# Xpost from AZ: High Tibial Osteotomy



## Dag Nabbit (May 27, 2009)

Anyone have one and ride after? I have severe osteoarthritis of the medial femoral condoyle and this is the fix. The docs love the biking as an activity for the shape my knee is in, and riding actually doesn't bother it now much. They expect me to ride just fine (after about a year, of course). I was just wondering what the finer points of riding after the operation were, recovery, complications etc.

A video not safe for the squeamish - so just purely for educational purposes, here's what the osteotomy looks like. Remember, "osteotomy" means cutting bone, so be prepared to see the bone saw! :band:


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## millertm (Jul 20, 2012)

That is a crazy operation, how much height did you loose? It seems like a nice way to use the non-damaged area of the joints. I was a bit hard to watch them cut out that piece of bone.

Mark


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## Dag Nabbit (May 27, 2009)

Haven't had the surgery yet, but probably won't lose much weight. I'm fairly lean as it its, and for my ACL repairs that I've had, I never dropped much. The fix should last 10-15 years, but it'll destroy the other half of my knee then it's on to a total knee replacement!


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## millertm (Jul 20, 2012)

I was wondering about height, not weight. If they are cutting out 1-2" of bone your fib-tib will be shorter. Good luck and I hope it helps with the pain.

Mark


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## Dag Nabbit (May 27, 2009)

derp. Read that wrong! I actually don't think there is that much in height lost since the surgery pushes the knee inward to correct the bit of bow-leggedness going on. That way I can use the good half of my knee. Pretty clever, really. It should last 10-15 years like that, and up to 84% of some cohorts of patients are pleased with the surgery at that time (I've been reading). It will ultimately lead to an total knee though.


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## DenverPoke (Apr 19, 2011)

Ugh... should not have checked this forum today...

This is one of the future options my ortho has talked with me about... I don't yet have severe arthritis, but I have all the ingredients in mixer thanks to a Ultimate Frisbee accident 2.5 yrs ago (grade II PCL tear (unrepaired), tib plateau fracture (repaired), and torn Meniscus (cleaned up)). 

My Ortho is recommending Supartz (Joint Fluid) as a way to slow down the onset of arthritis (I'm only 29)... Anyone try that with success instead of trying the bone hacking surgery?


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## Dag Nabbit (May 27, 2009)

For early onset arthritis the shots would probably help you. I've heard they can be pretty effective but they don't last too long (about 6 months) and they don't necessarily protect the knee much. You can still aggravate it and do some damage. I haven't had the shots, but if I could go back in time, I'd get the defect fixed, even when it wasn't bothering me because once the cartilage is gone, it doesn't come back on it's own. Maybe do chondrocyte injections or the OATS procedure, which transfers nice cartilage from non-weight bearing areas to the damaged part of the knee. It's not fun seeing the x-rays of your collapsed knee and the nice little bone spurs growing out due to years of impact. And I don't even run!


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## kinsler (Sep 13, 2011)

millertm said:


> I was wondering about height, not weight. If they are cutting out 1-2" of bone your fib-tib will be shorter. Good luck and I hope it helps with the pain.
> 
> Mark


No height is lost during a high tibial osteotomy. The tibia is cut across, but not all the through and then wedged opened while keeping the one side of the bone intact. Osteotomy is held open with a wedge of bone or bone substitute. The idea is to convert "bowlegged" to normal or slightly knocked knee. It's a very powerful surgery to off load damaged cartilage from the inside (medial) compartment of the knee.


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## cboyd1974 (Sep 7, 2012)

I had this surgery this past year, still recovering though. I had some complications though. Had my surgery March 19,2012. The performed the HTO which also includes relocating the knee cap, Cartilage transplant and an Osteochondral Allograft. Mine was about a 9 hour surgery. Straightened the leg about 13 degrees.It was more painful than what I was told. I would up getting an infection from the nerve block, which I was told was very rare. I was on crutches for about 4 months with no pressure, but was allowed to bend the knee. I was walking around 8 months but still had pain, but was allowed to ride my bike. 

