Continuous passive motion following cartilage surgery: does a common protocol exist?

The Most Common Rehabilitation Protocol After Matrix-Assisted Autologous Chondrocyte Implantation Is Immediate Partial Weight-Bearing and Continuous Passive Motion

Purpose

To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint.

Methods

A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation.

Results

Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cm², and the most common lesion location was the medial femoral condyle (n = 494). Twenty studies allowed partial WB postoperatively with all studies permitting full WB within 12 weeks. Twenty studies used CPM in their rehabilitation protocols and initiated its use within 24 hours postoperatively. Among 10 studies that reported time to return to sport, 9 (90%) allowed return by 12 months. While most protocols used strength training as well as the inclusion of proprioceptive training, there was disagreement on the timing and inclusion of specific PT modalities used during the rehabilitation process.

Conclusions

Based on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation.

Level of Evidence

Level II, systematic review of Level I-II studies.

Estimation of Tibiofemoral Joint Contact Forces Using Foot Loads during Continuous Passive Motions

Continuous passive motion (CPM) machines are commonly used after various knee surgeries, but information on tibiofemoral forces (TFFs) during CPM cycles is limited. This study aimed to explore the changing trend of TFFs during CPM cycles under various ranges of motion (ROM) and body weights (BW) by establishing a two-dimensional mathematical model. TFFs were estimated by using joint angles, foot load, and leg−foot weight. Eleven healthy male participants were tested with ROM ranging from 0° to 120°. The values of the peak TFFs during knee flexion were higher than those during knee extension, varying nonlinearly with ROM. BW had a significant main effect on the peak TFFs and tibiofemoral shear forces, while ROM had a limited effect on the peak TFFs. No significant interaction effects were observed between BW and ROM for each peak TFF, whereas a strong linear correlation existed between the peak tibiofemoral compressive forces (TFCFs) and the peak resultant TFFs (R2 = 0.971, p < 0.01). The proposed method showed promise in serving as an input for optimizing rehabilitation devices.

Comprehensive Rehabilitation of the Athlete: A Specific and Purposeful Approach

There is a need to improve the quality of rehabilitation in sports medicine to return athletes to optimal function safely and quickly, reducing the risk of reinjury. This paper describes a planning paradigm to guide clinical reasoning during individual treatment sessions and a model for planning the rehabilitation program from acute injury to return to play. The design of a rehabilitation program should be a collaborative, team effort, and accounting for the specific needs of the athlete. As the athlete progresses from acute injury management all the way back to full competition, the rehabilitation professional emphasizes the components of pain management, motion, motor control, and force production in varying degrees based upon phases of tissue healing and the athlete's response. Utilizing high-value, evidence-based treatments maximize both the effectiveness and efficiency of rehabilitation to restore and improve upon preinjury levels of physical performance.

Postoperative Management for Articular Cartilage Surgery in the Knee

The postoperative rehabilitation team plays a crucial role in optimizing outcomes after articular cartilage surgery. A comprehensive approach to postoperative physical therapy that considers the type of surgery, location in the knee, concurrent procedures, and patient-specific factors is imperative. While postoperative rehabilitation protocols should be specific to the patient and type of surgery performed and include phased rehabilitation goals and activities, the key principles for postoperative rehabilitation apply across the spectrum of articular cartilage surgeries and patients. These key principles consist of preoperative assessments that include physical, mental, and behavioral components critical to recovery; education and counseling with respect to expectations and compliance; and careful monitoring and adjustments throughout the rehabilitation period based on consistent communication among rehabilitation, surgical, and imaging teams to ensure strict patient compliance with restrictions, activities, and timelines to optimize functional outcomes after surgery.

Assessing Foot Loads in Continuous Passive Motion (CPM) and Active Knee Joint Motion Devices

BACKGROUND

Continuous passive motion (CPM) and active knee joint motion devices are commonly applied after various surgical procedures. Despite the growing use of active motion devices, there is a paucity of data comparing plantar loads between the different mobilization techniques. The aim of this study was to investigate foot loads during knee joint mobilization in continuous passive and active knee joint motion devices and to compare this data to the physiological load of full weight-bearing.

PATIENTS/MATERIAL AND METHODS

Fifteen healthy participants (7 women and 8 men, 25 ± 3 years, 66 ± 6 kg, 175 ± 10 cm, BMI 21.9 ± 2) were recruited. Plantar loads were measured via dynamic pedobarography using a continuous passive motion device (ARTROMOT-K1, ORMED GmbH, Freiburg, Germany) and an active motion device (CAMOped, OPED AG, Cham, Switzerland), each with a restricted range of motion of 0-0-90° (ex/flex) and free ROM for the knee joint. For the active motion device, cycles were performed at four different resistance levels (0-III). Data were assessed using the pedar^® X system (Novel Inc., Munich, Germany), which monitors loads from the foot-sole interface. Force values were compared between motion devices and normal gait, which served as the reference for conditions of full weight-bearing. P-values of < 0.05 were considered statistically significant.

