Cartilage Repair

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

References:

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