Rehabilitation of Articular Cartilage Lesions: Rehabilitation Guidelines

Transcription

1 Rehabilitation of Articular Cartilage Lesions: Rehabilitation Guidelines Kevin E Wilk, DPT, PT, FAPTA Rehab Articular Cartilage Introduction Most challenging of all lesions to successfully treat Athletes Active People Not sexy concepts not bejazz Just basic science principles that the surgeon & rehab specialist must adhere to Unforgiving structure Career threatening injury / 7 months post-op Life altering lesions Rehab Plays a Key Role in Ultimate Outcome Articular Cartilage Lesions Athletes Introduction Often painful condition Unable to play at competitive level Pain, swelling, dysfunction present Pain is limiting factor Where does the pain come from? articular cartilage synovium other structures Rx Options Medial Meniscus Allograft with Microfracture 30 yo female 12/26/08: 1cm x 15mm 7/30/09: healing - painful

2 Potter, Jain, Ma, et al: AJSM knees in 40 patients (28 ACLR, 14 non-op) MRI at time of initial injury then annually for a maximum of 11 yrs All patients sustained initial chondral injury Risk of cartilage loss doubled from yr 1 for the lateral & medial compartment & 3x for patella By 7 to 11 yrs: LFC 50x, MFC 19x,& patella 30x Size of the bone bruise associated to degeneration from yr 1 to yr 3 Potter, Jain, Ma, et al: AJSM 12 Articular Cartilage Function Overview Provides a low friction, resilient, weight bearing surface Absorbs mechanical shock - load Coefficient of friction 15 times less than that of ice on ice Mankin 71 Cartilage Injury Cartilage has remarkable durability Vulnerable to traumatic or degenerative conditions Cartilage has limited ability for repair or regeneration Cartilage Development & Aging Nutrition Immature Cartilage Blue-white color Thick Increased cellularity Many mitotic figures Higher water content Higher PG content Lower collagen content Mature Cartilage Thinner Less cellular Mitotic activity ceases Lower water content Lower PG content Higher collagen content Cartilage avascular Diffusion Immature: Underlying bone and synovial fluid Adult: Synovial fluid

3 Obstacles to Cartilage Repair Hypocellular Avascular Chondrocytes imprisoned in matrix Often an Associated Ligamentous injury Pain Swelling Catching History Locking Kettunen,Kujala:AJSM 01 Surveyed over 1300 former elite athletes in Finland Surveyed 814 individuals (control) Athletes in team sports higher risk of knee disability Specific sports at higher risk: soccer,wrestling,hockey, basketball Sports at low risk: endurance,track Deacon et al: Med J Austr 97 Evaluated 50 retired elite footballer Compared to 50 age matched cohorts Footballers with history of intra-articular ligamentous &/or meniscus injury 10 times greater risk of development of OA knee Articular Cartilage Lesions Treatment Options Non- Operative Treatment: Rehabilitation Injections Bracing Orthotics BMI (weight loss) Surgery Various Surgerical procedures

4 Articular Cartilage Lesions Classification Outerbridge System: Grade I - softening Grade II - fibrillation Grade III fissuring to bone Grade IV - full thickness Orthopedics 1997:20: Dye, Vaupel, Dye AJSM 1998 Conscious neurosensory mapping of internal structures without anesthesia Subjectively graded sensation: 0 (none) 4 (severe) Spatial localization: A (accurate localization) B (poor localization) Articular Cartilage Lesions Rehabilitation Concepts Successful rehabilitation requires knowledge of: 1: Biology of articular cartilage» factors influence healing & repair» such as motion, compression, etc.» nutrients» protection; shear & compression Promote Healing Do not Overload Healing Tissue

5 TIBIOFEMORAL COMPRESSIVE LOADS Level walking 3.4 x BW Morrison J Biomech 70 Up ramp 4.5 x BW Down ramp 4.5 x BW Up stairs 4.8 x BW Down stairs 4.5 x BW Rise from chair 3.2 x BW Dumbleton Biomech 72 Knee bend 4.2 x BW Ellis J Biomech Eng 84 TIBIOFEMORAL COMPRESSIVE LOADS Overview Kaufman, AJSM 1991 isokinetic 60 0 /sec x BW Kaufman, AJSM 1991 isokinetic 30 0 /sec x BW Ericson, AJSM 1986 cycling 1.2x BW Morrison, J Biomech level walking 3.4x BW Dahlkurst, Eng Med 82 squat ascent squat descent x BW 5.6x BW Nisell, AJSM 1989 isokinetic 30 0 /sec x BW

6 Proprioception & NM Control Progressive WB Loading Treat the Joint!!! Not Just an Isolated Injury It hurts after I exercise!!! Don t do that!!! Let s find a form of exercise for you to do!!!

