Unusual and challenging complex osteotomy

banner

Andrew has had a spectacular result from combined distal femoral and slope-changing osteotomies.

Andrew has been a really fascinating patient, and I would say one of the most challenging cases I have ever had to do as a knee surgeon. He presented to me in June 2018 with a background of Charcot-Marie-Tooth disease affecting both upper and lower limbs, but predominantly his lower limbs.

Two issues

From an osteotomy point of view he had two issues - 

  • one was progressive valgus which was making life very tricky for him at the knee, but also at the foot and ankle, as his ankle has been significantly affected by the Charcot-Marie-Tooth and he needs to have an osteotomy. Before this could be done his foot and ankle surgeon very sensibly suggested that he get the alignment straight in terms of his leg as he was loading through the ankle appropriately. We therefore elected to combine the HTO with a distal femoral osteotomy.
  • The other problem is that he has significant recurvatum ('back kneeing' too much), which makes both knees feel unstable and makes him feel as though he is going to fall. In fact at times he has had frank giving way as a result of this. 

We therefore elected to do a distal femoral osteotomy medial closing wedge to varise, and then a direct anterior approach to the proximal tibia to allow a slope changing osteotomy using Ronald van Heerwaarden's biological plating technique using a femoral head allograft and fixing the tibial tubercle back again. Having changed the slope perhaps we increased the inclination from front to back - this gets rid of the recurvatum. He initially had some discomfort but we got control of this and he says that ever since he left the recovery room he has had very little pain.

DFO and slope-changing osteotomy
DFO and slope changing osteotomy in patient with Charcot-Marie-Tooth disease

At four weeks

At four weeks he has no pain and he knee has a good straight leg raise with a comfortable bend to 90 degrees. He is not taking any painkillers currently as he has no discomfort. His X-rays look spot on. I am delighted that he is doing so well and his only question today was when can he have the other side done.

A new collaboration

Again a complex osteotomy done in an expert fashion. I was joined for the first time by Ronald van Heerwaarden at the Wellington Hospital - this was his first case that we we did in our new unit as a collaboration with himself, myself and Ragbir Khakha. I think with these very complex procedures they are not really possible to do without the right kind of team and that is exactly what we have set up at the Wellington with our focus on complex osteotomy through our osteotomy unit.

Testimonial from Andrew

I have a condition called CMT (type 1B), which is a progressive condition whereby the myelin outer of the nerves disappears with time, so that feedback from your touch nerves gets less and less with time.
The condition also tends to give people hip dysplasia, knee problems, and a lot of foot and ankle problems.
Those things all together (which I have) make things a little difficult for mobility and strength, but I've been lucky, and have been able to keep fit with a lot of cycling (as I can't run)......and a bit of skiing this year which I'm not sure I should be doing...... but awesome!!!
I'd seen an ankle surgeon years ago who suggested orthopaedic shoes and an ankle brace......not for me really, and so I thought that was the end of it.
I've had a bit of knee work done on my patella and ACL with Ian McDermott, and as we were chatting I asked if he had any good foot surgeons I could see.....just in case there was anything I could have done to make my feet a little less painful.
He suggested Ali Abbasain who told me there was loads they could do and he had dealt with plenty of CMT people. The only thing was that he didn't want to to do the right foot (worst one) until my right knee was straightened, as it had significant valgus.
So I did some more research for knee surgery and found that this could be corrected (Ian McDermott wasn't keen though). So I eventually came to reading about and seeing Adrian on YouTube, with some of his patients. I liked what I saw and I think I've chosen one of the best there is (read..... discount on the next one Adrian!!). So I got Ali to refer me in effect, and the rest is history (as of 4 weeks post op).
My expectations of the procedure was of success, as I probably wouldn't have done it otherwise. It was a team of three surgeons......not too many cooks here though.......
It did smart a lot in the recovery room, but that's down to the anaesthetist, but a couple of morphine jabs corrected that, and after 2 weeks no more meds in the day, and no more at night after 3.
So far, it looks really good and is healing very well. I've not gone to any physio yet.....just done it all myself with researching the net, and a little common sense.......and a few things Adrian doesn't need to know about (secret) but it's gone really well......
I've got the completion of my right foot surgery in the spring, and I'll be knocking on Adrian's door for the left knee at the end of next year, with the only fly in the ointment being my private health getting itchy feet as they've changed their rules.
Regarding advice for others that's a little difficult. Firstly, I seem to get through ops well with minimal pain, and I'll be up down the pub in a couple of days. Not everyone is like that and surgery may be a little scary (and it's not cheap), but you're in very good hands, and my quality of life will improve no doubt, and also it'll future proof me as much as possible which is a big thing for me."

Andrew

Patient

Leave a Comment: