Dr. Hive: tibial tubercle osteotomy (surgery for dislocating patella)

[Innisfree]

Plus MPFL reconstruction and lateral release surgery.

Any experience at all would be great to hear about, but especially immediate post-op and outcome a year or so later.

[RootAnn]

:popcorn:

I have two kids prone to pattellar subluxation. One did PT & has a J-brace for athletic stuff. The other just lives in fear. No one wants to talk surgery around us so I'm interested. 

[itsheresomewhere]

One surgeon recommended this for me. Another said I was the worst candidate for this as I would blow it out within a year as I am a very active person. I would then need a knee replacement. Then I read a bunch of stories about it and those who it fails are often the very active people.  For me-  I chose to not have it and have kept up with the exercises they recommended to strengthen the area.  I know the end it going to be a knee replacement later and am fine with it.  Honestly, I feel keeping myself active, weight down and doing the exercises just for this have helped.  Did they determine the cause? Mine is due to a birth defect in the knee. Both of mine have it yet only one is affected. 

[Innisfree]

1 hour ago, itsheresomewhere said:

One surgeon recommended this for me. Another said I was the worst candidate for this as I would blow it out within a year as I am a very active person. I would then need a knee replacement. Then I read a bunch of stories about it and those who it fails are often the very active people.  For me-  I chose to not have it and have kept up with the exercises they recommended to strengthen the area.  I know the end it going to be a knee replacement later and am fine with it.  Honestly, I feel keeping myself active, weight down and doing the exercises just for this have helped.  Did they determine the cause? Mine is due to a birth defect in the knee. Both of mine have it yet only one is affected. 

Thanks for your thoughts! This is concerning, though. 

My peep who has this issue has had physical therapy, but due to the knee's morphology, has been told that can't resolve the situation. Yes, it's a birth defect. Atm she's an active young person who must use a brace all the time. Even lying in certain positions in bed makes her feel like the patella is going to slip out of position. She needs to be able to be active for professional reasons. She's far from overweight.

She was told that now, her knee has sustained some damage, but not so much that the surgery and recovery would be particularly hard for her as an individual-- everyone does say it's major surgery. If she waits, there will be more damage, making surgery and recovery harder.

A knee replacement hasn't been mentioned.

[StarSailor]

(Yes I have a new account, but have homeschooled for 12 years and am long time wtm reader.  This question/issue has greatly impacted my family and pushed me to set up an account.)

Is the MPFL surgery for a child or an adult?  My response is long but i hope helpful.

our experience was with a young teen child, both knees done, 5 and 6 years ago.  MPFL with lateral release and plica excision. Second knee done one year after first.  Growth plates were not yet closed which impacted surgery options.

surgery required due to lack of or very shallow groove for kneecaps (deficient trochlea).  Severe J sign in both knees and subluxation every time she straightened either leg.  As a young teen, did extensive 3x week PT to see if muscle strengthening would help with subluxation.  PTs noted her leg muscles were already 4.4 out of 5.  But we tried 3 months of PT.  No change in subluxation.  

So we moved on to a very good pediatric hospital with a sports med orthopedic dept.  and within 6 months of that the first knee fully dislocated. The doc had warned me it would likely happen.  And within a couple of months the other knee fully dislocated.  Each time child would fall and scream from the intense pain.  Those screams are not something i will ever forget.  After that, one or other of the knees would fully dislocate every 6-8 weeks as mpfl ligament had snapped. My child was so afraid of it happening when she was out with friends as there was no warning, just falling and intense pain for a good 20 - 30 minutes.  We did try braces, but for her situation, no groove for kneecap, braces do not work, her knees sublux in the brace.  (This is common we were told)

we have a wonderful orthopedic surgeon.  He told us there was 85% success rate with MPFL surgery.  He had a few failures and in that case, he offered second surgery.  We went with surgery due to continued full dislocations.  I would travel to see this pediatric surgeon and specialty hospital if needed.

Each surgery required 6-9 months intensive PT (2-3 x week), plus 45 min morning and evening home exercise program.  First 3 weeks non weight bearing.  First 6-8 weeks in brace, locked straight at first and then slowly allowed to bend.  First goal was to recover knee flexibility, second goal was to rebuild quads.  Knee surgery causes quads to “ping” thus the need to rebuild them.  Restricted to walking and PT only for 3-4 months.  I am so glad surgeries were in middle school, would not have been possible to do a full load of high school with PT.