In November they went in with a scope to see what was wrong and found out my bone had never healed The hardware came loose and the tibia was shifting a half inch back and forth. The wound up redoing the HTO on November 19. It am partial weight bearing but still using crutches. No type of strengthening is allowed. I should be off crutches in 2 weeks, so I am hoping to at least be back on an exercise bike. It gets better everyday, I still get a little pinching in the knee, but hopefully that is just strengthening. I do no have any more arthritis pain no, so I am taking that as a good sign. My problems were compounded by the infection initially, so I am not saying do not have it done. For the first week it is very painful until you can get the pain medications adjusted. 

When they do the HTO, make sure they do a closed wedge where they place bone in between the bone. The first time they did the open wedge and the bone couldn't fuse completely together. 

I am familiar with the surgery after having it 2 times now. Mine is an unsual case, but things can happen.


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## Dag Nabbit (May 27, 2009)

Thanks for the insight! Sorry your surgery didn't go smoother. That is a long time being laid up! If you're like me, two weeks on the couch and I'm going batty. Nice to hear that the arthritis pain has left. Much of what I've read seems to show that this surgery is pretty effective. Too bad it ultimately leads to a total knee replacement though! I hope the revision works better for you than the first one.


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## cboyd1974 (Sep 7, 2012)

Thanks, it's been a long recovery hat's for sure. The main thing is to get full range of motion as soon as they allow it. Once you get to that point, the pain gets less everyday.

Here are some x-rays after the first and second surgery.

First Surgery








Second Surgery. Larger Screws and plate.
In this x-ray you can see how much more the bone was opened up, it's a large area to fill it. There is also a steel wedge attached to the plate to keep the bone separated. Its the big white square in the x-ray.


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## kinsler (Sep 13, 2011)

Xrays above show both a HTO (high tibial osteotomy) and a TTO (tibial tubercle osteotomy). The HTO moves the weight bearing axis in an attempt to shift this to a healthy area of the knee. In the case of the opening wedge HTO this is moving it from the medial/inside of the knee more toward the center if not even a bit into the lateral compartment.
The TTO shifts the tubercle (usually medial) to realign the extensor extension, i.e. the quadriceps tendon, patella and patella tendon.
Doing a closing wedge HTO isn't typically done. For one in order to shift the weight laterally or outside the bone is cut from the inside and wedged open. If you cut the bone twice and then wedge it close from the medial side you would worsen the deformity. The tibia isn't typically cut from the outside or lateral side- for one the fibula makes access difficult and secondly the peroneal nerve (which enables you to bend you ankle up) wraps around the fibular neck and would be at risk.
HTOs are definitely big surgeries, but they don't all go like cboyd's.


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## cboyd1974 (Sep 7, 2012)

I totally agree with Kinsler. My second surgery was 1,000 times better than the first. I just had my 3 month checkup yesterday. Bone is slowly filling in, so I should be off crutches in 2 more weeks. I am still not allowed to use an exercise bike at all, but next week I can start doing some leg presses at the gym with very light weight. The biggest problem for me at this point the amount of muscle I have lost in the past 11 months. It's going to take a long time to get it back.


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## cboyd1974 (Sep 7, 2012)

Just wanted to give you an update. My doctor has had me taking it slow still. At 3 1/2 months I am off of crutches in the unloader brace. Bone is filled in on the sides but still needs needs another couple months of filling in before I it ready for any real strenuous activities. 

First week on the exercise bike seems to be going pretty good. I have to limit to 15 minutes right now until I start to build some strength back up. The knee feels great on the bike other than some muscle paint, but that is to be expected. 

As it looks right now, I should be able to ride a bike on our gravel roads/paths this summer but not be able to get on any real trails until the end of this year. If you have the surgery done, please post your progress.


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## Dag Nabbit (May 27, 2009)

I'm glad to hear that you're moving along nicely. Gravel is better than nothing! Thanks for the update.

