After two consultations and three sets of imaging, I went back to see the surgeon today to finalise the plan for what, from here on in, is going to be known as “Operation Change the Narrative”, or OCN for short (you can never have enough acronyms now, can you?!)
Operation what?
Change the narrative is a phrase used in passing by the consultant when I saw him for either the first or second time earlier this year (lost track already!) to sum up what we’re trying to achieve here. Having had an unstable knee for a lot of years now and with over a decade of surgeries trying to fix it, none of which have ultimately been successful, it has pretty much been a repeating tale of woe.
However, now that we’re almost certain we know the ‘why’ for those failures, and we know that we can do something about that why, we’ve put a plan in place do exactly what it says on the tin, and ‘change the narrative’ (because, let’s be honest, this is all getting pretty boring and there has to be a happy ending at some point, right?)
So, the plan has been finalised. I’m looking at a bi-planar high tibial osteotomy (HTO) in late September to: try to reduce the slope of my tibia (improving stability in itself and also increasing the odds of yet another ACL reconstruction actually working down the line); and also to get me out of varus alignment (protecting the medial side of my knee as there’s no cartilage left at all there, which is going to be a problem if I don’t do something about it anyway).
In layman’s terms, that means the surgeon will break my lower leg, remove a wedge of bone and re-set it so that the posterior tibial slope is reduced and the weight-bearing line from my hip to ankle is redirected away from the inside of my knee too. He’ll also have a look at the bone tunnels from the previous surgeries and graft those if needed. Thankfully he's using donor bone if that’s the case, so no need to add hip bone harvesting to the surgery and recovery plan 😮💨. There’s also the possibility of a cartilage transplant as another option down the line but hopefully that won’t be necessary if the HTO does its job.
There are two main types of HTO: one (opening wedge) where they create an incision in the bone and jack it open, then let the bone regrow to fill the gap; and the second (closing wedge) where they cut out a wedge of bone then close it shut. In terms of choosing which way to go, BodyCad worked up two different models and it looks like the lateral closing wedge is the only option that will allow us to both reduce the tibial slope and treat the varus alignment, so that’s the way we’ll go. It’s a slightly older technique than surgeons typically use today (preference is for medial opening wedge as that effectively adds more bone into the joint rather than taking it out, but life is not perfect and that increases the tibial slope as a bi-product. I need quite a sizeable reduction in mine so that’s definitely NOT what we want!)
For anyone into medical tech, the BodyCad system looks pretty interesting (both from an engineering and a medtech marketing point of view). I'm not going to lie, I’m fascinated by this stuff and love the fact I sometimes get to learn and write about it in my day job! In summary, the consultant and BodyCad engineers use CT scans and x-rays to model your individual anatomy before working out the angles and cut depths required to achieve the surgeon’s stated aim (i.e. tibial slope reduction of at least 5 degrees, and/or shifting leg alignment to a new position to take pressure off the medial compartment, in this case). They then generate a model of your joint and design 3D-printed, personalised surgical cutting guides, equipment and fixings to a) allow the surgeon to get a really precise outcome, tailored to your individual bone shape/size and desired result, and b) reduce plate irritation after surgery (as the plates are all printed to fit your individual anatomy, rather than being generically sized and ‘bent’ to fit).
Point A is particularly important to me as we know I have some hypermobility in my knee too - thankfully not enough to contraindicate surgery - but reducing tibial slope can increase hyperextension further so my consultant needs to be super accurate. Why do I never seem to fit the straightforward option?! 😂
Once the plan is signed off by the consultant, it all arrives in a box ⬆️ (a bit like a box of Hotel Chocolat dropping through your door but more or less exciting, depending on your viewpoint), ready to go. It’s a good job its delivered to the hospital/surgeon, not my house or I’d have issues convincing the eldest not to have a really good look at it all first! 😅
Is this level of personalisation necessary? I don't know but I can see the theoretical benefits, even if the company's description of their 'fine osteotomy' process as 'a more natural solution' than knee replacement did make me laugh out loud. Yeah right, there's everything natural about cutting a wedge out of someone's tibia, wedging open or closing the gap, then fixing it with load of metalwork, isn't there?!
All of which brings me to the recovery. It’s lucky I work from home as my consultant initially advised 8-10 weeks off work 😱, which would be impossible, but he reckons I can probably be mentally back in the game and working from a laptop in bed from 2 weeks out, so that’s a relief! What with mega short mat leaves and no sick leave to speak of, maybe I’ll get to retire early and have a break then instead. Ah no, no pension... 😭
Anyway, one thing he mentioned (that actually reassured me, given an earlier post musing on the post-op advice given to ACL’ers and importance of bone density) is that with closing wedge HTO he’d usually say none weight bearing on crutches for two weeks but the fact women have lower bone quality (density) than men means he’s more inclined to advise 4+ weeks in this case, to reduce the risk of re-fracture. Then it's working back to full weight bearing as quickly as possible to mitigate any further muscle and bone density loss. Okay, so that’s not so great for mobility but the fact he's conscious of the differences is reassuring and suggests he really has thought round this the full 360°. After 10+ wasted years, I need to get this one right.
So, that’s it. We have a plan. Operation Change the Narrative starts in earnest from here with lots of prehab in the gym to get strong between now and the end of September.
Let’s do this! 💪🏻
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