Physiotherapy and rehabilitation after ACI/MACI chondral grafting - Henry Atkinson August 2009

Physiotherapy and rehabilitation chondral grafting ACI/MACI
Henry Dushan Edward Atkinson,  Jennifer Michelle Laver,  Elizabeth Sharp

Mr Henry D.E.Atkinson, MBChB, BSc Med Sci, MRCS, FRCS Tr & Orth
Consultant Trauma and Orthopaedic Surgeon
North Middlesex University Hospital, Sterling Way, London N18 1QX
North London Sports Orthopaedics

Miss Jennifer Michelle Laver, B App Sc (Physio)(Hons)
Senior Lower Limb Sports Physiotherapist
SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia

Mrs Elizabeth Sharp MSc (Man Ther) MCSP Grad Dip Phys
Clinical Director ESPH
ESPH ES Physical Health, 116 Lordship Lane, London, SE22 8HD
ESPH, 22 Harley Street, London W1G 9PL


The literature is heavily biased towards authors' clinical experience, with most studies analyzing the success of the surgery rather than the rehabilitation protocols. Most rehabilitation protocols have been devised for ACI, and aim to facilitate a healing response in the tissues without overloading them, and to allow a full restoration of function (Hambly et al 2006, Reinold et al 2006). The graft must be both protected and stimulated for it to remodel and mature (Gillogly et al 2006) (Reinold et al 2006). The repair site is at its most vulnerable for the first 3 months, and care needs to be taken to avoid excessive impact, loading and shearing forces (Hambly et al 2006).

The exact rehabilitation programme varies according to the location of the chondral graft and individual patient factors (age, health, body mass index, past history of other injuries, nutrition, motivation, previous activity levels, the individualized demands of sport, work and ADLs) (Gillogly et al 2006, Reinold et al 2006, Hambly et al 2006).

A period of partial immobilization is required to protect the graft (Hambly et al 2006). This is followed by a gradual increase in early restricted weight-bearing and ROM, such that stress is placed on the healing tissues to stimulate them without causing damage (Reinold et al 2006)(Hambly et al 2006).

Controlled weightbearing and ROM facilitate healing by enhancing synovial fluid diffusion (Hambly et al 2006, Reinold et al 2006) and improving the flow of fluid over the graft site (Hambly et al 2006). It also stimulates chondrocyte development (Gikas et al 2009, Gillogly et al 2006, Reinold et al 2006). As the patient progresses and the repair site heals, there is progressive weight bearing, restoration of  full ROM and muscle strengthening (Brittberg et al 2008, Hambly et al 2006, Reinold et al 2006).

Patients required a combination of OKC and CKC strengthening exercises to regain optimal quadriceps strength, as CKC exercises alone are not sufficient (Hambly et al 2006). CKC exercises are started from 4-6 weeks, and OKC are added from 8 weeks NBrittberg et al (2008).

Onne also needs to consider co-existing pathologies such as malalignment (Brittberg 2008, Gillogly et al 2006). If these are not addressed, it can lead to excessive forces and abnormal compressive forces that can damage the repaired tissue, so need to address causative or contributing factors to the chondral defect (Brittberg et al 2008)  


The phases of healing
(Hambley et al 2006, Reinold et al 2006)
With each successive phase the patient is allowed to accommodate greater load (Gillogly et al 2006)

Proliferation stage
The repair is protected for the first 4-6 weeks, while tissue fills the defect. (Reinold et al 2006), Hambly et al (2006). The implanted cells become adherent to the subchondral bone (Gikas et al 2009),and chondrocytes proliferate over the first 6 weeks (Reinold et al 2006). The rehabilitation aims during this ?protection? stage are to protect the healing graft from shearing or loading forces (Gillogly et al 2006, Horas et al (2003), to reduce knee swelling through cryotherapy, elevation and compression (Reinold et al 2006, Gillogly et al (2006, Hambly et al (2006)), regain ROM, and increase quadriceps control (Reinold et al 2006). Massage can be useful in preventing adhesions developing from scar tissue (Reinold et al 2006).

Transition stage of healing
This phase lasts from 4-12 weeks (Reinold et al 2006) during which there is an expansion of the chondrocyte matrix (Gikas et al 2009). The tissue is soft and not well integrated, and is almost liquid-like when probed arthroscopically (Hambly et al 2006). Maturation of the healing tissue allows for progression to higher level ROM and functional exercises (Reinold et al 2006).

Remodelling phase
Between 3 and 6 months the healing tissue remodels to from a more organized structure with increased strength and durability (Reinold et al 2006). The tissue progressively acquires properties similar to that of the adjacent articular cartilage (Gikas et al 2009). They have firmed-up, have a gelatin-like consistency, and are well integrated with adjacent articular cartilage and underlying bone (Hambly et al 2006). At this stage the knee should have regained a full ROM (Reinold et al 2006), and functional activities can be increased with the increased strength of the healing tissue (Reinold et al 2006). One should however avoid excess activity during this phase as it may cause degeneration of the healing tissue (Hambly et al 2006).

