sealant without sutures (occasionally sutures may be required). This can be performed via a mini-arthrotomy, a less invasive approach.

Transcription

1 Rehabilitation guidelines for patients undergoing surgery for autologous chondrocyte implantation (ACI), matrix induced autologous chondrocyte implantation (MACI) and autologous matrix induced chondrogenesis (AMIC) of the knee At the RNOH our emphasis is on patient specific rehabilitation, which encourages recognition of those who may progress slower than others. We also want to encourage clinical reasoning. Milestone driven These are milestone driven guidelines designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the outpatient clinic at RNOH by helping the patient and therapist to identify when a specialist review is required. Indications for surgery: Chondral and osteochondral defects of the knee Osteochondritis dissecans (spontaneous loss of a fragment of cartilage or bone and cartilage without trauma) Possible complications: Infection Bleeding Nerve damage Deep vein thrombosis Pulmonary embolism Persistent/recurrent pain Recurrent symptoms including locking, swelling, instability Failure of implant Persistent/recurrent joint crepitus Altered sensation in the knee post-operatively Surgical techniques: ACI technique: For this technique cells are harvested following arthroscopy and cultured. A periosteal flap is used or bilayer collagen membrane is sutured over the prepared cartilage defect, and the cell suspension is injected underneath. MACI technique: For this technique cells are harvested and cultured following arthroscopy using a collagen membrane matrix seeded with the cultured autologous chondrocytes. This cell-scaffold only requires fixing with a fibrin 1

2 sealant without sutures (occasionally sutures may be required). This can be performed via a mini-arthrotomy, a less invasive approach. AMIC technique: This technique is similar to microfracture but it involves using a collagen membrane to stabilise the microfracture clot, providing a more stable environment for new cartilage tissue formation. The membrane is attached with fibrin glue or sutures via an arthrotomy. Expected outcome: Improved function/mobility Reduced pain Full recovery may take up to twelve months Decreased joint clicking/ locking/ swelling/instability Pre-operatively Where possible the patient will be seen pre-operatively, and with consent, the following assessed: Current functional levels General health Social/work/hobbies Functional range of movement Balance/proprioception Gait/mobility, including walking aids, orthoses Post-operative expectations Patient information leaflet issued Post-operative management explained All ACTIVE trial patients will have completed a pre-operative assessment by the independent assessor. Post-operatively Always check the operation notes, and the post-operative instructions. Discuss any deviation from routine guidelines with the team concerned. Initial rehabilitation phase: in-patient stay (usually 0-3 days) Goals: To be safely and independently mobile with appropriate walking aid, adhering to weight bearing status To be independent with home exercise programme as appropriate 2

3 To understand self management/monitoring Restrictions: *Keep all patients in extension for 1 st week post-op* Patella / Trochlea grafts: o No range of movement exercises until 1 week post-op o Mobilise fully weight-bearing (FWB) with elbow crutches o Hinged knee brace locked in extension when weight-bearing for 4 weeks (can be unlocked for exercises to 45 degrees after 1 week) Femoral condyle grafts: o No range of movement exercises until 1 week post-op o Mobilise touch weight-bearing for 4 weeks, then partial weightbearing for a further 2 weeks o Knee brace locked in extension when weight-bearing for 1 week If sedentary employment, may be able to return to work from 2-4 weeks post-operatively, as long as provisions are made to elevate leg, and no complications Treatment: Pain-relief: ensure adequate analgesia Elevation: ensure elevating the leg with foot higher than waist Exercises: o Patella / Trochlea Teach static quads/gluts, co-contraction of quads/hamstrings o Femoral condyle Teach static quads/gluts, co-contraction of quads/hamstrings Education: teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned. Teach protection, rest, icing, compression and elevation (PRICE) Mobility: ensure patient is independent with transfers and mobility, including stairs if necessary On discharge from the ward: Independent and safe mobilising, including stairs if appropriate Independent and safe with home exercise programme 3

