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Rehabilitation After Articular Cartilage Procedures


Introduction

Articular cartilage defects of the knee appear to be an increasing cause of pain and functional disability in orthopedics and sports medicine. This pathology creates a significant challenge to the health care team, especially the physician who must decide on the appropriate treatment plan (see Chapter 31 ). The avascular nature of articular cartilage predisposes the individual to progressive symptoms and degeneration owing to the extremely slow and frequent inability to heal. Nonoperative rehabilitation and palliative care are frequently unsuccessful, especially as the size of the lesion increases, and further treatment is required to alleviate symptoms. This presents a significant challenge for patients, particularly young and more active individuals.

Traditional methods of treating these lesions have led to unfavorable results, stimulating the need for newer surgical procedures designed to facilitate the repair or transplantation of autogenous cartilage tissue. Postoperative rehabilitation programs vary greatly among physicians and should be individualized based on specifics of the lesion (size, depth, location, containment, quality of tissue), patient (age, activities, goals, quality of tissue, lower extremity alignment, body mass index [BMI], general health, and nutrition), and surgery (exact procedure, tissue involvement, and concomitant surgeries). Thus the development of an appropriate rehabilitation program is challenging and must be highly individualized to ensure successful outcomes.

The programs described in this chapter are designed according to the knowledge of basic science, anatomy, and biomechanics of articular cartilage as well as the biologic course of healing after surgery. The goal is to restore full function in each patient as quickly as possible without overloading the healing articular cartilage. In this chapter, the essential principles of rehabilitation after articular cartilage repair procedures are discussed as well as specific rehabilitation guidelines for debridement, abrasion chondroplasty, microfracture, osteochondral autograft transplantation (OAT), and autologous chondrocyte implantation (ACI).

Principles of Articular Cartilage Rehabilitation

Critical Points
Principles of Articular Cartilage Rehabilitation

Individualization

  • Develop the program based on specifics regarding the patient (demands of activities of daily living, work, and sport activities, body mass index), lesion (location, size), and operative procedure.

  • Age, obesity, poor nutrition, history of repetitive impact loading may slow down the rehabilitation process.

  • Younger patients with isolated defects and relatively healthy surrounding articular cartilage will progress more rapidly than older individuals with degenerative changes.

Create a Healing Environment

  • Biologic phases of maturation have been identified.

  • Controlled weight bearing and range of motion are essential to facilitate healing and prevent degeneration: stimulate matrix production, improve the tissue's mechanical properties, and nourish the articular cartilage.

  • Reduce weight bearing with the use of a pool and force platforms in early phases.

Biomechanics of the Knee

  • Articulation between the femoral condyle and the tibial plateau is constant throughout knee range of motion.

  • Area of contact between the patella and the trochlea gradually increases as the knee is flexed.

  • Rate of weight bearing, passive range of motion, and exercise progression is based on the exact location of the lesion.

  • Exercises are altered based on the biomechanics of the knee to avoid excessive compressive or shearing forces.

  • Open kinetic chain exercises are typically performed from 90 to 40 degrees of flexion.

  • Closed kinetic chain exercises are performed initially from 0 to 30 degrees and then progressed to 0 to 60 degrees.

Reduce Pain and Effusion

  • Look for a progressive decrease in volitional quadriceps activity with knee pain, distention.

  • Any increase in intraarticular joint temperature stimulates proteolytic enzyme activity, detrimental to articular cartilage.

  • Reduction in knee pain and swelling is crucial to minimize reflexive inhibition and restore normal quadriceps activity.

Restore Soft Tissue Balance

  • Avoid arthrofibrosis by restoring full passive knee extension, patellar mobility, and soft tissue flexibility of the knee and entire lower extremity.

  • Achieve at least 0 degree of extension within the first few days after surgery.

Restore Muscle Function

  • Use electrical muscle stimulation and biofeedback with exercises to facilitate active contraction and volitional control of the quadriceps musculature.

  • Machine weights and closed kinetic chain exercises are included as the patient progresses. Emphasize total leg strength rather than concentrating solely on the quadriceps.

  • Train core, hip, and ankle.

Enhance Proprioception and Neuromuscular Control

  • Proprioceptive and neuromuscular control drills of both lower extremities are included to restore dynamic stabilization of the knee.

Control the Application of Loads

  • Gradually increase the amount of stress applied to the injured knee as the patient returns to functional activities.

  • Monitor pain and effusion as signs of overloading.

  • Consider orthotics, insoles, and bracing to alter the applied loads on the articular cartilage during functional activities.

Team Communication

  • Communication among surgeon, physical therapist, and patient before and after surgery is essential.

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