7 Articular Cartilage Lesions Rehabilitation Concepts Successful rehabilitation requires knowledge of: Specific patient variables Age Desired activity level LE alignment Body weight (BMI) Concomitant injuries Meniscus status Articular Cartilage Lesions Rehabilitation Concepts Specific Rehabilitation Concepts: ROM Flexibility Knee extension & flexion Muscular strength Quadriceps Above & below (hips) Proprioception Stabilization of knee joint Gradual return to Activities/Sports ACL REHABILITATION Range of Motion Full passive extension immediately Gradual restoration of flexion Week 1: 90 degrees Week 2: degrees Week 3: degrees Week 4: 125 degrees or > Week 8-12: heel to gluts

8 Stabilization From ABOVE & BELOW Co-Activation to Enhance Dynamic Stability Co-Activation to Enhance Dynamic Stability

9 RDLs Establish Hip Control RDLs

10 Who Needs Core Stability?? Wilk,Escamilla,Fleisig, et al: AJSM 94 Escamilla, Feisig, Wilk, et al: Med Sci Spts 98 Wilk et al: AJSM Wilk et al: AJSM 96 Wilk et al: AJSM 96 Escamilla, et al: Med Sci Spts 98

11 Typical Quadriceps EMG Curves (%MVIC) Quadriceps Activity: SQ&LP>LE between LE>SQ&LP between 0-50 Inverse EMG Relationship Between Leg Extension and Squat/Leg Press Forward Lunge Long & Short Flexing Knee Angle (deg) Extending Escamilla & Wilk: JOSPT 08 Escamilla & Wilk: Clin Biomech 08 Wall Squat Long & Short Nagura : J Appl Biomech 06 Nisell: AJSM 89 WB & NWB Exercises References Escamilla et al: ACL & PCL loading. J Eng in Med 12 Escamilla et al: ACL forces WB & NWB Ex. JOSPT 12 Escamilla, et al: lunges etc ACL/PCL. MSSE 10 Escamilla, et al: wall squat 1 leg squat. MSSE 09 Escamilla et al: cruciate forces wall squats. MSSE 09 Escamilla et al: PF during various lunges. JOSPT 08 Escamilla et al: PF forces side /front lunge. Clin Biomech 08 Escamilla et al: Techniques variation squat. MSSE 01 Escamilla et al: Squat v leg press. MSSE 01 Wilk et al: Comparison OKC CKC. AJSM 97 Wilk et al: PF Rehab OKC v CKC JOSPT 98 Wilk et al: UE OKC & CKC. J Sports Rehab 01 Wilk et al: OKC vs CKC JOSPT 99 Knees over the toes!!! Oh No!!! Biomechanics of LE Exercise Knees over toes concept Knees over toes during squatting or lunges if excessive increase loads on ACL During lunge: 10+2 cm During squat: 9+2 cm Escamilla et al; MSSE 10 Escamilla et al: MMSE 09 Escamilla et al: JOSPT 09 (PF)

12 ACL Rehabilitation Advanced Strengthening Phase Strengthening Ex Days Leg press (45-100) Wall Slides (0-75) Perturbation Training to Enhance NM Control Rehab Articular Cartilage Rehab Specifics Patellofemoral Lesions Motion Flexibility ( Q, G/S) Patella position» Correct tilt Control PFJR Treat above & below» Hip control» Pelvic control» Foot/ankle position Tibiofemoral Lesions Motion, motion, motion Control WB forces Shock absorbers (Q) Location of lesion Control WB forces Slow to run, jumping Slow to return to sports