Maturation phase
This begin at 4-6 months and can continue as long as 15-24 months (Reinold et al 2006, Hambly et al (2006). The healing tissue is putty-like at 9 months post-op (Hambly et al 2006). Horas et al showed fibrocartilage present in the superficial and central layers of the graft 6 months post-ACI, with deep areas showing signs of hyaline cartilage (type II collagen and aggrecan-proteoglycan) (Horas et al (2003). There is a gradual return to pre-operative activities as able and RTS, with an emphasis on regaining functional rather than high impact activities (Reinold et al 2006).

 
Tibio-femoral chondral grafts

One must attempt to avoid compressive forces when the chondral lesion is on the weightbearing surface of the femoral condyles (Reinold et al 2006)

0-2 weeks (NWB phase)
The knee is braced. Controlled ROM can stimulate the cells to make specific matrix markers and encourages cellular nutrition via synovial diffusion (Reinold et al 2006)

2-6 weeks (NWB ROM phase)
Isometric quadriceps are started early post-operatively (Brittberg 2008, Gillogly et al 2006, Reinold et al 2006, Marlovits et al (2005). SLR can be commenced once the patient has achieved full knee extension. Discard brace from 6 weeks (Gillogly et al 2006, Reinold et al 2006)

6-12 weeks (Weightbearing phase)
MRI evaluation of MACI grafts of the femoral condyle showed high rates of attachment by 37.4 days, with 87.5% of patients having a completely attached graft and repair tissue, while 6.25% had partial attachment and 6.25% had complete detachment. As the healing tissue gains strength, weightbearing is progressed from PWB (at 6 weeks) to FWB (at 8-10 weeks) (Reinold et al 2006)(Marlovits et al 2005) (Gillogly et al 2006). Maturation of the healing tissue allows for progression to higher level ROM and functional exercises (Reinold et al 2006); one can aim for full ROM and start the bike at low resistance (Gillogly et al 2006, Reinold et al 2006) (Hambly et al 2006).

Hydrotherapy may help to facilitate normal gait, and increase strength, balance and proprioception in a PWB environment (from 4-6 weeks) (Hambly et al 2006, Reinold et al 2006)(Reinold et al 2006)(Gillogly et al (2006). Mini-squats (0-45 degrees), squats (0-60degress) and leg presses (0-90 degrees) can also be started (Horas et al 2003). Low load OKC and CKC (<90 degrees) exercises can be started (Reinold et al 2006, Horas et al (2003). Wilk et al found that compressive force on the tibiofemoral joint was maximum at 90 degrees flexion during OKC knee extension, and at 91 degrees in a CKC squat (Wilk et al (1996).

3-6 months (consolidation phase)
One can commence leg presses (0-90), bilateral squats (0-45), and knee extension 0-90 (Gillogly et al 2006, Reinold et al 2006).

6-12 months
Resistance can be progressed as able and jogging may start at 8-10 months; 9-12 months for larger grafts (Gillogly et al 2006, Reinold et al 2006).

12-18 months
Commence proprioceptive exercises such as side-to-side and diagonal weight shift, mini-squats on an unstable surface, lunges, balance on an unstable surface, and wobbleboard (Reinold et al 2006, Gillogly et al 2006). High impact sports may be restarted at 12-18 months if painfree (Gillogly et al 2006, Reinold et al 2006)(McNickle et al 2009).

Patello-femoral chondral grafts
One needs to minimize shear forces when the chondral lesion is on the patella or in the trochlea, but maintain PFJ mobility to avoid later difficulty in recruiting the quadriceps and poor ROM (Reinold et al 2006).

0-2 weeks (No Load)
The primary aims are to reduce swelling, regain ROM, increase quadriceps control and progress weightbearing (Reinold et al 2006). Patients are immediately allowed to WBAT in a knee brace locked at 0 degrees (Gillogly et al 2006, Reinold et al 2006) as the patella and trochlea are not in contact in full extension (Grelsamer and Klein 1998, Reinold et al 2006). Isometric quadriceps and SLR are also safe during this time for the same reasons (Grelsamer and Klein 1998) (Brittberg 2008, Gillogly et al 2006, Reinold et al 2006). Partial weightbearing stimulates the cells to make specific matrix markers and encourages cellular nutrition via synovial diffusion (Reinold et al 2006).

2-6 weeks (protection phase)
Can increase to FWBAT from week 2 and add ROM exercises. Some authors have even recommended ROM from day 1 (Gillogly et al (2006), Reinold et al (2006). No active knee extension should be performed (Gillogly et al 2006, Reinold et al 2006).