A couple of things I recommend:  a good sports med orthopedic surgeon (their goal is to return child to sports);  use a CPM machine from right after surgery until knee flexibility returns;  an experienced PT who has had MPFL patients;  do it all within one insurance year - that way only pay deductibles once and its costly to do that much PT;  do ALL the PT and home exercise programs so can return to full function;  a wheelchair for first 2-3 weeks is very helpful as it gives an adjustable leg rest every where you go.  Also while leg brace is locked for first 3 weeks you need a car child can sit in with leg fully extended.  We used donor grafts for the replacement ligaments.  They can use one from back of knee but that means in incision on back of knee in addition to mpfl incision on front of knee.

my child is very glad they did surgery.  The dislocations prior to surgery were awful and very limiting.  Having said that, and noting my child’s severe subluxations prior to surgery - her knees still are loosy-goosey because of the shallow grooves for her patellas. BUT neither knee has dislocated since surgery 5 and 6 years ago.  The new mpfl ligaments have held and have kept her from full dislocations.  Doc would prefer child wear knee braces for sports but child hates the braces and as mentioned braces don’t stop subluxations.  She does continue once a day 3-4 x week exercises, but its no different than a regular workout.

Now that child’s growth plates have closed doc has offered second surgery, same as OP’s tubular osteotomy as he thinks that would help with the knee grove issues.  But it is offered as an option, not required.  Child is busy with high school/college and has chosen to live with subluxations.  

we do have an adult friend that needed mpfl surgery from sports injury.  They are several years out from successful surgery.  The challenge as a working adult was time needed for Intensive PT post surgery.  They chose to stop PT after a few months but did extensive home exercise program every am and pm.  They were highly motivated to return to full function.

i am more than happy to answer questions about our experience.  It was long and hard but we would choose surgery again.

[itsheresomewhere]

17 minutes ago, Innisfree said:

Thanks for your thoughts! This is concerning, though. 

My peep who has this issue has had physical therapy, but due to the knee's morphology, has been told that can't resolve the situation. Yes, it's a birth defect. Atm she's an active young person who must use a brace all the time. Even lying in certain positions in bed makes her feel like the patella is going to slip out of position. She needs to be able to be active for professional reasons. She's far from overweight.

She was told that now, her knee has sustained some damage, but not so much that the surgery and recovery would be particularly hard for her as an individual-- everyone does say it's major surgery. If she waits, there will be more damage, making surgery and recovery harder.

A knee replacement hasn't been mentioned.

Hospital for Specialized Surgery had some of the best information about it and how it may not be the answer.  I completely get on it feeling like it is slipping out of place when in bed.  The special exercises they gave do help with it.  I do have damage but I was told the damage when I blow it out after the surgery would be far worse.  If she hasn’t gotten a second opinion, get one especially from a sports medicine orthopedist. And have her go get a running store evaluate her feet for new shoes if she hasn’t done this before.  The sneakers they recommended really do help my knees more than I thought.  

[Innisfree]

2 minutes ago, itsheresomewhere said:

sports medicine orthopedist.

This is the specialist she's talked with, at a good teaching hospital.

Do you know for sure that the procedure suggested for you was the same?

[Innisfree]

4 minutes ago, itsheresomewhere said:

Hospital for Specialized Surgery

Thanks for this, I'll check it out.

[RootAnn]

I found a couple old threads.  Linking for anyone who finds this later:

Tightening the Patella Ligament?

Dr. Hive: possible patellar (knee cap) subluxation (popped out and in again) what to do?

[itsheresomewhere]

4 minutes ago, Innisfree said:

This is the specialist she's talked with, at a good teaching hospital.

Do you know for sure that the procedure suggested for you was the same?

That is the procedure recommended.  There was a really neat group on the internet for it.  Lots of stories about it and how the outcome was for varies ages.  The best outcomes were for those really young or not very active in the group. Unfortunately, it closed or was taken down.

Edited December 9, 2021 by itsheresomewhere

[Kanin]

Oh wow! I totally had this as a child, and never knew what it was called! I never even told my parents. I just sort of... waited and my knee would go back where it should. Crazy to think now that I never told anyone. It was very scary in the moment!

I've wondered what this was called for 30 years! Thanks Hive!

Thankfully, it went away by the time I was a teenager. 

[CatMom]

My daughter first dislocated her right knee when she was 10. We did do physical therapy. She tended to dislocate it about once a year after that. We always would do therapy afterwards. Her doctor really did not want to do surgery because so many kids grow out of it. Her knee would swell so much every time that it would take months for the swelling to go down. She finally had surgery when she was 16. After that, though, her left knee started to dislocate also. The last time she did it, she was out of the country, and it was so hard on her. She had surgery for that knee at 19. 
 

She is now 22, and I would say that it was life changing for her. I wish she had it done sooner on her right knee because she does still have pain from the damage from the prior injuries when she has to stand for long periods of time. Always being in fear of the pain was no fun. She played soccer when she was younger, but stopped because of the fear of it dislocating. It just wasn’t worth it to her.

She had the lateral release and reconstruction. The recovery on the first surgery was worse than the second. She missed about a week and a half of school for the first surgery. It was a little school, though, so not too hard to get around. Of course, there were months of physical therapy, too. The second surgery was during college, and we did it after Christmas , but before classes started. Again, about a week and a half before she could go places on crutches. She took the pain meds from the doctor about 3 days, and then went to ibuprofen.

I know it’s not the exact surgery, but I hope this helps!