Articular Cartilage Injury to the Knee: Current Concepts in Surgical Techniques and Rehabilitation Management

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1 Articular Cartilage Injury to the Knee: Current Concepts in Surgical Techniques and Rehabilitation Management Combined Sections Meeting 2014 Las Vegas, Nevada, February 3 6, 2014 James L. Carey, MD, MPH Assistant Professor of Orthopaedic Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania Brian J. Eckenrode, PT, DPT, OCS Assistant Professor of Orthopaedic Physical Therapy Coordinator of the Orthopaedic Clinical Residency Arcadia University Glenside, Pennsylvania Mark V. Paterno PT, PhD, MBA, SCS, ATC Coordinator of Orthopaedic and Sports Physical Therapy Associate Professor Sports Medicine Biodynamics Center Division of Occupational Therapy and Physical Therapy Cincinnati Children's Hospital Medical Center Cincinnati, OH Laura Schmitt PT, MPT, PhD Assistant Professor, Division of Physical Therapy School of Health and Rehabilitation Sciences Ohio State University Columbus, OH 1

2 Disclosures: 2

3 Course Description: Rehabilitation of articular cartilage injuries of the knee provide a challenge to the practicing physical therapist due to the complex and variable injury pattern. This course will familiarize the physical therapist with the current palliative, reparative, and restorative surgical techniques for cartilage injuries of the knee. This session will review the basic science of articular cartilage, incidence, diagnostic techniques, and various surgical procedures utilized in the management of knee articular cartilage injuries. The post-operative rehabilitation and return-to-activity guidelines following knee cartilage surgery will be discussed. The format for this session will include lecture and interactive discussions between presenters and attendees. Learning Objectives: Upon completion of this session, learners should be able to: Discuss the basic science of knee articular cartilage and how cartilage pathology can impact function and recovery Compare the different diagnostic techniques and clinical examination findings associated with knee cartilage injuries Differentiate between the various surgical techniques utilized for knee articular cartilage injuries Integrate the knowledge of knee joint anatomy and biomechanics with how it relates to the different knee surgical articular cartilage procedures Review the rehabilitative differences between the various knee cartilage surgical procedures Apply relevant literature findings related to the prognosis for patient with a knee cartilage injury Design an appropriate rehabilitation plan following knee cartilage injury surgery that considers the biomechanical and tissue healing factors utilizing current evidence-based practice Prepare an evidence-based return-to-sport rehabilitation program following knee cartilage surgery 3

4 Outline: I. Introduction/Incidence and associated risk factors II. Cartilage-basic science/age-related changes 1. Articular Cartilage a. Function b. Composition c. Structure d. Biphasic nature 2. Cartilage biomechanics and response to forces a. Tensile, compressive, shear 3. Cartilage response to injury 4. Cartilage factors that influence healing 5. Age-related changes a. In composition, structure and function b. Implications for injury/degeneration III. Diagnostic imaging/clinical diagnosis/surgical management IV. Post-operative rehabilitation 1. Guiding principals of rehabilitation a. Procedure specific i. Tissue healing/maturation process ii. Defect size iii. Defect location b. Rehab specific i. Biomechanical considerations ii. Monitor reactivity iii. Protocol progression iv. Patient education-expectations c. Rehabilitation guidelines i. Microfracture ii. OATS/Mosaicplasty iii. ACI V. Return to sports/activity after articular cartilage Injury a. Evidence regarding return to sports after articular cartilage injury: who can resume impact activity? b. Objective assessment of readiness to return to sport after articular cartilage injury VI. Prognosis 1. Articular cartilage defects a. Natural history i. Risk for osteoarthritis conflicting evidence ii. Function and quality of life b. Outcomes following articular cartilage repair and regeneration procedures i. Muscle strength and Joint mechanics ii. Function patient reported and performance based outcomes iii. Return to sport rates c. Factors that influence outcome d. Implications for rehabilitation 4