13 Articular Cartilage Lesions Classification Size of lesion» Smaller lesions are shouldered and may not progress. Size of Lesion: < 2 cm 2 = small 2 to 5 cm 2 = moderate > 5 cm 2 = large Articular Cartilage Lesions Classification Outerbridge System Grade I - softening Grade II - fibrillation Grade III fissuring to bone Grade IV - full thickness Orthopedics 1997:20: Articular Cartilage Lesions Classification Rehab Articular Cartilage Motion, Motion, Motion Low intensity Long duration Articular Cartilage Rehabilitation

14 Articular Cartilage Lesions Diagnostic Concepts Chondral or osteochondral lesions found in 61-68% of knees examined arthroscopically Aroen: AJSM 04 Curl: Arthroscopy 97 Hjelle: Arthroscopy 02 Zamber: Arthroscopy 89 But less frequent in patients younger than 45 yrs of age Aroen: AJSM 04 Surgerical Options for Localized Articular Cartilage Lesions Arthroscopic lavage Arthroscopic debridement Arhtroscopic abrasion chondroplasty Microfracture or picking Osteochondral autograft transfers Autologous chondrocyte implanation Which procedure is best??? Rehab Must Match the Surgery Debridement MST ACI OCG Palliative Reparative Restorative The Treatment Algorithm: Cartilage Repair Centers Smaller, Less Complex, Less Invasive The Treatment Algorithm: Cartilage Repair Centers Larger, More Complex, More Invasive Small < 2 cm 2 Defect Larger > 2 cm 2 Defect Low Demand Patient High Demand Patient Low Demand Patient High Demand Patient Size Activity Age Factors Compliance Cost Etiology Social Chondroplasty Failure Marrow Stimulation Failure OATS ACI MS OATS ACI < 40 Age > 40 OATS ACI Factors Size Cost Activity Etiology Age Social Patient Expectations 2-3 cm 2: MS, OATS ACI Failure ACI Allograft ACI Allograft Failure Redo ACI Allograft Articular Cartilage Lesions Rehabilitation Concepts Successful rehabilitation requires knowledge of: 2: Specific surgical variables» nature of lesion (acute, chronic)» location of lesion (femur, trochlea, patella)» size of defect» depth of lesion» WB area** Articular Cartilage Lesions Rehabilitation Concepts Successful rehabilitation requires knowledge of: 3: Exact surgical procedure» tailor rehab to procedure 4: Specific patient variables» age, activity level» LE alignment» Concomitant injuries» Meniscus

15 Articular Cartilage Lesions Rehabilitation Concepts Successful rehabilitation requires knowledge of: 5: Phases of articular cartilage healing Four Phases of Healing Proliferation Phase Transitional Phase Remodeling Phase Maturation Phase Phases of Articular Cartilage Healing Four Biological Phases I: Proliferation Protection Phase» First 6-8 weeks of healing» Cell multiply & produce matrix II: Transitional Protection Phase» Weeks 8-12/16» Repair tissue is spongy, delicate phase III: Remodeling Functional Phase» Weeks 12/16-32» Remodeling to articular(fibrocartilage) IV: Maturation Phase (8-18> months)» Fibrocartilage matures, increases in strength,etc. Crenshaw et al: Clin Orthop 00

16 Knee Bracing for the Osteoarthritic Knee Patient Hewitt, Noyes, Barber, Heckmann: Orthop patients symptomatic medial OA Before bracing 78% reported knee as fair to poor, had pain with ADL s Following 9 weeks of bracing: 33% rated knee as fair poor, 39% pain w/ ADL s Asymptomatic walking tolerance increased from 51 min to 139 min following 1 yr Lidenfeld, Hewitt: Clin Orthop patients with medial arthrosis tested Gait analysis, functional score Compared biomechanics to 11 normal subjects Pain decreased by 48% Function improved by 79% Mean adduction moment decreased by 10% Kirkley,Webster-Bogaert, et al: JBJS patients randomly assigned to one of 3 groups: neoprene sleeve, valgus brace, control group Assessed pain, stair climbing, 6 minute walking test, quality of life Tested after 6 months of wear Significant reduction in pain, 3.3 x reduction with brace group Braced out performed neoprene or control Articular Cartilage Lesions Injections PRP Stem Cells Corticosteroids Viscosupplementation Articular Cartilage Lesions Injections - PRP Platelet Rich Plasma (PRP) Does PRP work?» 50/50 proposition Dragood» 6,047 pubmed articles Significant improvements Patel: AJSM 13 Cerza: AJSM 12 Sanchez: Arthroscopy 12

