Rehabilitation of Articular
Cartilage Lesions: Rehabilitation
Guidelines
Kevin E Wilk, DPT, PT, FAPTA
Rehab Articular Cartilage
Introduction
• Most challenging of all lesions to
successfully treat
Athletes
Active People
• Not sexy concepts – not bejazz
• Just basic science principles that
the surgeon & rehab specialist
must adhere to
• Unforgiving structure
• Career threatening injury /
7 months post-op
Life altering lesions
Rehab Plays a Key Role in
Ultimate Outcome
Articular Cartilage Lesions Athletes
Introduction
Medial Meniscus Allograft with Microfracture
30 yo female
Often painful condition
Unable to play at competitive level
Pain, swelling, dysfunction present
Pain is limiting factor
Where does the pain come from?
 articular cartilage
 synovium
 other structures
Rx Options
12/26/08: 1cm x 15mm
7/30/09: healing - painful
Potter, Jain, Ma, et al: AJSM ‘12
Potter, Jain, Ma, et al: AJSM ‘12
• 42 knees in 40 patients (28 ACLR, 14
non-op)
• MRI at time of initial injury then
annually for a maximum of 11 yrs
• All patients sustained initial chondral
injury
 Risk of cartilage loss doubled from yr 1
for the lateral & medial compartment &
3x for patella
 By 7 to 11 yrs: LFC 50x, MFC 19x,&
patella 30x
 Size of the bone bruise associated to
degeneration from yr 1 to yr 3
Articular Cartilage Function
Cartilage Injury
Overview
• Cartilage has remarkable
durability
• Provides a low friction,
resilient, weight bearing
surface
• Absorbs mechanical shock
- load
• Coefficient of friction 15
times less than that of ice
on ice
Mankin ‘71
• Vulnerable to traumatic or
degenerative conditions
• Cartilage has limited ability for
repair or regeneration
Cartilage Development & Aging
Nutrition
• Cartilage avascular
•
•
•
•
•
•
•
Immature Cartilage
Blue-white color
Thick
Increased cellularity
Many mitotic figures
Higher water content
Higher PG content
Lower collagen content
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•
•
•
•
•
Mature Cartilage
Thinner
Less cellular
Mitotic activity ceases
Lower water content
Lower PG content
Higher collagen content
Diffusion
• Immature: Underlying bone
and synovial fluid
• Adult: Synovial fluid
History
Obstacles to Cartilage Repair
Often an Associated
• Hypocellular
• Avascular
• Chondrocytes
“imprisoned” in
matrix
Ligamentous injury
Pain
Swelling
Catching
Locking
Kettunen,Kujala:AJSM ‘01
• Surveyed over 1300 former elite
athletes in Finland
• Surveyed 814 individuals (control)
Athletes in team sports higher risk
of knee disability
Specific sports at higher risk:
soccer,wrestling,hockey, basketball
• Sports at low risk: endurance,track
Deacon et al: Med J Austr ‘97
• Evaluated 50 retired
elite footballer
• Compared to 50 age
matched cohorts
Footballers with history of
intra-articular ligamentous
&/or meniscus injury – 10 times
greater risk of development of
OA knee
Articular Cartilage Lesions
Treatment Options
Non- Operative Treatment:
 Rehabilitation
 Injections
 Bracing
