Variability of online available physical therapy protocols from academic orthopedic surgery programs for arthroscopic meniscus repair

Quality and Variability of Physical Therapy Protocols Varies Widely for Osteochondral Allograft Transplantation of the Femoral Condyles

OBJECTIVE

To assess the quality and variability of osteochondral allograft (OCA) transplantation rehabilitation protocols associated with academic orthopedic programs in the United States.

DESIGN

A systematic review was performed to collect all publicly available online rehabilitation protocols for femoral condyle OCA transplant from US academic orthopedic programs participating in the Electronic Residency Application Service. These protocols were evaluated for inclusion of different rehabilitation components as well as timing of suggested initiation of these activities.

RESULTS

A total of 22 protocols were included. Although 91% of protocols recommended bracing, wide variation exists in total time of utilization. Median time for full weight bearing (FWB) was 7 weeks (range 4-8). On average, each protocol mentioned 9 (range 2-18) different strengthening exercises. The median time suggested to return to high-impact activities was 9 months (range 8-12). Only 3 protocols (14%) offered criteria of advancement for each phase as well as criteria for discharge.

CONCLUSION

Very few of the academic orthopedic programs have published online rehabilitation protocols following OCA transplantation. Although there is wide variation between the protocols, it allowed the identification of trends or patterns that are more common. However, there is need for more standardized evidence-based rehabilitation protocols which are easy to understand and follow by patients.

Rehabilitation Variability After Elbow Ulnar Collateral Ligament Reconstruction

Background

Investigations specifically delineating the safest and most efficacious components of physical therapy after ulnar collateral ligament (UCL) reconstruction of the elbow are lacking. As such, while a number of recommendations regarding postoperative therapy have been published, no validated rehabilitation guidelines currently exist.

Purpose

To assess the variability of rehabilitation protocols utilized by orthopaedic residency programs in the United States (US) and those described in the scientific literature.

Study Design

Cross-sectional study.

Methods

Online UCL reconstruction rehabilitation protocols from US orthopaedic programs and from the scientific literature were reviewed. A comprehensive scoring rubric was developed to assess each protocol for the presence of various rehabilitation components as well as the timing of their introduction.

Results

Overall, 22 protocols (14%) from 155 US Electronic Residency Application Service (ERAS) orthopaedic programs and 8 protocols published in the scientific literature detailing UCL reconstruction postoperative rehabilitation were identified and reviewed. After reconstruction, the majority of ERAS and review article protocols (77% and 88%, respectively) advised immediate splinting at 90° of elbow flexion. The mean time to splint discontinuation across all protocols was 2.0 weeks (range, 1-3 weeks). There was considerable variability in elbow range of motion recommendations; however, most protocols detailed goals for full extension and full flexion (>130°) at a mean 5.3 weeks (range, 4-6 weeks) and 5.5 weeks (range, 4-6 weeks), respectively. Significant diversity in the inclusion and timing of strengthening, proprioceptive, and throwing exercises was also apparent. Thirteen ERAS (59%) and 7 review article (88%) protocols specifically mentioned return to competition as an endpoint. ERAS protocols permitted return to competition significantly earlier than review article protocols (29.6 vs 39.0 weeks, respectively; P = .042).

Conclusion

There is notable variability in both the composition and timing of rehabilitation components across a small number of protocols available online. While our understanding of postoperative rehabilitation for UCL reconstruction evolves, outcome-based studies focused on identifying clinically beneficial modalities and metrics are necessary to enable meaningful standardization.

High short-term return to sports rate despite an ongoing healing process after acute meniscus repair in young athletes

PURPOSE

Acute meniscus repair in young athletes is always a challenge due to the long rehabilitation process and time to return to sport (RTS). The purpose was to investigate signal alterations in short-term follow-up after acute meniscus repair on specific magnetic resonance imaging (MRI) scan sequences. It was hypothesized that (1) MRI signal changes over the first postoperative healing phase and represent a continuous healing process and (2) meniscus healing properties correlates with clinical outcomes and RTS.

METHODS

Young athletes with traumatic meniscus lesion and arthroscopic meniscus repair within 6 weeks and available preoperative MRI were enrolled. Clinical examination, outcome scores (IKDC, KOOS, Lysholm Score, Tegner activity score) and RTS were surveyed preoperatively and 6 and 12 weeks and 6 months after surgery. Radiological follow-up examinations were performed 2, 4, 6, 12 weeks and 6 months after operation using a 3T-MRI. Evaluation was based on ISAKOS meniscus classification system, meniscus healing were classified according to Henning's criteria.

RESULTS

At final follow-up (FU) 30 patients (28 month, 2 week) with a total of 35 meniscus tears (19 medial, 16 lateral) were included. Clinical scores improved significantly after surgery: IKDC Score (preOP: 39.4 ± 18.5, final FU: 78.8 ± 15.3) KOOS (preOP: 45.7 ± 22.1, final FU: 82.7 ± 12.5) and Lysholm Score (preOP: 42.8 ± 23.7, final FU: 84.4 ± 13.8) (p < 0.01). Tegner activity score showed a steadily increase to 4 (range 3-9) at 6 months but did not reached the pre-injury level of 6 (range 3-9). RTS rate was 100% whereof 44.8% reached their pre-injury level. MRI examination revealed a continuous healing process and menisci were classified as 55.9% healed, 35.3% partially healed and 8.8% non-healed at final FU.

CONCLUSION

This study showed that MRI signal alterations of the meniscus steadily occur within the first 6 months postoperatively. MRI reveals an ongoing healing process at final FU that have to be carefully considered when RTS is discussed with high demanding patients. However, young athletes provide good clinical results and RTS rate even though MRI alterations are still present.

LEVEL OF EVIDENCE

Therapeutic study, prospective case series, Level IV.