I still don't have a surgery date, since I had trouble with my MRI - there's a little piece of tool that doc #1 left in there 15 years ago, posterior to my femur that blacks out the MRI, so I just had a CT scan yesterday so the doc can see my tunnels.....oh yeah, turns out that my ACL (#3) has been blown again so we're working on #4 now. That's why I needed the MRI so the doc can see the condition and size of my ligament tunnels. He should be able to do both the osteotomy and ACL reconstruction at the same time. I was not pleased to find out that the ACL was toast....again. I see the doc again next week, then we should be able to set some surgery dates.

I did get an offloader/ACL brace last week and it has been a godsend - I can walk with about 95% less pain now, just due to the brace. It works that good. Before 5 minutes of standing would put me down. So, in the meantime, I'm gonna test the brace on a little ride this weekend.......

Here's an xray of the cause of the arthritis. Pretty much total medial compartment collapse. Suuuuuuucks bad. BTW, doc is planning on the closing wedge lateral osteotomy. 5 degree correction. Now if I can just get the ACL figured out.


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## cboyd1974 (Sep 7, 2012)

My medial compartment was completely collapsed as well. Very painful no matter what I did. The corrected my knee around 12 degrees which left a pretty large opening to fill. First week on the exercise bike feels great. I do about 20 minutes right now. I could do more by my good knee is starting to give me trouble from using it solely for the past year. I get no arthritis pain anymore, but it still swells some. By 3pm, I get start to limp quite bit because the muscles are so week. Hopefully in another 5 weeks I will be allowed to some more aggressive leg strengthening. Good luck with you surgery.


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## cboyd1974 (Sep 7, 2012)

I just wanted to give you a quick update. I went to my 5 months appointment 2 weeks ago. Bone is filled in on the outside side now and is little by little becoming denser. I am allowed to do any strengthening as long as my foot stays in contact with a surface. Basically leg curls, jumping or twisting. Unloader brace is only needed if I am on my leg for a prolonged period of time. Anything more than 15 minutes right now, my leg gets very unstable because I have been on crutches for about a year. It is still painful to walk sometimes, but its mostly muscle pain. Only slight pinching when they swelling goes up. 

Since I was released to ride a bike, we went out last night for a short little ride. Just went to a local area that has some gravel paths. Only rode for 40 minutes because I am just going to take it slow. It went pretty well I think. I can stand up and crank a little on the pedals on small hills with only minor pain. we rode about 2 miles on very loose gravel, I was just happy be out and moving almost normally. 

Right now this marks 13 months since my first operation. The original recovery time I was told was a full year, but since I had complications with the infection and the bone not healing, my full recovery time will most likely be 24 months. Finally starting to see the light at the end of the tunnel. Being on crutches for the past year has definitely put a strain on my mentally and physically, but it has just given me the appreciation for things you would normally take for granted.


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## xcguy (Apr 18, 2004)

What a long strange trip it's been. Hang in there. I've had some long recoveries, none as long as the one you're going through. Appreciating the small things is something that never leaves you.


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## Dag Nabbit (May 27, 2009)

Finally got in for some surgery two weeks ago, and things are moving nicely. Most of the pain has subsided, and swelling is fairly minimal, considering. No infections, and everything is where it needs to be. Time for leg lifts and more Netflix and chocolate milk. Still on course to start weight bearing at 2 months post-op, six weeks from now. The osteotomy was way worse than an ACL. That mofo hurt! Even that super morphine had trouble beating back the ache. So now I'm up and about easily. The leg can tolerate time under my heart so I can sit at my desk with out throbbing and swelling. Done with the CPM, already have 90 degrees. I'll stay there for another week or so. Doc is taking it slow. Fine with me. He did do a medial opening wedge, and the correction was only 5 degrees. My off-loader brace was only 3 and helped a ton, so I'm pretty optimistic about 5 degrees.

Got some sweet pics. This was one week out. Staples came out yesterday. 


Look at that poor chicken leg!


25 staples total. 16 on the main incision. 6 more weeks of crutches.