 Orthotics
 BMI (weight loss)
Surgery
 Various Surgerical procedures
Articular Cartilage Lesions
Classification
Outerbridge System:
•
•
•
•
Grade I - softening
Grade II - fibrillation
Grade III – fissuring to bone
Grade IV - full thickness
Orthopedics 1997:20:525-538
Dye, Vaupel, Dye AJSM 1998
• Conscious neurosensory mapping of
internal structures without anesthesia
• Subjectively graded sensation:
0 (none) – 4 (severe)
• Spatial localization:
A (accurate localization) –
B (poor localization)
Articular Cartilage Lesions
Rehabilitation Concepts
• Successful rehabilitation
requires knowledge of:
1: Biology of articular cartilage
»
»
»
»
factors influence healing & repair
such as motion, compression, etc.
nutrients
protection; shear & compression
Promote
Healing
Do not
Overload
Healing Tissue
TIBIOFEMORAL COMPRESSIVE LOADS
• Level walking
3.4 x BW
• Up ramp
4.5 x BW
• Down ramp
4.5 x BW
• Up stairs
4.8 x BW
• Down stairs
4.5 x BW
Morrison J Biomech ’70
TIBIOFEMORAL COMPRESSIVE LOADS
Overview
Kaufman, AJSM 1991
isokinetic 600/sec 550 4x BW
Kaufman, AJSM 1991
isokinetic 300/sec 550 3.5x BW
Ericson, AJSM 1986
Morrison, J Biomech
cycling
level walking
• Rise from chair 3.2 x BW Dumbleton Biomech ’72
Dahlkurst, Eng Med’82 squat – ascent 1400
squat – descent 1400
• Knee bend
Nisell, AJSM 1989
4.2 x BW Ellis J Biomech Eng ‘84
1.2x BW
3.4x BW
5.0x BW
5.6x BW
isokinetic 300/sec 650 9.0x BW
Proprioception & NM Control
Progressive WB Loading
Treat the Joint !!!
Not Just an Isolated Injury
“It hurts after I exercise !!!”
Don’t do that !!!
Let’s find a form of exercise for you to do !!!
Articular Cartilage Lesions
Rehabilitation Concepts
• Successful rehabilitation
requires knowledge of:
• Specific patient variables
Age
Desired activity level
LE alignment
Body weight (BMI)
Concomitant injuries
Meniscus status
ACL REHABILITATION
Range of Motion
 “Full” passive extension
immediately
• Gradual restoration of flexion
Week 1: 90 degrees
Week 2: 105 - 110 degrees
Week 3: 115 - 125 degrees
Week 4: 125 degrees or >
Week 8-12:” heel to gluts”
Articular Cartilage Lesions
Rehabilitation Concepts
• Specific Rehabilitation Concepts:
ROM
Flexibility
Knee extension & flexion
Muscular strength
Quadriceps
Above & below (hips)
Proprioception
Stabilization of knee joint
Gradual return to Activities/Sports
Stabilization From
ABOVE & BELOW
Co-Activation to Enhance
Dynamic Stability
Co-Activation to Enhance
Dynamic Stability
RDLs
Establish Hip Control
RDLs
Who Needs Core Stability ??
45 -100
Wilk,Escamilla,Fleisig, et al: AJSM ’94
Escamilla, Feisig, Wilk, et al: Med Sci Spts ‘98
Wilk et al: AJSM ‘94
0-30
Wilk et al: AJSM ‘96
Wilk et al: AJSM ‘96
Escamilla, et al: Med Sci Spts ‘98
Typical Quadriceps EMG Curves (%MVIC)
Quadriceps Activity:
SQ&LP>LE between 6095°
LE>SQ&LP between 0-50°
Inverse EMG Relationship
Between Leg Extension
and Squat/Leg Press
Forward Lunge Long & Short
Flexing
Knee Angle (deg)
Extending
Wall Squat Long & Short