4 Initial rehabilitation phase: 1-6 weeks Goals: All exercises should be pain free Achieving range of movement within restrictions Restrictions: Patella/trochlea grafts: o Commence range of movement exercises 0-45 until week 4 o Mobilise fully weight-bearing with elbow crutches o Hinged knee brace locked in extension when weight-bearing for 4 weeks (can be unlocked for exercises to 45 degrees) Femoral condyle grafts: o Commence/progress range of movement as symptoms allow aiming for full range at 6 weeks o Mobilise touch weight-bearing for 4 weeks post-op, then partial weight-bearing for a further 2 weeks o Can then be weaned from brace at this stage as control allows Treatment: Advice/education: comprehensive education and instruction on restrictions and on carrying out activities of daily living (to avoid activities that can provoke excessive shear forces or impact) Posture advice/education Swelling management Gait re-education Stretches of tight structures as appropriate Mobility: ensure safely and independently mobile with/without walking aid Exercises: o Patella/trochlea grafts: Teach closed chain AROM/AAROM knee flexion and extension in lying/sitting, closed chain quads within 0-45 degrees range, static quads, co-contraction of quads/hamstrings o Femoral condyle grafts: 4

5 Teach closed chain AROM/AAROM knee flexion and extension in lying/sitting, open chain quads if pain allows, closed chain quads from 4 weeks (within range and within weight bearing restrictions), static quads, co-contraction of quads/hamstrings Low resistance isometric exercises Active exercises against gravity progressing to low resistance Patella mobilisations as appropriate Stationary cycling can be introduced from week 4 as long as resistance is minimal and there is sufficient ROM to complete a revolution without pain Manual therapy: o Soft tissue techniques as appropriate Hydrotherapy if appropriate Pacing advice as appropriate Milestones to progress to next phase: Achieving stated range of movement Pain free exercises Recovery rehabilitation phase: 6 weeks 12 weeks Goals: Optimise normal movement Improve strength and balance/proprioception Restrictions: Femoral condyle grafts: o Partial weight-bearing week 4-6 and FWB from week 6 The repair site is most vulnerable during the first 3 months after ACI/ MACI Avoid impact (i.e jogging, aerobics) as well as excessive loading and shearing forces All exercises should be pain free Treatment: Advice/education: Comprehensive education and instruction on restrictions and on carrying out activities of daily living (to avoid activities that can provoke excessive shear forces or impact) 5

6 Posture advice/education Swelling management Mobility: Ensure safely and independently mobile with/without walking aid Exercises o Controlled active range of movement (AROM) of the knee o Strengthening of muscles stabilising the knee including introduction of resistance and/or COG shift e.g resistance work with therabands/weights and duration. Progressive quadriceps, especially closed chain (depending on weight bearing status and comfort for femoral condyles) o Strengthening exercises of other muscle groups as appropriate. o Core stability work o Exercises to teach patient to find and maintain neutral extension in standing, avoiding hyper extension, with good control o Balance/proprioception work once appropriate, including double leg to single leg stand +/- eyes open/closed o Stretches of tight structures as appropriate, ensuring normal flexibility of quadriceps, hamstrings and calf muscles o Review lower limb biomechanics and kinetic chain. Address issues as appropriate o Biofeedback may be used if altered sequencing of muscles o Ensure mobility of patello-femoral joint o Incorporate functional dynamic test with the patient whilst working on proprioceptive control e.g descending stairs, gait and sit to stand Manual therapy: o Soft tissue techniques as appropriate o Joint mobilisations as appropriate Hydrotherapy if appropriate Pacing advice as appropriate Milestones to progress to next phase: Pain free exercises Mobilising independently Able to dynamically stabilise knee during single leg stand/squat (may take slightly longer with femoral condyles due to restricted weight bearing during first 6 weeks) 6