5 VII. The future of rehabilitation after articular cartilage injury: Movement towards consensus VIII. Q&A 5

6 References: Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med 2005;33: Buckwalter et al. Articular Cartilage and Osteoarthritis. AAOS Instructional Course Lectures, Volume 54, 2005; p Chambers HG, Shea KG, Carey JL. AAOS Clinical Practice Guideline: diagnosis and treatment of osteochondritis dissecans. J Am Acad Orthop Surg May;19(5): Ebert JR, Fallon M, Ackland TR, Wood DJ, Janes GC. Arthroscopic matrix-induced autologous chondrocyte implantation: 2-year outcomes. Arthroscopy 2012;28: e1-2. Ebert JR, Lloyd DG, Ackland T, Wood DJ. Knee biomechanics during walking gait following matrixinduced autologous chondrocyte implantation. Clin Biomech (Bristol, Avon) 2010;25: Ebert JR, Lloyd DG, Wood DJ, Ackland TR. Isokinetic knee extensor strength deficit following matrix-induced autologous chondrocyte implantation. Clin Biomech (Bristol, Avon) 2012;27: Ebert JR, Robertson WB, Lloyd DG, Zheng MH, Wood DJ, Ackland T. Traditional vs accelerated approaches to post-operative rehabilitation following matrix-induced autologous chondrocyte implantation (MACI): comparison of clinical, biomechanical and radiographic outcomes. Osteoarthritis Cartilage 2008;16: Ebert JR, Robertson WB, Woodhouse J, et al. Clinical and magnetic resonance imaging-based outcomes to 5 years after matrix-induced autologous chondrocyte implantation to address articular cartilage defects in the knee. Am J Sports Med 2011;39: Gillogly SD, Myers TH, Reinold MM. Treatment of full-thickness chondral defects in the knee with autologous chondrocyte implantation. J Orthop Sports Phys Ther Oct;36(10): Granan LP, et al. Timing of anterior cruciate ligament reconstructive surgery and risk of cartilage lesions and meniscal tears: a cohort study based on the Norwegian National Knee Ligament Registry. Am J Sports Med May;37(5): Harris JD, et al. Failures, re-operations, and complications after autologous chondrocyte implantation--a systematic review. Osteoarthritis Cartilage Jul;19(7): Heir S, Nerhus TK, Rotterud JH, et al. Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery. The American journal of sports medicine. Feb 2010;38(2): Logerstedt DS, et al. Knee pain and mobility impairments: meniscal and articular cartilage lesions. J Orthop Sports Phys Ther Jun;40(6):A1-A35. Løken S, et al. Autologous chondrocyte implantation to repair knee cartilage injury: ultrastructural evaluation at 2 years and long-term follow-up including muscle strength measurements. Knee Surg Sports Traumatol Arthrosc Nov;17(11): Magnussen RA, et al. Treatment of focal articular cartilage defects in the knee: a systematic review. Clin Orthop Relat Res Apr;466(4):

7 Mithoefer K et al. Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete. J Orthop Sports Phys Ther (3): Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical Efficacy of the Microfracture Technique for Articular Cartilage Repair in the Knee: An Evidence-Based Systematic Analysis. The American Journal of Sports Medicine 2009;37: Pearle et al. Basic science of articular cartilage and osteoarthritis. Clin Sports Med. 2005;24:1-12. Reinold MM, et al. Current concepts in the rehabilitation following articular cartilage repair procedures in the knee. J Orthop Sports Phys Ther Oct;36(10): Slauterbeck JR, et al. Geographic mapping of meniscus and cartilage lesions associated with anterior cruciate ligament injuries. J Bone Joint Surg Am Sep;91(9): Tandogan RN, et al. Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc. 2004;12: Tetteh et al. Basic Science and surgical options for articular cartilage injuries of the knee. JOSPT. 2012;42(3); Widuchowski W, Widuchowski J, Faltus R, et al. Long-term clinical and radiological assessment of untreated severe cartilage damage in the knee: a natural history study. Scandinavian journal of medicine & science in sports. Feb 2011;21(1): Widuchowski W, Widuchowski J, Koczy B, Szyluk K. Untreated asymptomatic deep cartilage lesions associated with anterior cruciate ligament injury: results at 10- and 15-year follow-up. The American journal of sports medicine. Apr 2009;37(4): Wilk KE, et al. Rehabilitation of articular lesions in the athlete's knee. J Orthop Sports Phys Ther Oct;36(10):

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