Nagura : J Appl Biomech ’06
Nisell: AJSM ‘89
Knees over the toes !!!
Oh No !!!
Escamilla & Wilk: JOSPT ’08
Escamilla & Wilk: Clin Biomech ‘08
WB & NWB Exercises References
Escamilla et al: ACL & PCL loading. J Eng in Med ’12
Escamilla et al: ACL forces WB & NWB Ex. JOSPT ‘12
Escamilla, et al: lunges etc – ACL/PCL . MSSE ‘10
Escamilla, et al: wall squat – 1 leg squat . MSSE ’09
Escamilla et al: cruciate forces wall squats. MSSE ’09
Escamilla et al: PF during various lunges. JOSPT ’08
Escamilla et al: PF forces side /front lunge. Clin Biomech ’08
Escamilla et al: Techniques variation squat. MSSE ’01
Escamilla et al: Squat v leg press. MSSE ’01
Wilk et al: Comparison OKC – CKC. AJSM ’97
Wilk et al: PF Rehab – OKC v CKC JOSPT ‘98
Wilk et al: UE OKC & CKC. J Sports Rehab ‘01
Wilk et al: OKC vs CKC JOSPT ‘99
Biomechanics of LE Exercise
Knees over toes concept
• Knees over toes during
squatting or lunges if
excessive – increase loads on
ACL
During lunge: 10+2 cm
During squat: 9+2 cm
Escamilla et al; MSSE ’10
Escamilla et al: MMSE ‘09
Escamilla et al: JOSPT ’09 (PF)
ACL Rehabilitation
Advanced Strengthening Phase
Strengthening Ex Days
 Leg press (45-100)
 Wall Slides (0-75)
Perturbation Training to
Enhance NM Control
Rehab Articular Cartilage
Rehab Specifics
Patellofemoral Lesions
• Motion
• Flexibility ( Q, G/S)
• Patella position
» Correct tilt
• Control PFJR
• Treat above & below
» Hip control
» Pelvic control
» Foot/ankle position
Tibiofemoral Lesions
• Motion, motion, motion
• Control WB forces
• Shock absorbers (Q)
• Location of lesion
• Control WB forces
• Slow to run, jumping
• Slow to return to sports
Articular Cartilage Lesions
Articular Cartilage Lesions
Classification
Classification
• Size of lesion
Outerbridge System
» Smaller lesions are
“shouldered” and may not
progress.
• Size of Lesion:
• < 2 cm2 = small
• 2 to 5 cm2 = moderate
• > 5 cm2 = large
Articular Cartilage Lesions
Classification
•
•
•
•
Grade I - softening
Grade II - fibrillation
Grade III – fissuring to bone
Grade IV - full thickness
Orthopedics 1997:20:525-538
Rehab Articular Cartilage
Motion, Motion , Motion
• Low intensity
• Long duration
Articular Cartilage
Rehabilitation
Surgerical Options for Localized
Articular Cartilage Lesions
Articular Cartilage Lesions
Diagnostic Concepts
• Chondral or osteochondral lesions
found in 61- 68% of knees
examined arthroscopically
Aroen: AJSM ’04
Curl: Arthroscopy ’97
Hjelle: Arthroscopy ’02
Zamber: Arthroscopy ’89
• But – less frequent in patients
younger than 45 yrs of age
Aroen: AJSM ‘04
 Arthroscopic lavage
 Arthroscopic debridement
 Arhtroscopic abrasion
chondroplasty
 Microfracture or picking
 Osteochondral autograft
transfers
 Autologous chondrocyte
implanation
Which procedure is best ???
Debridement MST ACI OCG
Rehab Must Match the Surgery
Palliative
The Treatment Algorithm: Cartilage Repair Centers
Smaller, Less Complex, Less Invasive
Chondroplasty
Failure
Larger > 2 cm2 Defect
Factors