Check out that new hardware! 




They put bone putty in my ACL tunnels. The plate is just temporary. It comes off in December when I get the ACL done.

cboyd, I hope you keep making good progress! That's a long road you're on.


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## cboyd1974 (Sep 7, 2012)

Looks like your surgery is coming a long great. It will be one crazy looking scar when it's all healed. The pain for that first week is incredible. Nothing they gave me even helped it. 

I am just about 6 months put now. Still taking it slow because I have quite a bit swelling and fluid from not using it that long. I start to struggle walking on it around 1pm. Walking is still difficult due to loosing so much muscle. Riding a bike about a mile or 2 a couple times a week. I'm so out of shape I'm taking my time getting my cardio up. Just from walking without crutches I have lost 5 of the 30lbs I gained.

Good luck with you recovery and keep us updated. I will do the same.


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## cboyd1974 (Sep 7, 2012)

Any new updates for you? Just curious how things were going for you?


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## kno-endo-ridin' (Aug 18, 2013)

*10 weeks post op*



cboyd1974 said:


> Any new updates for you? Just curious how things were going for you?


I'm new to the forums, so was very interested to read people's experiences on here.
I am just over 10 weeks post op - had an ACL reconstruction and high tibial osteotomy (opening wedge) done in one go. Post op was sickeningly painful until about 3 - 4 weeks - but I blame myself having tried to wean myself off meds too early, and I paid for it. I was in a zimmer brace and using a cryo-cuff for 9 weeks, and non-weight bearing for the same 9 weeks. I'm now fully weight bearing and down to one crutch on occasion, although I walk with a really gimpy limp. I have started some physio - stationary bike, flexion and extension exercises, and some strengthening stuff - it's slow going but already I can see the change in flexibility and muscle definition. Couldn't believe how quickly muscle atrophy happened. : (
Before surgery my knee didn't bother me at all riding - unless I came off - but was no fun for skiing (out of the question), running (too painful), hiking (too unstable). Snow shoeing was good. Am expecting to get full return to mtb'ing in due course, and know it will be a long recovery but will be well worth delaying the full knee replacement for 10-15 yrs.
Thanks for sharing your experiences.


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## cboyd1974 (Sep 7, 2012)

I haven't heard anything from Dag Nabbit lately. I was curious how his recovery is going.

Mine is pretty much a failure. Still walking around in sever pain, even worse than what I had before the surgery. 

Just saw my doctor 2 weeks ago. All of the knee arthritis is coming back and cartilage is collapsing again. Not sure why but he thinks when the plate came loose last time it did a lot of damage to all of the work done previously. I was told a knee replacement is going to be needed, its just a matter of how long we can prolong it. My two options were try a cortisone injection or to remover bone spur that developed on my knee cap. I chose to try the injection. It seemed like it was helping a little, then Saturday got a sharp pain and knee buckled. I am pretty sure it is the bone spur, but honestly I am lost at this point. 

I have tried to get an appointment for a second opinion from multiple doctors, but most well established doctors in my area tell me they aren't taking new patients or only will take then if they are ready for a knee replacement. It's over 18 months since my first HTO and I am still no where closer to even being able to walk without pain. If anyone has any recommendations for doctors in the Maryland please let me know.


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## xcguy (Apr 18, 2004)

Well, cboyd, you have the rest of your life to think about. Sounds like it's time for a knee replacement.


