Dr. Anthony A. Schepsis

Coastal Orthopedics
Beverly, MA
Professor of Orthopedic Surgery
Boston University School of Medicine

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Autologous Chondrocyte Implantation in the Knee Protocol

Postoperative Rehabilitation Protocol for Carticel Chondrocyte Implantation in the Knee

Anthony A. Schepsis, M.D.

Coastal Orthopedics

Beverly-Lahey Health

978-927-3040

GENERAL GUIDELINES

Program is designed to protect the Carticel Implantation, minimize stress on the grafted area, preserve joint motion, and rehabilitate the extremities.

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated (unless otherwise specified by the physician):

· Showering – once dressing removed; no immersion until stitches/staples removed and wounds healed, if brace is present may remove for shower.

· Driving: when safely able to operate the controls of the vehicle. Earlier for left knee surgery (assuming automatic transmission), and longer for right leg surgery.

· Return to work/school will depend on the individual needs.

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:

· Formal PT begins after patient is able to begin to bear weight usually 4-6 weeks

· 3 times per week is optimal

· Home exercises daily as instructed by the therapist/doctor

· Supervised physical therapy takes place for approximately 3-5 months post-op

PHASE I: Protection Phase

Begins immediately following surgery and lasts approximately six weeks. Patient is to protect the healing tissue from load and shear forces. Brace locked at 0° during weight-bearing activities. Sleep in the locked brace for __________ weeks.

Goals:

· Protect healing bony and soft tissue structures

· Decrease pain and effusion

· Gradually improve knee flexion

· Restore full passive knee extension

· Regain quadriceps control

Weight bearing Status:

: Non weight bearing for________weeks

Toe touch weight bearing allowed based on quad function

(approximately 20-30 lbs) for__________weeks

· Partial weight bearing (approximately . body weight) for ______weeks

· May progress to weight bear as tolerated on_______ weeks

Therapeutic Exercises:

ROM:

· Gain full passive knee extension ASAP (towel extension exercise)

Initiate Continuous Passive Motion (CPM) day 2: 8-12 hours/day

o Progress 5°-10° /day

o May continue CPM 6-8 hours/day for 4-6 weeks

· Motion guidelines on CPM

o 1-2 weeks: Knee flexion  60-90°

o 3-4 weeks: Knee flexion 90°

o 5-6 weeks: Knee flexion 120°

· Stretch hamstrings and calf daily

Strengthening:

· Ankle pumps using rubber tubing

· Quad sets starting ______days/weeks

· Isometrics of the quad and hamstrings (co-contraction in brace) starting _______days/weeks

· Straight leg raises starting _____days/weeks

Swelling Control:

· Ice, elevation and compression Use cryocuff/ice as long as swelling is present, most critical for the first few days

Criteria to Progress to Phase II

· Full passive knee extension

· Knee flexion to 120°

· Minimal pain and swelling

· Good quadriceps control

PHASE II: Transition Phase

Begins 6 weeks post-op, and extends to the 12th post-op week. Discontinue post-operative

brace at ____week. Consider using an interim brace such as a short-runner or un-loader type.

Goals:

· Gradually increase ROM

· Gradually improve quadriceps strength and endurance

· Gradual increase to functional activities

Weight-bearing Status:

· Progress weight-bearing as tolerated

· 8-12 weeks: Progress to full weight-bearing

· 8-12 weeks: Discontinue crutches

Therapeutic Exercises:

ROM:

· Gradually increase ROM

o Knee flexion to 125°-135°

o Maintain full extension

· patellar mobilization and soft tissue mobilization

· Continue stretching program (hip, knee, and ankle)

Strengthening:

· May continue hip flexion/extension/Abduction/Adduction

· Open chain knee flexion is OK, but not knee extension

· Closed kinetic chain for knee extension utilizing resisted band while standing and weight

machines as follows. Leg press is OK, active open chain knee flexion is OK.

· Stationary bike and/or elliptical machines can be used for cardio and leg conditioning;

low resistance and gradually increase time

· Balance and Proprioception activities (e.g. single leg stance or mini-trampoline)

· Initiate front and lateral step-ups

· Continue use of pool for GAIT training and exercise until able to walk without limp, full weight bearing, and go up stairs without pain

Functional Activities:

As pain and swelling decrease, the patient may gradually increase functional activities. The

patient may also begin gradually increasing standing and walking. Increase biking and

swimming activities.

Criteria to Progress:

· Full ROM

· Acceptable Strength (estimated by manual effort)

o Hamstrings within 10-20% of other leg

o Quadriceps within 20-30% of other leg

· Balance testing within 30% of other leg

· Patient is able to walk 1-2 miles or bike 30 minutes

PHASE III: Maturation Phase

Begins approximately 12 weeks post-op, and extends to 26 weeks post-op.

Goals:

· Improve functional strength and proprioception utilizing closed and/or open kinetic chain exercises

· Increase functional activities

Therapeutic Exercises:

ROM:

· Patient should maintain 125°-135° flexion

Strengthening:

· Continue lower extremity exercise progression with emphasis on quads tone and strength

· Bilateral squats (0°-60°)

· Treadmill progressive walking program as tolerated

· Stairmaster/elliptical trainer, swimming is OK

Functional Activities:

As patient improves, increase walking (distance, cadence, incline, etc)

Criteria to Progress:

· Full non-painful ROM

· Strength within 80-90% of other leg

· Balance and stability within 75% of other leg

· Rehabilitation and functional activities do not cause pain, inflammation and swelling

PHASE IV: Functional Activities Phase

Return to sport/ strenuous activities at approximately 32-52 weeks

Goals:

· Safe and gradual return to work or athletic participation

· This may involve sports specific training, work hardening or job restrictions as needed

· Maintenance of strength, endurance and function

· Running progression

· Figure 8 progression, Carioca, Backward running, cutting

· Jumping (plyometrics) if needed for sport (i.e., volleyball or basketball)

***These instructions are to be used as general guidelines. There are a lot of individual variations depending on individual case and additional surgery performed to go any faster even if the patient seems able, since the most important consideration is graft protection. Call Dr. Schepsis if there are questions or concerns at 978-927-3040978-927-3040

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