REHABILITATION
Rehabilitation after cartilage repair
Microfracture Rehabilitation
Basic science evidence has demonstrated that compressive loading may have a positive impact on articular cartilage healing. Shear loading is detrimental. Rehabilitation for microfracture depends on lesion size, location and other concomitant surgery.
Reinold MM, Wilk KE, Macrina LC, Dugas JR, Cain EL. Current concepts in the rehabilitation following articular cartilage repair procedures in the knee. J Orthop Sports Phys Ther. 2006 Oct;36(10):774-94. Review
Irrgang JJ, Pezzullo D: Rehabilitation following surgical procedures to address articular cartilage lesions of the knee. J Orthop Sports Phys Ther 28:232-240, 1998.
Biomechanical considerations for rehabilitation of the knee. Clinical Biomechanics 15: 160-166, 2000
Recommended programme for Microfracture
1 Femoral or tibial lesions
- Regain full range of movements and patella mobilisation.
- Continuous passive mobilisation 6-8 hrs per day or in the absence of CPM, passive flexion and extension of the knee with 500 repetitions three times per day
- Touch-down (10% body weight) weight bearing for 6-8 weeks
- Exercise bike without resistance at 2 weeks
- Resistance exercises by 12 weeks
- No free weights until 16 weeks
- No return to contact/pivoting sport or jumping for 4-9 months
2 Patello-femoral lesions
- Use knee brace restricting flexion to avoid lesion coming in to contact with patella/trochlea (usually 0-20) for 8 weeks
- Continue passive mobilisation and start early weight bearing in brace
- Avoid lesion contact point with resistance exercises for 4 months
- Similar rehabilitation after 12 weeks
Steadman RJ, Rodkey WG, Rodrigo JJ: Microfracture: Surgical technique and rehabilitation to treat chondral defects. Clinical Orthopaedics and Related Research 2001; 391: 362-369.
The rehabilitation could be altered for lesions smaller than 2 cm2 with earlier weight bearing and possibly avoid CPM.
Marder RA, Hopkins G Jr, Timmerman LA. Arthroscopic microfracture of chondral defects of the knee: a comparison of two postoperative treatments. Arthroscopy. 2005 Feb;21(2):152-8
Autologous Chondrocyte Implantation Rehabilitation
Femoral Condyle
Postoperative period
- 7-10 days of extension splint to avoid shear forces on graft and allow early cell adherence
- Some centres prefer early CPM
- No driving for 6 weeks
Weeks One - Six
Goals -
- Restore full passive extension
- Prevent adhesions
- Aid joint nutrition
- Pain relief
- Aim gradually increasing range of motion and full range by 6 weeks
- Patellofemoral joint mobilisation
- Isometric exercises to regain Grade 3 or greater muscle power
- Crutches for 6 weeks touch weight bearing (and up to 10 weeks)
- Multi-angle Q and H contractions, including early propioceptive exercises.
- OKC exercises 60° - 75°, no resistance, concentric and eccentric work.
- Maintenance exercises for rest of body
- At 4 weeks Hydrotherapy (if appropriate)
- Exercise bike - Low resistance
Weeks Six - Twelve
Goals -
- Increased loading to stimulate hyaline-like cartilage formation
- Promote neuromuscular responses
- Progression weight bearing as comfort allows
- Progress duration and resistance of closed chain exercises (no weights)
- Early plyometric exercises
- Correct muscle balance as indicated and gait re-education
- Increase proprioceptive work
- If not yet gained Full ROM (or not improving range) refer back to medical team for opinion
Three - Six Months
Goals -
- Strength and endurance training
- Improve stability and proprioception
- Cycling
- Treadmill - supervised only
- Squatting
- Exercise bike - increase resistance as able
Six Months - One Year
Goals -
- Increase endurance and confidence
- Injury prevention
- Increase agility after 9 months
- Jog/Run unsupervised
- Plyometric exercises
- Sports specific training
- Non-contact competitive sports (on agreement with consultant)
- Progressive gym work
One Year Onwards
- Return to all sports - after clinic review with medical team
- No limitations in activities
- All gym work
Patella/Trochlea
Avoid open chain exercises beyond 30 degrees flexion for the first 6 weeks
Passive full range of motion to be regained as for femur
Weight bearing could be progressed earlier
Reference
Active trial rehabilitation programme
http://www.active-trial.org.uk/ACTIVESite/RehabPhysios.htm
Stanmore ACI protocol
Bailey A, Goodstone N, Roberts S. et al Rehabilitation after Oswestry autologous chondrocyte implantation: the Oscell protocol. Journal of Sport Rehabilitation 2003 12:104-118
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