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## Dag Nabbit (May 27, 2009)

Sorry, I wrote an update a few weeks ago, but I see it didn't post. First, I'm sorry to hear about all your trouble. That can't be easy. I expect a full knee too, but only after about 10 years with some reprieve in mean time! I feel bad considering the luck you've had, but my HTO is rather fine. I was walking on my own at 9 weeks, slowly at that though, which was about July 4th. I got the "all clear" from the doc on the 17th of July, as in the x-ray shows that the bone was healed. My leg was picking up strength, so I pursued some riding. I then bought a cross bike for some canal riding, and took to the road. July 25 I managed a nice 25 mile road spin, felt good! After that, I've been commuting to work, about 25 mile round trip most of the week. Finally, on August 25, after a month of riding (about 300 canal/road miles), I took to the dirt and got a mountain bike ride in. A short 4 miles, but a start. I've since bumped that up to about 20 easy dirt miles. I've done a tough climb or two, even some hike-a-bike (very minimal) but it works well. There is grinding at times, but the old pain is gone. As long I keep moving anyway. If I stand anywhere for a while, then it locks a bit and gets pretty achy, buy otherwise, I'm back on the bike, dirt and road. I wish the same could be said about your knee!


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## cboyd1974 (Sep 7, 2012)

Sounds like you are doing great! 

For a while there I was feeling a little down. Being in severe pain really and limping around gets to you after a 18 long months. Since I injured my knee in September 2011 
I have gained over 40 pounds. About a week and a half ago I just got tired of not being able to do anything anymore, so I set out to loose all of the weight I gained to help my knee as much as possible. Since then I started watching my calories/fat intake and tried to do some sort of exercise each day. On good knee days I use a recumbent exercise bike and on bad days I put the bike on the coffee table and use my arms. Right now I am down 16 pounds and I can already feel a difference. Still painful when I walk, but its a lot easier on the rest of my body.

On a good note, I found a Orthopedic that only takes very special cases. He looked over all my reports and feels that he can make a difference without replacement. I go see him on Monday, so I guess we will see.


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## Dag Nabbit (May 27, 2009)

I'm glad your making things turn around for yourself. It can be tough when it's been so long. The weight loss will help a ton. I ended up watching a bunch of food documentaries while I was on the couch and changed my diet to a whole food, plant based diet and I ended up losing about 15 pounds. I haven't weighed 150 in almost 20 years. I figured that alone could get me at least another year out of the osteotomy alone. If you need some good food motivation, check out Forks over Knives. It's on Netflix if you have it. Really good flick. I hope that doc can get it fixed up for you!


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## cboyd1974 (Sep 7, 2012)

I saw three other orthopedics in the past 9 days. All of them said when they reviewed my surgery records. 

Two Basically told me the same but also said there is so much hardware in my leg it will be about a 2 year recovery through a series of 2 surgeries. One to remove the plate (about a year healing/strengthening time and the second a full replacement. 

Doctor I just saw today said it looks like there is still non union of the tibia. He said there is a 85% chance that I have been walking on a broken leg for the past 11 months. Going for a CT scan tonight so I sure hope the bone is healed enough. Not sure if I can take another HTO. I'll try and update when I find things out.

I'm glad you knee is coming along great.


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## Dag Nabbit (May 27, 2009)

Ugh. That's about all I got. I'd hate to go through so much trouble! Even with a timely recovery, it's quite a bit to put up with. I wish you could have had the same experience that I've had! I still have an ACL surgery to go through in December, but I'd certainly take that over another HTO! I hope you can find an easy way to get it all together and pain free. Eventually, you'll get there!


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## Dag Nabbit (May 27, 2009)

How about an update? Would you believe I'm still mucking with this semi-operational piece of appendage?! It's been a long year, with only dreams of big mountain rides, but my knee upgrade is almost complete. The osteotomy ended up working like a dream. Starting with only being able to stand weighted for about 5 minutes, by six months after surgery, I was pretty much thoughtless what I did with my knee. Dishes, no problem. Buy groceries, done. Wait in line somewhere without a bench, could be done! It's really amazing what a sliver of bone can do.

Anyway, the second half of the fix, the ACL, was done on December 11. I'm one month out today, and all is going well. Most ACL revisions start walking immediately as bearable, and on the stationary bike as well. Being my fourth ACL and having a recent osteotomy, the doc has me six weeks no weight. What evs. I can do it. I was quite happy to get my first pedals on the stationary today though. The end is near! They were planning on leaving the plate in from the first surgery, but they wasted about two hours working around it, so they ended up taking it out. Should have done that in the first place! It would have been a 45 minute surgery rather than three hours. For that, my tibia is kind of swiss cheese since six, rather largish screws came out. No bone putty for the holes. They fill of their own accord.