Size

Cost

Activity

Etiology

Age

Social

Compliance
Marrow Stimulation
High Demand Patient
< 40
Age
OATS
OATS
ACI
ACI
ACI
Articular Cartilage Lesions
Rehabilitation Concepts
• Successful rehabilitation
requires knowledge of:
2: Specific surgical variables
» nature of lesion
(acute, chronic)
» location of lesion (femur,
trochlea, patella)
» size of defect
» depth of lesion
» WB area**
Low Demand Patient
> 40
MS
Failure
OATS
Restorative
The Treatment Algorithm: Cartilage Repair Centers
Larger, More Complex, More Invasive
Small < 2 cm2 Defect
Low Demand Patient
Reparative
High Demand Patient
2-3 cm2: MS, OATS
ACI
ACI
Allograft
Factors

Size

Cost

Activity

Etiology

Age

Social

Patient Expectations
Failure
Failure
ACI
Allograft
Redo ACI
Allograft
Articular Cartilage Lesions
Rehabilitation Concepts
• Successful rehabilitation
requires knowledge of:
3: Exact surgical
procedure
» tailor rehab to procedure
4: Specific patient variables
» age, activity level
» LE alignment
» Concomitant injuries
» Meniscus
Articular Cartilage Lesions
Rehabilitation Concepts
• Successful rehabilitation
requires knowledge of:
5: Phases of articular
cartilage healing
• Four Phases of Healing
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–
–
–
Proliferation Phase
Transitional Phase
Remodeling Phase
Maturation Phase
Phases of Articular Cartilage Healing
Four Biological Phases
I:
Proliferation – Protection Phase
» First 6-8 weeks of healing
» Cell multiply & produce matrix
II:
Transitional – Protection Phase
» Weeks 8 -12/16
» Repair tissue is spongy, delicate phase
III: Remodeling – Functional Phase
» Weeks 12/16 - 32
» Remodeling to articular(fibrocartilage)
IV: Maturation Phase (8-18> months)
» Fibrocartilage matures, increases in strength,etc.
Crenshaw et al: Clin Orthop ‘00
Knee Bracing for the
Osteoarthritic Knee Patient
Hewitt, Noyes, Barber,
Heckmann: Orthop ‘98
• 18 patients symptomatic medial OA
• Before bracing 78% reported knee as fair to
poor, had pain with ADL’s
• Following 9 weeks of bracing: 33% rated
knee as fair poor, 39% pain w/ ADL’s
• Asymptomatic walking tolerance increased
from 51 min to 139 min following 1 yr
Lidenfeld, Hewitt: Clin Orthop ‘97
• 11 patients with medial arthrosis
tested
• Gait analysis, functional score
• Compared biomechanics to 11
normal subjects
• Pain decreased by 48%
• Function improved by 79%
• Mean adduction moment
decreased by 10%
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•
Kirkley,Webster-Bogaert,
et al: JBJS ‘99
• 119 patients randomly assigned to one of
3 groups: neoprene sleeve, valgus brace,
control group
• Assessed pain, stair climbing, 6 minute
walking test, quality of life
• Tested after 6 months of wear
• Significant reduction in pain, 3.3 x
reduction with brace group
• Braced out performed neoprene or control
Articular Cartilage Lesions
Articular Cartilage Lesions
Injections
Injections - PRP
PRP
Stem Cells
Corticosteroids
Viscosupplementation
• Platelet Rich Plasma (PRP)
• Does PRP work?
» 50/50 proposition Dragood
» 6,047 pubmed articles
• Significant improvements
Patel: AJSM ‘13
Cerza: AJSM ‘12
Sanchez: Arthroscopy ‘12
Viscosupplementation
• Hyalronic acid intraarticular injection
• Not a new concept
» 1960’s used on race horses for chondral injuries
» Used in Sweden since 1975
» In Canada since 1992
• HA functions as “backbone” for matrix PG
• Normal component of synovial fluid
» Lubricate cartilage
» Improves viscoelascity (HA dependent)
» Improves shear velocity
Glucosamine Supplements
Rutjes et al: Ann Intern Med ‘12
• Viscosupplementation for Knee OA –
systematic review & meta-analysis
• 89 trials involving 12,660 adults included
“Small & clinically irrelevant benefits
with an increased risk for serious adverse
events”
• Glucosamine & Chondroitin Sulfate
treatment is NOT a new concept
• These products have been widely used in
Europe & Asia for several yrs
• Interest in the USA
» 1977 book entitled “The Arthritis Care”
recounted authors’ experience
with G & CS
» Declared it useful – rapid interest
