GENZYME TISSUE REPAIR CHONDROCYTE RE-IMPLANTATION REHABILITATION PROTOCOL LISA M. GIANNONE, PT ACTIVE CARE PHYSICAL THERAPY AND SPORTS MEDICINE PART ONE-THEORY
GENZYME TISSUE REPAIR
LISA M. GIANNONE, PT
ACTIVE CARE PHYSICAL THERAPY AND SPORTS MEDICINE
The rehabilitation protocol for Carticel is focused on graft protection and load control through the compartments within which the lesion(s) are located.
The principles that are used to protect against over stressing or overloading the graft early on have to do with weight bearing and range of motion restrictions. The middle and later phases of the protocol deal with the specific and biomechanically directed use of strength training and neuromuscular re-education.
Restricting weight bearing loads and limiting stressful motion serve to protect the graft site by avoiding forces that may compress or slough the newly implanted cells.
Developing muscular control, strength and endurance can protect the graft site by serving as a shock absorption system for forces that act through the joint and "across" the lesion.
The unique aspects of this protocol have to do with the use of biomechanical principles that take into account the location of the repair, the load tolerance of the repair, the alignment of the total extremity and the effective counter stress ability of the muscle groups surrounding the joint.
A proper progression in rehabilitation must follow the progressive healing of the repair site and its ability to tolerate compressive and shear loads. Those loads are represented as standing, walking, stair climbing, kneeling, squatting, jogging, running, cutting, i.e., the total of functional motions that the joint will be expected to go through.
PART TWO - KEY PRINCIPLES
I. Range of Motion Training
Femoral Condyles - Start comfortably at 0 to 40 degrees. Progress daily by 5 to 10 degrees or as tolerated to reach 90 to 110 degrees (or the maximum available on the CPM) in 2 weeks.
Trochlear Groove - Start comfortably at 0 to 40 degrees. Maintain this range for the first 2 weeks post-op. Increase the range by 5 degrees per day over the next 2 weeks to attain 90 to 110 degrees by the 4th post-op week.
Trochlear groove patients should avoid active range of motion exercise for the first 3 to 4 weeks, gaining self range in an assisted fashion only. The early phases of Physical Therapy will also be focused on gaining range of motion according to the following guidelines:
0 to 90 by 3 weeks post-op
0 to 110 by 4 weeks post-op
0 to 130 by 6 weeks post-op
Full range by 8 weeks post-op
0 to 40 by 4 weeks post-op
0 to 90 by 6 weeks post-op
0 to 120 by 8 weeks post-op
Full range by 3 months post-op
II. Protection of the Graft - Weight Bearing
Femoral condyle patients may begin PWBing at 2 weeks post-op.
Weightbearing Progression: Instruct the patient to use crutches until 6 weeks post-op. A patient can gradually increase WBing through their leg from the 2nd to 6th week after surgery. They may progress to 1 crutch after the 4th week if pain and swelling allow. The principle is to not fully WB the repair site until 6 weeks post-op. Patients are allowed to gradually add weight to their leg as their quad muscle begins to work as a load shock absorber.
Bracing: Patients braces are locked at 0 degrees with the onset of PWBing. As quad tone improves, which should be assessed by the physician or Physical Therapist, the brace can be opened 20 degrees at a time. In this way, the patient is only allowed to open the brace for a range through which he /she has adequate quad muscle control.
It may take up to 8 weeks for the patient to be able to ambulate painfree without the use of any assistive devices. If straight plane ambulation remains painful or causes effusion, an unloader brace may be used for all WBing activities to remove the single compartmental overloads involved with gait.
Trochlear groove patients may begin PWBing at 2 weeks post-op.
Weightbearing Progression: Instruct the patient to use crutches for a full 6 weeks post-op. In this way, the patient is prevented from being fully WBing until that time. A patient may progress to one crutch after the 4th week post-op if pain and swelling allow. Trochlear patients WBing progression will be done primarily with the leg locked in full extension (see below).
Bracing: Trochlear patients must remain in their braces, locked at 0 degrees, until the 4th post-op week. This provides the patient with a stable leg to ambulate on and does not load the trochlear repair because the patella does not significantly engage in the groove when the knee is fully extended. These patients may begin to open their braces at the 4th week post-op, initially by 20-30 degrees. Quad muscle function is even more important with trochlear lesion. Proper quad control and use helps to stabilize the patellar position in the trochlea thus avoiding increased patellofemoral loads. Therefore, expect a slower progression in opening their braces.
It may take up to 8 to 10 weeks to ambulate comfortably without devices. Unloader braces will not be effective with these patients secondary to the location of their repairs. A trochlear patient would be more likely to benefit from patellofemoral taping or a PF joint stabilizing soft brace if needed.
For anterior condyle lesions, loading in ranges of extension will need to be avoided.
For posterior femoral condyle lesions, loading in positions of flexion greater than 45 degrees needs to be avoided.
For larger trochlear groove lesions, tolerating loads in ranges of flexion greater than 30 degrees will be more difficult.
Early quad control is gained by a heavy emphasis on isometric quad exercises with the knee locked in full extension. The exercises (primarily quad sets and straight leg raises) should be performed 1 to 2 times daily. The proper mastering of these exercises is critical and will determine the effectiveness of the progression through the next phases of strengthening. Proper quad control can not be emphasized enough. The lack of this control is frequently the reason a patient fails to progress effectively through the next levels of strengthening and function.
Patients start their exercises isometrically, as holds, to simplify the command to the muscle as well as isolate the forces through the joint in positions/ranges that are completely painfree. In this way, progressive strength training can commence without applying excessive loads on the healing repair site.
Isometric exercise to the quads can then progress to positions of standing (like a squat hold or a wall hold for example). This incorporates the next level of demand on the muscle group, assuming the strength is adequate, in such a way that the repair site is not compromised by excessive loading.
Patient should be worked in simple positions that are mechanically set up to unload the repair site yet place sufficient demand on the muscles to create a strengthening adaptation.
Patients should not be progressed to the higher levels of exercise, either in complexity of position or increasing loads, until they can thoroughly master the basic isometric closed chain positions.
Patients will spend a large portion of their rehabilitation time developing adequate closed chain strength. It is difficult to gain effective muscle strength and maintain it after a surgical intervention such as this. The tendency for a patient to lose neuromuscular control and thus begin to atrophy is great and should be guarded against by an acutely attentive PT.
IV. Functional Training
Excessive or early weightbearing.
Ambulation with improper alignment.
Inadequate muscle strength and control.
Overworking in rehabilitation.
Progressed beyond capability for present time and ability post-op.
Introduction of a new physical stress (return to work, for example).
Need for anti-inflammatory intervention, rest or ice.
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THE CENTER FOR ORTHOPAEDICS AND SPORTS MEDICINE
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