Quater for reference.

Overall the ACL recovery should be roughly 3 weeks faster than the osteotomy. This leaves me with some dates, as I remember my previous milestones.

Walking without the arm sticks - January 29 (49 days post-op, 7 weeks)
First canal commute to work - Feb 15 (66 days, ~9 weeks)....I'll have to get some Valentine's chocolates for my CX bike.
First MTB ride - March 16 (95 days, ~14 weeks)....just in time for the spring fling.

So all is well, if not nearly done. By May I should be 100% ready for dirt riding challenges.


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## cboyd1974 (Sep 7, 2012)

Looks like everything is healing great for you. 

Just to give you quick update. My HTO is now considered a partial union of the tibia. I only have about 30% of the bone filled in. The plate will have to stay in forever unless I opt to have another HTO with a bone graft. I think I will deal with the pain of the plate for now. 

I had a knee scope done a week ago. The doctors removed several pieces of bone and lots of other "junk" in there as well. (He actually used the word "junk" to refer to it). I had less pain in my knee immediately. Meniscus transplant is already severely worn, but still intact. I had very little pain after the surgery. Three hours out of surgery I was in less pain then I was on a normal basis.

Got some bad news at my follow up appointment today. My articular cartilage has a very large fissure, and is totally unrepairable due to the amount of damage done to it. I am pretty much left with getting a partial knee replacement sometime in the very near future. I am not allowed to do any real strength training other than swimming or cycling to prevent any further damage. 

Only so much I can do with it at this point, so I came home and ordered a new bike to get back into shape with. Keep me updated on how things progress for you.


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## Dag Nabbit (May 27, 2009)

Bummer to hear about the the healing and cartilage, but at least the junk is out. I've had a bunch of that before. No bone pieces though. Glad it feels better! Riding always seems to help me, gets the juices moving through the knee. I might be up for a partial too in about 10 years. Or TKR. Who knows.

My last check up went well. Been walking for about two weeks. My knee is still pretty lose, and I was worried I already jacked it somehow, but the doc said that that's because my medial meniscus is gone. Without that, there's some extra movement. After that, he tugged on the new graft pretty well and said it's good to go. Gone for two seven mile rides so far. Finally starting strength training in PT. Should be hitting the mountain bike sometime in March, probably start riding to work before Valentine's day.

I got a cool shot of my knee from the surgery. Easy to tell which half is the bad half. You've got fissures? I don't have hardly any articular cartilage on the medial part of my knee! It should be smooth and close like the bottom pic, which is the good lateral half. That bone on bone banging into each other when walking sucks big time. Standing was terrible for it too. Much better now.

From 010814_Knee

Good luck with the recovery!


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## Volsung (Nov 24, 2011)

Bumping an old thread. Reading your experiences I'm glad I'm (only, psh) having TTO and not HTO or HTO+. How have your recoveries gone?

I have to go on a dumb river boat cruise in Europe in September (not my idea of vacation), so my surgery has to wait. This stupid injury really messes up my plan of volcanic fatbiking in Iceland on our 3 day layover, which was the main thing I was looking forward to. Now all this trip does is postpone my recovery.

I'm kind of ok not mountain biking for a while as long as I can regular bike. However, reading this thread makes me wonder if I'll even be good for spring gravel or the 250 mile 24 hour gravel race I'm kind of signed up to do August 2018.

And good tip on the weight loss. The day before my wedding in 2014 I did a body fat analysis and I was 167 lbs 4.9% fat. Now I'm 195 and unknown fat. Its mainly muscle but my knees don't know that.


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## pat shanks (Apr 12, 2010)

I had one in 2015. It hasnt bothered me much. my athritis does though, just not much while riding. 
Im 33 and staring down a PKR 

How are the knees doing, Dag and Cboyd?


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