» In 2000; $640 million supplement sales
» Alternative Medicine & Veterinary
Glucosamine Supplements
• Glucosamine & Chondroitin Sulfate
treatment is NOT a new concept
• These products have been widely used in
Europe & Asia for several yrs
• Interest in the USA
» 1977 book entitled “The Arthritis Cure”
recounted authors’ experience
with G & CS
» Declared it useful – rapid interest
» In 2000; $640 million supplement sales
» Alternative Medicine & Veterinary
Leffler et al: Mil Med ‘99
• Randomized double blind/placebo controlled trial
• 32 males US navy diving & special forces teams with
OA knee &/or low back
• received G 1500 mg,CS 1200 mg, maganese
ascorbate 228 mg daily for 16 weeks
• Assessed symptoms, x-rays, pain, function –run time
• Placebo grp: no significant change
• Rx grp: significant improvement knee score 26%,
physical exam score by 40%, no change in running
times
Clegg et al: New Eng J Med ‘06
• 1583 patients with symptomatic knee OA
mean age 59 yrs (65% females)
• Excluded 1655 patients for various reasons
• Treatment groups:
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313 placebo
317 Glucosamine
318 Chronitin Sulfate
317 Glucosamine & CS
318 Celecoxib
• Treatment plan for 24 weeks
• Able to take up to 400 mg actaminophen for pain
• Primary outcome 20% reduction in knee pain
Clegg et al: New Eng J Med ‘06
• Conclusions:
• “Glucosamine and chondroitin sulfate alone
or in combination did not reduce pain
effectively in the overall group of patients
with osteoarthritis of the knee.
• Exploratory analyses suggest that the
combination of glucosamine and
chondroitin sulfate may be effective in the
subgroup of patients with moderate-tosevere knee pain. “
Glucosamine & Chondroitin
Sulfate Supplemention
• Consumer Reports June 2006
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Tested 17 national avaiable products
Contained labeled amounts
Cost – related to ingredients
Rated the supplements: adequate to inadequat
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Kirkland (Costco)
Wal-Mart Spring Valley
Target
Vitamin World
GNC
Cosamine DS
.25/day
.40/day
.45/day
.45/day
.60/day
1.25/day
Essentials to Cartilage Restoration
• Alignment:
• Unload the involved compartment
• Normalize the biomechanics
Rehabilitation Following
Articular Cartilage
Repair Surgery
Surgerical Techniques for
Articular Cartilage Lesions
Kevin E Wilk, DPT
Moseley,et al: N Engl J Med ‘02
• 180 randomly assigned to one of 3 groups:
• Arthroscopic debridement
• Arthroscopic lavage
• Arthroscopic placebo
• Assessed at multiple points over 24 mos
regarding subjective scoring but also walking &
stair ambulation
 At no point did the Rx groups report less pain
than the placebo groups
 Similar knee results at 2 yrs but placebo group
still higher knee scores
Microfracture
Rehab Following Microfracture
Protection Phase (week 0-8)
• Full passive knee extension immediately
• Immediate motion: 0-450
 Week 1: 0-90
 Week 2: 0-105
 Week 4: 0-125
• Motion exercise hourly (use opposite leg)
• CPM use 6-8 hours per day
• No brace, may use elastic compression
sleeve or wrap for swelling
Rehab Following Microfracture
Rehab Following Microfracture
Transitional Phase (week 8-14)
Protection Phase (week 0-8)
• Weight bearing progression:
NWB 2-4 weeks or (NWB for 4-6 wks)
25% BW week 6-7
50% BW weeks 7-8
FWB week 8-9
*Depends on location & extent of lesion(size)
• OKC exercise for 5-6 weeks
• CKC leg press at week 4-5
• Bicycle once ROM permits (low resistance/seat)
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•
Full weight bearing week 8
Full ROM week 6-7
Initiate functional rehab drills
Pool exercise program
» Control joint compressive/shear forces
» Consider orthotics or brace
• Gradually increase walking program
Rehab Following Microfracture
Rehab Following Microfracture
Maturation Phase (week 14-22)
Return to Activity Phase (week 22-26)
• Progress strengthening exercises
» Progress CKC exercises
» Lunges,squats,step-overs,etc
• Progress functional drills, proprioception