17 Viscosupplementation Hyalronic acid intraarticular injection Not a new concept» 1960 s used on race horses for chondral injuries» Used in Sweden since 1975» In Canada since 1992 HA functions as backbone for matrix PG Normal component of synovial fluid» Lubricate cartilage» Improves viscoelascity (HA dependent)» Improves shear velocity Rutjes et al: Ann Intern Med 12 Viscosupplementation for Knee OA systematic review & meta-analysis 89 trials involving 12,660 adults included Small & clinically irrelevant benefits with an increased risk for serious adverse events Glucosamine Supplements Glucosamine & Chondroitin Sulfate treatment is NOT a new concept These products have been widely used in Europe & Asia for several yrs Interest in the USA» 1977 book entitled The Arthritis Care recounted authors experience with G & CS» Declared it useful rapid interest» In 2000; $640 million supplement sales» Alternative Medicine & Veterinary Glucosamine Supplements Glucosamine & Chondroitin Sulfate treatment is NOT a new concept These products have been widely used in Europe & Asia for several yrs Interest in the USA» 1977 book entitled The Arthritis Cure recounted authors experience with G & CS» Declared it useful rapid interest» In 2000; $640 million supplement sales» Alternative Medicine & Veterinary Leffler et al: Mil Med 99 Randomized double blind/placebo controlled trial 32 males US navy diving & special forces teams with OA knee &/or low back received G 1500 mg,cs 1200 mg, maganese ascorbate 228 mg daily for 16 weeks Assessed symptoms, x-rays, pain, function run time Placebo grp: no significant change Rx grp: significant improvement knee score 26%, physical exam score by 40%, no change in running times

18 Clegg et al: New Eng J Med patients with symptomatic knee OA mean age 59 yrs (65% females) Excluded 1655 patients for various reasons Treatment groups:» 313 placebo» 317 Glucosamine» 318 Chronitin Sulfate» 317 Glucosamine & CS» 318 Celecoxib Treatment plan for 24 weeks Able to take up to 400 mg actaminophen for pain Primary outcome 20% reduction in knee pain Clegg et al: New Eng J Med 06 Conclusions: Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-tosevere knee pain. Glucosamine & Chondroitin Sulfate Supplemention Consumer Reports June 2006» Tested 17 national avaiable products» Contained labeled amounts» Cost related to ingredients» Rated the supplements: adequate to inadequat Kirkland (Costco).25/day Wal-Mart Spring Valley.40/day Target.45/day Vitamin World.45/day GNC.60/day Cosamine DS 1.25/day

19 Essentials to Cartilage Restoration Alignment: Unload the involved compartment Normalize the biomechanics Rehabilitation Following Articular Cartilage Repair Surgery Surgerical Techniques for Articular Cartilage Lesions Kevin E Wilk, DPT Moseley,et al: N Engl J Med randomly assigned to one of 3 groups: Arthroscopic debridement Arthroscopic lavage Arthroscopic placebo Assessed at multiple points over 24 mos regarding subjective scoring but also walking & stair ambulation At no point did the Rx groups report less pain than the placebo groups Similar knee results at 2 yrs but placebo group still higher knee scores Microfracture

20 Rehab Following Microfracture Protection Phase (week 0-8) Full passive knee extension immediately Immediate motion: Week 1: 0-90 Week 2: Week 4: Motion exercise hourly (use opposite leg) CPM use 6-8 hours per day No brace, may use elastic compression sleeve or wrap for swelling Rehab Following Microfracture Protection Phase (week 0-8) Weight bearing progression: NWB 2-4 weeks or (NWB for 4-6 wks) 25% BW week % BW weeks 7-8 FWB week 8-9 *Depends on location & extent of lesion(size) OKC exercise for 5-6 weeks CKC leg press at week 4-5 Bicycle once ROM permits (low resistance/seat) Rehab Following Microfracture Transitional Phase (week 8-14) Full weight bearing week 8 Full ROM week 6-7 Initiate functional rehab drills Pool exercise program» Control joint compressive/shear forces» Consider orthotics or brace Gradually increase walking program