RESULTS

Normal gait revealed peak forces of 694 ± 96 N, defined as 100 %. The CPM device produced plantar forces of less than 1.5 N. Using the active motion device in the setting of 0-0-90° produced foot loads of < 1.5 N (resistance 0-II) and 3.4 ± 9.3 N with a resistance of III (p < 0.001). Conditions of free ROM resulted in foot loads of 4.5 ± 4.5 N (resistance 0), 7.7 ± 10.7 N (resistance I), 6.7 ± 10.4 (resistance II) and 6.7 ± 6.9 N with a resistance of III (p < 0.001), corresponding to 0.6 %, 1.1 %, 1.0 % and 1.0 % of full weight-bearing, respectively.

CONCLUSION

Motion exercises of the knee joint can be performed both with passive and active devices in accordance with strict weight-bearing restrictions, which are often recommended by surgeons. Also, active motion devices can be used when the ankle joint or foot have to be offloaded. Further studies assessing intraarticular joint load conditions have to be performed to confirm the findings obtained in this study.

Microfracture of Articular Cartilage

Microfracture is a treatment option for symptomatic, full-thickness cartilage defects. Microfracture is most likely to be successful when performed in nonobese patients under the age of thirty years for small (<2 to 4-cm2) femoral condylar defects that have been symptomatic for a short time (less than twelve to twenty-four months). Microfracture has acceptable short-term clinical results, but results can be expected to decline over time. Long-term studies that compare microfracture with advanced cartilage restoration techniques are required to ascertain whether these newer techniques provide longer-lasting results.

Microfracture is more cost-effective than autologous chondrocyte implantation: a review of level 1 and level 2 studies with 5 year follow-up

PURPOSE

Focal cartilage defects in the knee may have devastating effect on the knee joint, where two of the main surgical treatment options are microfracture and autologous chondrocyte implantation. Comparative studies have failed to establish which method yields the best clinical results. A cost-effectiveness analysis of microfracture and autologous chondrocyte implantation would contribute to the clinical decision process.

METHODS

A PubMed search identifying level I and level II studies with 5 year follow-up was performed. With the data from these studies, decision trees with associated service provision and costs connected to the two different techniques were designed. In addition to hospital costs, we included costs connected to physiotherapy following surgery. To paint a broader cost picture, we also included indirect costs to the society due to productivity loss caused by work absence.

RESULTS

Four high-quality studies, with a follow-up of 5 years, met the inclusion criteria. A total of 319 patients were included, 170 undergoing microfracture and 149 autologous chondrocyte implantation. The re-operation rate was 23 (13.5%) following microfracture, and 18 (12.1%) for autologous chondrocyte implantation. Both groups achieved substantially better clinical scores at 5 years compared to baseline. Microfracture was more cost-effective when comparing all clinical scores.

CONCLUSION

Microfracture is associated with both lower costs and lower cost per point increase in patient reported outcome measures. There is a need of well-designed, high-quality randomized controlled trials before reliable conclusions regarding cost-effectiveness in the long run is possible.

LEVEL OF EVIDENCE

III.

Rehabilitation and Postoperative Management Practices After Osteochondral Allograft Transplants to the Distal Femur: A Report From the Metrics of Osteochondral Allografts (MOCA) Study Group 2016 Survey

Context:

We present the current spectrum of postoperative management practices for patients receiving distal femur osteochondral allograft (OCA) transplants.

Evidence Acquisition:

The Joint Restoration Foundation database was examined in cooperation with the Metrics of Osteochondral Allografts study group to identify 121 surgeons who had performed at least 1 OCA transplant in the past year; 63% of surgeons responded.

Study Design:

Clinical survey.

Level of Evidence:

Level 3.

Results:

Postoperative weightbearing restrictions ranged from immediate nonweightbearing with full weightbearing by 12 weeks to immediate weightbearing as tolerated. Most surgeons who performed fewer (<10) OCA transplants per year followed the most restrictive protocol, while surgeons who performed more (>20) OCA transplants per year followed the least restrictive protocol. One-third of surgeons with the most restrictive protocol were more likely to change their protocol to be less restrictive over time, while none of those with the least restrictive protocol changed their protocol over time. Fifty-five percent of surgeons permitted return to full activity at 26 weeks, while 27% of surgeons lifted restrictions at 16 weeks.

