What About Rehab After Cartilage Transplantation for the Knee?Much has been written about the use of autologous chondrocyte implantation (ACI) to treat deep or large defects in the knee joint cartilage. But what happens afterwards? Are people able to put weight on the leg right away? Most of the patients are competitive athletes (that's how they damaged the knee in the first place). Are they able to return to competitive play? How long does that take?
These are some of the questions surgeons from the Department of Orthopedic Surgery at the University Hospital Freiburg in Germany researched and wrote about. They reviewed all previous studies published on the topic of postoperative rehabilitation following autologous chondrocyte implantation (ACI). They summarized their findings in this article.
Autologous chondrocyte implantation is a fairly new cell-therapy for cartilage defects of the knee. The first study published on the topic was in the early 1990s. So it's been around for about 20 years but it is still being studied and improved upon.
The basic technique involves harvesting healthy cartilage cells from a non-weight bearing surface of the patient's knee joint. Those cells are transplanted and used to fill in the defect (hole) in the damaged cartilage lining the joint surface.
The goal of the procedure is to create biologic remodeling of the cartilage. But that's only part of the total picture. The athlete still has to regain knee motion and strength. Recovering normal nerve and motor control over all movements is essential. Athletes must be able to make quick changes in direction, move from one position to another, jump, and pivot over and over. Without normal neuromuscular control, reinjury is a real concern.
Rehab must be guided according to what's happening with the transplanted tissue. Studies show that these transplanted chondrocytes (cartilage cells) start to stick right away. Care must be taken not to disturb them. Load and shear forces must be avoided. At first, the area remains more liquid than solid (like jello just starting to set up).
But movement is important because the old saying, motion is lotion is still true. Movement and the pumping action of the knee as it bends and straightens is what help deliver blood to the area. Blood with its oxygen and nutrients feeds the chondrocytes. So how do we keep the knee moving without walking on it?
That's where rehab specialists (physical therapists) come in. The therapist moves the leg for the patient starting on day one after surgery. This is called passive range of motion (PROM) exercise. Some surgeons are trying continuous passive motion (CPM) machines with patients. The leg is placed in this motor-driven device and moved continuously bending and straightening the leg for the patient.
Studies using CPM following knee replacement surgery have not shown an overall benefit. There is limited evidence to support the use of CPM after autologous chondrocyte implantation. More studies are clearly needed. Whether passive motion is delivered by hand or by a machine, the goals are the same: prevent scar tissue from building up, restore joint motion, and keep the quadriceps muscle tuned up.
The physical therapist addresses other areas as well. The knee joint (including the patella or kneecap) is manually (a hands-on treatment technique) mobilized or moved. The therapist does this without moving the joint by gently applying traction and tiny oscillations (movements) to the bones that make up the joint. Mobilization techniques are also applied to the soft tissues around the joint to keep them soft, moveable and free of adhesions.
Other treatment modalities (tools) used by the therapist during the early post-operative phase include cold therapy (called cryotherapy) and manual lymph drainage. These two therapies may help decrease swelling, pain, and decrease the temperature around the healing cartilage. Cryotherapy is important because studies show that too much heat in a joint can cause breakdown of the chondrocytes (cartilage cells).
When the incisions heal, patients can begin aquatic (water-based) therapy. Aquatic therapy is considered beneficial throughout the postoperative period. Working in the water reduces the effects of gravity and therefore unloads the joint. The weight-bearing force placed on the joint is only 25 percent of the body weight when the water is up to the armpits. Moving through water at waist level reduces the load to 50 per cent of the person's body weight.
When the repair tissue starts to solidify (moves from a jello to spongy consistency), then there is enough strength to withstand some partial weight-bearing activities. How much weight and how soon the patient can put weight on the knee are still unknown areas. Some therapists have experimented with partial weight-bearing (minimal loading of the knee) as early as two weeks after implantation.
Around eight weeks after surgery, the transplant has filled in the defect and new, healthy cartilage cells are present. As the tissue continues to build and remodel over the next weeks (the patient is now three to six months out from the surgery), the therapist steps up the rehab program. Patients are instructed how to increase weight-bearing and improve walking pattern. Pool-therapy is especially helpful in starting gait training. Full weight-bearing on land is usually allowed eight to 12 weeks after the implantation procedure.
Around six months post-op, the transplanted tissue changes from spongy to the consistency of soft plastic. Now the therapist can progress the rehab program to focus on strengthening, endurance, and functional training. Studies consistently show that quadriceps strength is a major factor in the success of this procedure.
In fact, regaining full quadriceps strength is considered the most important goal of rehab following autologous chondrocyte implantation (ACI). Additional areas of focus in rehab include restoring proprioception (joint sense of position) and sensorimotor control.
Full return-to-sports can still take a while. The final healing phase of the chondrocytes is called maturation. If there are no complications (e.g., wound infection, overgrowth of the graft, graft failure), the entire process from start to finish can take two to three years. The biggest deterrent to recovery is putting weight on the joint too early and/or another traumatic injury disturbing the delicate transplanted tissue.
For physical therapists working with patients who have had an autologous chondrocyte implantation procedure, the authors of this review article provide a detailed proposed rehabilitation plan. They present a step-by-step protocol from the preoperative phase (before surgery) through the early weeks after surgery (one to six weeks postoperative). Details of the rehab program from weeks six to 12, 12 to 26, and beyond 26 weeks are also included.
The authors conclude by pointing out the need for future high-quality studies in this area. Patients, surgeons, and physical therapists need evidence-based research to formulate rehab programs that meet individual athlete's needs. Cartilage repair is a fairly new procedure. Everyone wants the best outcomes possible and that means finding the right postoperative training protocol. The surgical procedure is important but the follow-up is equally important.
Anja HirschmÃ¼ller, MD, et al. Rehabilitation After Autologous Chondrocyte Implantation for Isolated Cartilage Defects of the Knee. In The American Journal of Sports Medicine. December 2011. Vol. 39. No. 12. Pp. 2686-2696.
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