21 Rehab Following Microfracture Maturation Phase (week 14-22) Progress strengthening exercises» Progress CKC exercises» Lunges,squats,step-overs,etc Progress functional drills, proprioception Stretching & flexibility drills Progression in functional activities Rehab Following Microfracture Return to Activity Phase (week 22-26) Continue strengthening & flexibility exercises Continue bicycle program Functional activities: Low impact: week Moderate impact: week High impact: week Rehabilitation Microfracture Rehab Overview Drop locked brace crutches Full passive extension CPM - motion Immediate PROM Lots of motion, motion EMS to quads Progress to CKC Running: week Microfracture Results 86% normal/near normal knee function 43% Previous level of activity (no restrictions) 43% Previous activity level (few restrictions) 14% Level of participation decreased Steadman JR et al: J Orthopaedics 98 Mithoefer, Williams, Warren: AJSM 06 Microfracture surgery on 32 high impact pivoting athletes (?) 66% reported good-excellent results 44% returned to impact sports After initial improvement scores decreased in 47% of the athletes Return to sports significantly higher with:» Athletes 40 yrs of age or less» Lesion size 200mm2» Pre-Operative symptoms less than 12 months» No prior surgerical intervention Mithoefer, Williams, Warren: JBJS 06 Femoral chondral microfracure in 48 pts. Minimum FU 2 years results:» 67% good excellent results» 25% fair results» 8% poor results Best results observed in patients:» Lower body mass index (BMI) worse results BMI >30kg/m» Good fill grade of defect on MRI» Shorter duration of symptoms MRI on 24 knees 54% good repair tissue fill 29% moderate fill 17% poor tissue repair & fill

22 Mosaicplasty Osteochondral Autograft Transfer OSTEOCHONDRAL AUTOGRAFT TRANSFER Articular cartilage & subchondral bone plug harvested from NWB Osteochondral plugs Various diameters mm Insert plugs into defect Rehabilitation variables: Mosaicplasty Donor Sites REHABILITATION FOLLOWING OSTEOCHONDRAL AUTOGRAFT PROCEDURE Protection Phase (Week 0-8) Brace locked during ambulation (2-4 weeks) WB progression» NWB for 2-4 weeks» PWB (toe-touch) weeks 3-6» PWB (½ - ¾ BW) weeks 5 8» FWB with control weeks 8

23 REHABILITATION FOLLOWING OSTEOCHONDRAL AUTOGRAFT PROCEDURE Protection Phase (Week 0-8) ROM progression» Week 1: 0-90» Week 2: 0-105» Week 3: 0-115» Week 6: ROM as tolerated REHABILITATION FOLLOWING OSTEOCHONDRAL AUTOGRAFT PROCEDURE Protection Phase (Week 0-8) Strengthening program, isometrics, SLR, OKC exer. Mini-squats week 5 Leg press week 3-4 Bicycle (when ROM permits) Gradual return to functional activities REHABILITATION FOLLOWING OSTEOCHONDRAL AUTOGRAFT PROCEDURE Transitional Phase (Week 8-14) Full WB week 8 Knee ROM: Initiate CKC and functional activities (step-ups, lunges, balance drills, proprioceptive) Pool program - progress Gradually increase functional exercises & activities REHABILITATION FOLLOWING OSTEOCHONDRAL AUTOGRAFT PROCEDURE Maturation Phase (Week 16-24) Progress all strengthening exercises» Control excessive shear & compression Progress walking, bicycle program Light activities (week ) Continue flexibility, ROM exercises REHABILITATION FOLLOWING OSTEOCHONDRAL AUTOGRAFT PROCEDURE Return to Activity Phase (Week 22-32) Continue strengthening and flexibility exercises, bicycle Functional activities:» Low-impact: 4-4½ months» Moderate-impact: 5-6 months» High-impact: 6-9 months Mosaicplasty in Athletes 78 athletes with minimum 3 year f/u» 64% returned to same level of play» 19% returned to lower level of play» 17% no sports post-op 8% worse following surgery Of 78 athletes, 43 had some OA changes pre-op Picture 1 yr post-op Hangody et al, reported at 2001 AAOS