7 Intermediate rehabilitation phase: 12 weeks 6 months Goals: Optimise normal movement/control Grade IV-V muscle strength in operated leg Pain free exercises Treatment: Pain relief Advice/education Posture advice/education Mobility: progression of mobility and function Gait re-education Exercises: o Range of movement o Strengthening through range o Core stability work o Stretches of tight structures as appropriate o Review lower limb biomechanics and kinetic chain. Address issues as appropriate o Introduction of sports specific and occupation specific rehabilitation Balance/proprioception o Introduction of unstable base including use of uni/multidirectional wobble boards, trampet, gym ball and Dyna-cushion (progress with distractions including throwing, catching, reaching, turning) o Tie in core stability work o Progress from static to dynamic exercises as appropriate Introduce gym work including unrestricted static cycling, rowing, stepper Manual Therapy: o Soft tissue techniques as appropriate o Joint mobilisations as appropriate Hydrotherapy is appropriate Pacing advice as appropriate Milestones to progress to next phase: Able to dynamically stabilise the knee and be independently functional in everyday activities Failure to meet milestones: Refer back to team/discuss with team 7

8 Continue with outpatient physiotherapy if still progressing and appropriate goals Final rehabilitation phase: 6 months 1 year Goals: To be fit to return to high impact sports at 1 year if set as patient goal Hopping/changes of direction with good control Optimum balance/proprioception Establish long term maintenance programme Restrictions: From Month 9 may commence sport specific training and return to contact sport from 1 year post-op Treatment: Mobility/function: Progression of mobility and function, increasing dynamic control with sport specific training to functional goals Exercise: o Sports specific/functional exercises o Address any issues raised from patient return to activity o Functional dynamic work including running hopping and jumping (if sufficient dynamic stability) Return to low-impact activity/sports including light jogging on running machine, unlimited swimming Pacing advice Milestones for discharge: Good proprioceptive control dynamically Return to normal functional level Return to sports if set as patient goal 8

9 Failure to progress If a patient is failing to progress, then consider the following: Possible problem Action Swelling Ensure elevating leg regularly Use ice as appropriate if normal skin sensation and no contraindications Decrease amount of time on feet Pacing Use walking aids Circulatory exercises If decreases overnight, monitor closely If does not decrease over a few days, refer back to surgical team Pain Research has shown that the cartilage is continuing to heal for up to 3 years and this may account for slower progressing patients Decrease activity Ensure adequate analgesia Elevate regularly Decrease weight bearing and use walking aids as appropriate Pacing Modify exercise programme as appropriate. Should continue isometric work at all times If persists, refer back to surgical team Breakdown of wound e.g. Refer to surgical team inflammation, bleeding, infection Recurrent instability Refer back to surgical team Ensure exercises not too advanced for patient Address core stability Numbness/altered sensation Review immediate post-operative status if possible Ensure swelling under control If new onset or increasing refer back to surgical team If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned 9

10 Summary of evidence for physiotherapy guidelines A comprehensive literature search was carried out to identify research relating to rehabilitation following autologous chondrocyte Implantation of the knee and the ACTIVE trial. After reviewing the articles and information, the physiotherapy guidelines were produced on the best available evidence. ACTIVE trial protocol. Autologous chondrocyte transplantation/implantation versus existing treatments. (April 2008, Version 3.6.) Bailey A, Goodstone N, Roberts S et al (2003). Rehabilitation after oswestry autologous chondrocyte implantation: the OsCell protocol. Journal of sports rehabilitation. (12, ) Clare C et al (2005) Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints: systematic review and economic evaluation. Health technology assessment (HTA) database, 98. Hambly K, Bobic V, Wondrasch B, Van Assche D, Marlovitis S (2006). Autologous chondrocyte implantation, postoperative care and rehabilitation. The american journal of sports medicine. (34, ) Knutsen G et al (2007), A randomized trial comparing autologous chondrocyte implantation with microfracture. The journal of bone and joint surgery. (89, ) Kreuz PC et al (2007), Importance of sports in cartilage regeneration after autologous chondrocyte implantation. The american journal of sports medicine. (35, ) Riegger-Krugh C et al (2008), Autologous chondrocyte implantation: current surgery and rehabilitation. Medicine and science in sports and exercise. (40 (2), ) The use of autologous chondrocyte implantation for the treatment of cartilage defects in knee joints, (2005). National institute for health and clinical excellence. Review of technology appraisal