• Stretching & flexibility drills
• Progression in functional activities
• Continue strengthening &
flexibility exercises
• Continue bicycle program
• Functional activities:
Low impact: week 16-20
Moderate impact: week 22-26
High impact: week 26-34
Rehabilitation Microfracture
Rehab Overview
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Drop locked brace crutches
Full passive extension
CPM - motion
Immediate PROM
Lots of motion, motion…
EMS to quads
Progress to CKC
Running: week 16-20
Mithoefer, Williams, Warren: AJSM ‘06
• Microfracture surgery on 32 high impact pivoting
athletes (?)
• 66% reported good-excellent results
• 44% returned to impact sports
• After initial improvement – scores decreased in
47% of the athletes
• Return to sports significantly higher with:
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Athletes 40 yrs of age or less
Lesion size 200mm2
Pre-Operative symptoms less than 12 months
No prior surgerical intervention
Microfracture Results
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86% normal/near normal knee function
43% Previous level of activity (no restrictions)
43% Previous activity level (few restrictions)
14% Level of participation decreased
Steadman JR et al: J Orthopaedics ‘98
Mithoefer, Williams, Warren: JBJS ‘06
• Femoral chondral microfracure in 48 pts.
• Minimum FU 2 years results:
» 67% good – excellent results
» 25% fair results
» 8% poor results
• Best results observed in patients:
» Lower body mass index (BMI) worse results BMI >30kg/m
» Good fill grade of defect on MRI
» Shorter duration of symptoms
• MRI on 24 knees – 54% good repair – tissue fill
29% moderate fill
17% poor tissue repair & fill
Mosaicplasty
Osteochondral Autograft Transfer
OSTEOCHONDRAL
AUTOGRAFT TRANSFER
Mosaicplasty
Donor Sites
• Articular cartilage &
subchondral bone plug
harvested from NWB
• Osteochondral plugs
• Various diameters 2.5 - 10 mm
• Insert plugs into defect
• Rehabilitation variables:
REHABILITATION
FOLLOWING
OSTEOCHONDRAL
AUTOGRAFT PROCEDURE
Protection Phase (Week 0 - 8)
• Brace locked during
ambulation (2 - 4 weeks)
• WB progression
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NWB for 2-4 weeks
PWB (toe-touch) weeks 3 - 6
PWB (½ - ¾ BW) weeks 5 – 8
FWB with control weeks 8
REHABILITATION
FOLLOWING
OSTEOCHONDRAL
AUTOGRAFT PROCEDURE
Protection Phase (Week 0 - 8)
• ROM progression
» Week 1: 0 - 90°
» Week 2: 0 - 105°
» Week 3: 0 - 115°
» Week 6: 0 - 125°
ROM as tolerated
REHABILITATION FOLLOWING
OSTEOCHONDRAL
AUTOGRAFT PROCEDURE
Protection Phase (Week 0 - 8)
• Strengthening program,
isometrics, SLR, OKC exer.
• Mini-squats week 5
Leg press week 3-4
• Bicycle (when ROM permits)
• Gradual return to functional
activities
REHABILITATION FOLLOWING
OSTEOCHONDRAL
AUTOGRAFT PROCEDURE
REHABILITATION FOLLOWING
OSTEOCHONDRAL
AUTOGRAFT PROCEDURE
Transitional Phase (Week 8 - 14)
Maturation Phase (Week 16 - 24)
• Full WB week 8
• Knee ROM: 0 - 135°
• Initiate CKC and functional
activities (step-ups, lunges,
balance drills, proprioceptive)
• Pool program - progress
• Gradually increase functional
exercises & activities
REHABILITATION FOLLOWING
OSTEOCHONDRAL
AUTOGRAFT PROCEDURE
• Progress all strengthening exercises
» Control excessive shear & compression
• Progress walking, bicycle program
• Light activities (week 16-20 )
• Continue flexibility, ROM exercises
Mosaicplasty in Athletes
Return to Activity Phase (Week 22-32)
• 78 athletes with minimum 3 year f/u
• Continue strengthening and flexibility
exercises, bicycle
» 64% returned to same level of play
» 19% returned to lower level of play
» 17% no sports post-op
• 8% worse following surgery
• Functional activities:
» Low-impact: 4 - 4½ months
» Moderate-impact: 5-6 months
» High-impact: 6 - 9 months
• Of 78 athletes, 43 had some
OA changes pre-op
• Picture 1 yr post-op
• Hangody et al, reported at 2001 AAOS
Hangody, Fules: JBJS (A):’03
• 831 patients mosaicplasty on knee joint
• Long term follow-up results:
» 92% good – excellent result femoral condyle
» 87% good- excellent result tibial plateau