Conclusion:

Characterization of the spectrum of postoperative management practices after OCA transplantation provides a foundation for future investigations regarding patient outcomes and associated cost to establish best practice guidelines. Fundamentally, surgeons with more experience with this procedure tended to be more aggressive with their postoperative rehabilitation guidelines. Most commonly, rehabilitation provided for some degree of limited weightbearing; however, the spectrum also included immediate full weightbearing practices.

Effect of muscle contractions on cartilage: morphological and functional magnetic resonance imaging evaluation of the knee after spinal cord injury

Objective

To evaluate the effect of complete absence of muscle contractions on normal human cartilage in the presence of joint motion.

Methods

Patients with complete acute spinal cord injuries were enrolled. All patients underwent magnetic resonance imaging (MRI) on both knees as soon as their medical condition was stable and at six months after the primary lesion. All patients received rehabilitation treatment that included lower-limb passive motion exercises twice a day. The MRIs were analyzed by two radiologists with expertise in musculoskeletal disorders. A region of interest was established at the patellar facets and trochlea, and T2 relaxation times were calculated. The area under the cartilage T2 relaxation time curve was calculated and standardized.

Results

Fourteen patients with complete spinal cord injuries were enrolled, but only eight patients agreed to participate in the study and signed the informed consent statement. Two patients could not undergo knee MRI due to their clinical conditions. Initial knee MRIs were performed on six patients. After six months, only two patients underwent the second bilateral knee MRI. Both patients were neurologically classified as Frankel A. An increase in T2 values on the six-month MRI was observed for both knees, especially in the patellofemoral joint.

Conclusion

The absence of muscle contractions seems to be deleterious to normal human knee cartilage even in the presence of a normal range of motion. Further studies with a larger number of patients, despite their high logistical complexity, must be performed to confirm this hypothesis.

Avascular necrosis complicating chondral resurfacing techniques

Autologous chondrocyte implantation (ACI) and mosaicplasty have become established operations used to treat full-thickness chondral lesions in the knee and elsewhere. Although complications of both have been documented, there are no previous reports of avascular necrosis (AVN) complicating these procedures. Awareness of AVN as a complication of ACI might have prompted an earlier diagnosis, with possible non-surgical treatment or more minor surgery being possible. At the very least, an appropriate form of management could have been initiated earlier, so shortening the period of disability and suffering for the patient.

Knee cartilage defect: marrow stimulating techniques

Painful chondral defects of the knee are very difficult problems. The incidence of these lesions in the general population is not known since there is likely a high rate of asymptomatic lesions. The rate of lesions found during arthroscopic exam is highly variable, with reports ranging from 11 to 72 % Aroen (Aroen Am J Sports Med 32: 211-5, 2004); Curl(Arthroscopy13: 456-60, 1997); Figueroa(Arthroscopy 23(3):312-5, 2007;); Hjelle(Arthroscopy 18: 730-4, 2002). Examples of current attempts at cartilage restoration include marrow stimulating techniques, ostochondral autografts, osteochondral allografts, and autologous chondrocyte transplantation. Current research in marrow stimulating techniques has been focused on enhancing and guiding the biology of microfracture and other traditional techniques. Modern advances in stem cell biology and biotechnology have provided many avenues for exploration. The purpose of this work is to review current techniques in marrow stimulating techniques as it relates to chondral damage of the knee.

Management strategies for osteochondritis dissecans of the knee in the skeletally immature athlete

SYNOPSIS

Osteochondritis dissecans (OCD) is a disorder resulting in focal breakdown of the subchondral bone, with potential disruption of the overlying articular cartilage. The femoral condyles of the knee are the most common locations for OCD, and the incidence of OCD appears to be increasing among active children. Juvenile OCD (JOCD) can be distinguished from adult OCD by the presence of open growth plates. Due to a lack of evidence on its early diagnosis, optimal treatment, and long-term course of healing, JOCD presents a unique challenge for the health care team. Approximately 50% to 67% of stable JOCD lesions heal successfully with nonoperative treatment. For unstable lesions and stable lesions that fail nonoperative treatment, a variety of surgical interventions can be utilized to stimulate bony healing and address articular cartilage lesions. It is recommended that rehabilitation of JOCD be tailored to the individual patient, based on the stage and radiographic status of the lesion and the mode of surgery employed when surgically addressed. Although there is a growing body of literature on this condition, the etiology and optimal methods for treatment, rehabilitation, and evaluating outcomes remain inconclusive due to a lack of quality evidence.

LEVEL OF EVIDENCE

Therapy, level 5.