I for sure will  practice switching from pedal to pedal in my drive way before heading out.

Sleeping

I can’t tell you how wonderful it is to be able to sleep without the brace. The last couple of nights have been so much better. Can roll over now more easily, though have to prop my operated leg on a pillow. Sleeping on your back, night after night is very difficult and absolutely impacts quality and quantity of sleep. I have been taking a pain killer at night most nights, just to sleep, even though there has been no pain — which is not good — and now have to get myself off them.

Exercise

Today, I tried my exercises for the first time and was quite worn out at the end of my session which took about 1 hour. Am supposed to do this twice a day. I can already put my entire weight on operated leg which would have been unimaginable at this stage (4 weeks post-op) for my last leg. I have no idea why my right leg is doing so much better than my left leg did and neither did my surgeon.  I am a little lighter in weight this time around (about 15 pounds) and had been eating much more healthily prior to surgery  and post surgery this time around, but am not convinced it’s either of those things that is causing a more rapid recovery, though they certainly can’t be hurting it. My surgeon said that even when both knees are operated on at the same time, there can be very different rates of recovery for each.

Bruising and Hemosiderin

I have no bruising now on my more recently operated leg, however, I have some residual bruising at 6 months post-surgery on my first leg.  From Google research, I’ve come to the conclusion that some bruises can take up to 2 years to go away. I think the dark shadowy patches on my first leg are evidence of “hemosiderin”. Essentially caused by iron breaking out of your red blood cells (from trauma, surgery, etc.) and not being reabsorbed and disappearing the way a regular bruise does.  Apparently a Q laser or an IPL laser can help with re-absorption. I could have a visit to a dermatologist in my future, but will not bother with exploring this until second leg is fully healed. 

 

Incision/Scar

My incision is about 2.5 cms longer on my right leg than the left, unfortunately. I have been putting Mederma and Bio Oil on it and hope they help.

Fun Stuff

Today, I put on a dark blue pair of skinny jeans — and stood in front of a full length mirror and was very pleased with my reflection.  Oddly, my first leg, which I was worried had not been straightened enough, now looks very, very straight!  There is absolutely no gap at all between my knees! And even my calves are touching!

Anyways, that’s it for me. I am entering the long stretch of physio that has to be endured and will try not to get too frustrated with the general lack of mobility and difficulty doing everyday things. I know from previous experience that there will be ups downs each day. But, what is really front and centre for me is that my goal has been achieved — and safely so.  I am looking at the end of May for being able to walk without a cane and feeling generally back to normal. Just in time for summer.  And, it’s going to be a much more carefree summer for me this year.

 

I’ll write again when there’s something worth reporting.

 

Wishing all readers and contributors all the best.

 

 

 

 

Hello from the UK

Hello from the UK

Hello, I’m Jools and I am one day post op for my second HTO. The first one was completed in November 2013 and I hope that through my blogs you will get a clear idea of what is involved. I’m going to be upfront and honest because I believe you should not undertake this operation without having the full facts and more importantly the necessary support in place to help you recover emotionally and physically. It’s going to be a heck of a ride!!!