» 79% good – excellent on patellar defects
• 3% donor site morbidity
• 4 deep infections
• 36 post-operative painful hemathrosis
Hangody, Fules: JOSPT ‘06
• 831 patients mosaicplasty on knee joint
• Long term follow-up results:
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92% good – excellent result femoral condyle
87% good- excellent result tibial plateau
79% good – excellent on patellar defects
94% good – excellent talar surfaces
• 69 of 89 underwent 2nd look arthroscopy –
exhibited congruent gliding surfaces, survival of
hyaline cartilage, and filling in of defect
Osteochondral Allograft
Osteochondral Allograft
Autologous Chondrocyte
Transplantation
Autologous Chondrocyte Implantation
Indications
Femoral Condyle
OCD
Trochlea
Autologous Chondrocyte Implantation
Advancing Indication: Patella
• Facet vs diffuse patellar involvement
• Aggressive treatment of underlying
instability or malalignment
Rehab Following ACI
Protection Phase (Week 0-8)
• ROM guidelines
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1st 24 hours: CPM/Motion ???
Day 2-3: ROM 0-45
Gradual increase ROM 0-90
Week 4: 0-105
Week 6: 0-125
Week 8: 0-135
• CPM – 6-8 hours/day
• Full passive knee extension
Rehab Following ACI
Rehab Following ACI
Protection Phase (Week 0-8)
Protection Phase (Week 0-8)
• Weight bearing progression:
» NWB for 2 weeks
» TTWB for 4 weeks
» FWB at 8 weeks
• Brace locked full extension
during ambulation & sleep
• Ambulation in unlocked brace
at 8 weeks
• Strengthening exercises
NWB
» Electrical muscle stimulation quads
» Quad sets & SLR (flexion)
» Hip abd/adduction
» AROM knee ext (week 3)
» Bicycle (ROM permits)
• Light resistance
» Pool program
Rehab Following ACI
Rehab Following ACI
Transitional Phase (Week 8-16)
Maturation Phase (Week 16-24)
• Discontinue locked brace week 6 -8
» Motion in brace week 8
• Weight bearing progression:
» Week 6: 50% BW
» Week 8: 100% BW with crutch
•
•
•
•
• Full non-painful ROM
• Progress strengthening program
» Light resistance
» Control shear & compression
» Emphasize bike,CKC and pool exercises
Progress to CKC functional exercises
Initiate proprioception drills
Pool program week 4-5 (incision determines)
Walking program (week 8-10)
• Progress stretching exercises
• Increase walking & functional activities
Rehab Following ACI
Autologous Chondrocyte Implantation
Modified Cincinnati Rating Scale: 7/95 to 12/00
Functional Activities (Week 26-52)
All Defects
Excelle
nt
• Progress functional activities:
Low impact activities: 5-6 months
Moderate impact activities: 6-9 months
High impact activities(?): 9-12 months
Very
Good
Good
Fair
Poor
Autologous Chondrocyte Implantation
Modified Cincinnati Rating Scale
Peterson,Minas: CORR ’00
Patella/Trochlea/MFC Defects
• 92 patients underwent ACI; F/U 2-9 yrs
• Good to excellent results
Excellent
V. Good
»
»
»
»
Good
Fair
Poor
92% isolated femoral condyle
67% multiple lesions
89% OCD
65% patella
• Repair tissue biopsy “hyaline-like”
Mithofer,Peterson,Mandelbaum:
AJSM ‘05
• 45 soccer players under ACI
surgery of the knee
• 72 % returned to competitive play
• 80% of the players returned to presurgery level
• Average length of play – 52months
following surgery
Autologous Chondrocyte Implantation
(2nd generation)
• Alternative flap to periosteum
• Scaffold to avoid flap
• All implants in place at 1mo (MRI)
CaReS R : Matrix imbedded ACI
Autologous Chondrocyte Implantation
(2nd generation)
• Cultured or minced articular cartilage
» One or two stages
» Autologous (MACI, CAIS, NeoCart)
» Allograft juvenile (DeNovo NT)
DeNovo NT
Hybrid Procedure: OCT & De Novo
Courtesy: Dr Parker
Articular Cartilage Rehabilitation
Rehab Following Surgery
• Delicate balance of forces &
applied stress
• Motion to stimulate healing /
repair
• Control shear & compression
forces
• Rehab varies based on surgery
& lesion
• Monitor signs & symptoms
closely
• Progress slowly & sequentially to
recondition cartilage
• Caution: repetitive high impact
loading till ?? Long Term Results
Thank You !!!!