24 Hangody, Fules: JBJS (A): patients mosaicplasty on knee joint Long term follow-up results:» 92% good excellent result femoral condyle» 87% good- excellent result tibial plateau» 79% good excellent on patellar defects 3% donor site morbidity 4 deep infections 36 post-operative painful hemathrosis Hangody, Fules: JOSPT patients mosaicplasty on knee joint Long term follow-up results:» 92% good excellent result femoral condyle» 87% good- excellent result tibial plateau» 79% good excellent on patellar defects» 94% good excellent talar surfaces 69 of 89 underwent 2 nd look arthroscopy exhibited congruent gliding surfaces, survival of hyaline cartilage, and filling in of defect Osteochondral Allograft Osteochondral Allograft Autologous Chondrocyte Transplantation Autologous Chondrocyte Implantation Indications Femoral Condyle OCD Trochlea

25 Autologous Chondrocyte Implantation Advancing Indication: Patella Facet vs diffuse patellar involvement Aggressive treatment of underlying instability or malalignment Rehab Following ACI Protection Phase (Week 0-8) ROM guidelines»1 st 24 hours: CPM/Motion???» Day 2-3: ROM 0-45» Gradual increase ROM 0-90» Week 4: 0-105» Week 6: 0-125» Week 8: CPM 6-8 hours/day Full passive knee extension

26 Rehab Following ACI Protection Phase (Week 0-8) Weight bearing progression:» NWB for 2 weeks» TTWB for 4 weeks» FWB at 8 weeks NWB Brace locked full extension during ambulation & sleep Ambulation in unlocked brace at 8 weeks Rehab Following ACI Protection Phase (Week 0-8) Strengthening exercises» Electrical muscle stimulation quads» Quad sets & SLR (flexion)» Hip abd/adduction» AROM knee ext (week 3)» Bicycle (ROM permits) Light resistance» Pool program Rehab Following ACI Transitional Phase (Week 8-16) Discontinue locked brace week 6-8» Motion in brace week 8 Weight bearing progression:» Week 6: 50% BW» Week 8: 100% BW with crutch Progress to CKC functional exercises Initiate proprioception drills Pool program week 4-5 (incision determines) Walking program (week 8-10) Rehab Following ACI Maturation Phase (Week 16-24) Full non-painful ROM Progress strengthening program» Light resistance» Control shear & compression» Emphasize bike,ckc and pool exercises Progress stretching exercises Increase walking & functional activities Rehab Following ACI Functional Activities (Week 26-52) Progress functional activities: Low impact activities: 5-6 months Moderate impact activities: 6-9 months High impact activities(?): 9-12 months Autologous Chondrocyte Implantation Modified Cincinnati Rating Scale: 7/95 to 12/00 All Defects Excelle nt Very Good Good Fair Poor

27 Autologous Chondrocyte Implantation Modified Cincinnati Rating Scale Patella/Trochlea/MFC Defects Peterson,Minas: CORR 00 Excellent V. Good Good Fair Poor 92 patients underwent ACI; F/U 2-9 yrs Good to excellent results» 92% isolated femoral condyle» 67% multiple lesions» 89% OCD» 65% patella Repair tissue biopsy hyaline-like Mithofer,Peterson,Mandelbaum: AJSM soccer players under ACI surgery of the knee 72 % returned to competitive play 80% of the players returned to presurgery level Average length of play 52months following surgery Autologous Chondrocyte Implantation (2 nd generation) Alternative flap to periosteum Scaffold to avoid flap All implants in place at 1mo (MRI) CaReS R : Matrix imbedded ACI Autologous Chondrocyte Implantation (2 nd generation) DeNovo NT Cultured or minced articular cartilage» One or two stages» Autologous (MACI, CAIS, NeoCart)» Allograft juvenile (DeNovo NT)

28 Hybrid Procedure: OCT & De Novo Courtesy: Dr Parker Articular Cartilage Rehabilitation Rehab Following Surgery Delicate balance of forces & applied stress Motion to stimulate healing / repair Control shear & compression forces Rehab varies based on surgery & lesion Monitor signs & symptoms closely Progress slowly & sequentially to recondition cartilage Caution: repetitive high impact loading till?? Long Term Results Thank You!!!!