6-12 weeks (gentle activity)
The brace can be discontinued at 6 weeks (Gillogly et al 2006, Reinold et al 2006). aim for full ROM and start bike, hydrotherapy, low load OKC (0-20 degrees) and CKC (0-45 degrees) exercises
Patients should aim for a full ROM. They may be started with hydrotherapy, the bike, low-load OKC (0-20 degrees), CKC (0-45 degrees), mini-squats (0-45 degrees) at 6-8 weeks, leg presses (0-60 degrees) at 8-10 weeks, and active knee extension (at 0-30 degrees) (Reinold et al 2006). Brittberg et al stated that contact pressures on the PFJ are maximal from 40-70 degrees knee flexion, and exercises in this range should be avoided until the grafted tissue is strong and mature enough to withstand shear forces Brittberg (2008); forces on the PFJ are low near full extension (25-0 degrees) (Hambly et al 2006) and posterior shear forces on the tibiofemoral joint are relatively low at 0-45 degrees of a squat (Wilk et al 1996), thus CKC exercises are safest in 0-45 degrees flexion (Grelsamer et al 1998).

3-6 months (Early strength)
As the patient progresses, CKC exercises, lower limb strengthening, leg extensions at 0-90 (not into heavy load), can begin (Reinold et al 2006). Leg presses (0-90), squats (0-60), wall squats (Gillogly et al 2006, Reinold et al 2006), and increased time with the bike (Gillogly et al 2006).
 
6-12 months
There is a gradual return to pre-operative activities and RTS as able, looking at functional rather than high impact activities (Reinold et al 2006). Increase range with OKC and CKC, and progress resistance as able (Gillogly et al 2006, Reinold et al 2006).


REFERENCES

Bartlett W, Skinner JA, Gooding CR, Carrington RWJ, Flanagan AM, Briggs TWR, and Bentley G (2005): Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: A prospective, randomized study. Journal of Bone and Joint Surgery (Br) 87-B: 640-645

Brittberg M (2008): Autologous chondrocyte implantation ? technique and long-term follow-up. Injury 39 (1-supplement): S40-49

Gillogly SD, Myers TH and Reinold MM (2006): Treatment of Full-Thickness Chondral Defects in the Knee With Autologous Chondrocyte Implantation. Journal of Orthopaedic and Sports Physical Therapy 36 (10): 751-764

Gikas PD, Bayliss L, Bentley G and Briggs TWR (2009): An overview of autologous chondrocyte implantation. Journal of Bone and Joint Surgery (Br) 91-B (8): 997-1006

Grelsamer RP and Klein JR (1998): The Biomechanics of the Patellofemoral Joint. Journal of Orthopaedic and Sports Physical Therapy 28 (5): 286-298

Hambly K, Bobic V, Wondrasch B, Van Assche and Marolvits S (2006): Autologous Chondrocyte Implantation Postoperative Care and Rehabilitation. American Journal of Sports Medicine 34 (6): 1020-1038

Horas U, Pelinkovic D, Herr G, Aigner T and Schnettler R (2003): Autologous Chrondrocyte Implantation and Osteochondral Cylinder Transplantation in Cartilage Repair of the Knee Joint. Journal of Bone and Joint Surgery (American) 85-A (2): 185-192

Jones CW, Willers C, Keogh A, Smolinski D, Fick D, Yates PJ, Kirk TB and Zheng MH (2008): Matrix-Induced Autologous Chondrocyte Implantation in Sheep: Objective Assessments Including Confocal Arthroscopy. Journal of Orthopaedic Research 26: 292-303
 
Lutz GE, Palmitier RA, An KN and Chao EYS (1993): Comparison of Tibiofemoral Joint Forces During Open-Kinetic Chain and Closed-Kinetic-Chain Exercises. The Journal of Bone and Joint Surgery (American Volume) 75-A: 732-739

McNickle AG, L?Heureux DR, Yanke AB and Cole BJ (2009): Outcomes of Autologous Chondrocyte Implantation in a Diverse Patient Population. American Journal of Sports Medicine 37 (7): 1344-1350

Marlovits S, Striessnig G, Kutscha-Lissberg F, Resinger C, Aldrian SM, Vecsei V and Trattnig S (2005): Early post-operative adherence of matrix-induced autologous chondrocyte implantation for the treatment of full-thickness cartilage defects of the femoral condyle. Knee Surgery, Sports Traumatology, Arthroscopy 13: 451-457

Reinold MM, Wilk KE, Macrina LC, Dugas JR and Cain EL (2006): Current Concepts in the Rehabilitation Following Articular Cartilage Repair Procedures in the Knee. Journal of Orthopaedic and Sports Physical Therapy 36 (10): 774-794

Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR and Boyd ML (1996): A Comparison of Tibiofemoral Joint Forces and Electromyographic Activity During Open and Closed Kinetic Chain Exercises. American Journal of Sports Medicine 24 (4): 518-527



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