Rehabilitation Considerations Following OATS and Osteochondral Allograft Surgery Walter L Jenkins PT DHS ATC Associate Professor Department of Physical Therapy College of Allied Health Sciences E by olliegoblue33

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									Rehabilitation Considerations Following OATS and Osteochondral Allograft
                                  Surgery
                             Walter L. Jenkins, PT, DHS, ATC
                                   Associate Professor
                             Department of Physical Therapy
                             College of Allied Health Sciences
                                  East Carolina University

Rehabilitation Considerations Following OATS and Osteochondral Allograft Surgery
 Principles of Treatment
    Examination Based Approach
    Healing Response
    Post-Op Management
    TFJ Biomechanical Factors
    Functional Activities
    Therapeutic Exercise

Principles of Treatment
 Examination Based Approach
     History
     Ligament Instability/Pseudo-Instability
     ROM
     Pain/Crepitus
     Gait Evaluation
     Lower Extremity Alignment

Examination Based Approach
 History
    Chief Complaint
    Current History
    Previous History
    Medications
    Activity Level
    Goals

Ligament Instability/Pseudo-instability

Knee Joint ROM
 ROM loss is commonly observed in patients with articular cartilage injury
   Shelbourne KD, Biggs A, Gray T. Deconditioned knee: The effectiveness of a
   rehabilitation program that restores normal knee motion to improve symptoms and
   function. N Am J Sports Phys Ther 2007;2:81-89.
Lower Kinetic Chain ROM
 Knee Joint OA
    Treatment
        Hip joint mobilization

    Pre-Treat Variables
        Hip or groin pain/ paresthesia

        Anterior thigh pain

        Passive knee flexion ROM loss

        Passive hip IR ROM loss

        Pain with hip distraction

 Outcome
    If 1 variable was present 92% success
    If 2 variables were present 97% success
     Currier LL, et al. Physical Therapy 2007;87:1106-1119.

Examination: Knee Joint
 Osteoarthritis
    Increased valgus opening of the knee
    Decreased quadriceps strength
    Gait
       Greater knee adduction

       Less knee flexion

        Rudolph KS, Schmitt LC, Lewek MD. Age-Related Changes in Strength, Joint
        Laxity, and Walking Patterns: Are They Related to Knee Osteoarthritis?
        Physical Therapy 2007;87:1422-1432.

Principles of Treatment
 Healing Response
     Surgical approach
        Open approach
     Surgical procedure
        OATS
        Osteochondral Allograft


Principles of Treatment
 Healing Response
     Osteochondral Autografts
        Donor location?
             Non-articulating portion of the trochlea

             Needs proper treatment for healing

                CPM for up to 10 hours or more per day
Principles of Treatment
 Healing Response
     Osteochondral Auto/Allograft
        Surgical location
             Normal gait (wb vs. nwb)

                Stance = 0° to 30°
                Swing = 0° to 67°
             Needs proper treatment for healing

                CPM for up to 10 hours or more per day

Principles of Treatment
 Healing Response
     Osteochondral Allograft
        Allografts appear to heal less consistently and incorporate into the native tissue
         more slowly

Principles of Treatment
 Immediate Post-Operative Treatment
     0 to 6-8 weeks post-op
     Fracture Healing
        Distal femur
        Proximal tibia
        Patella


Principles of Treatment
 Intermediate - Return to Activity Phases
     Slowly introduce stress to the healing tissue
        Radiographic and
         Symptom-base approach
             Full ROM

                 Passive Motion
             Limited Arcs of Motion

                 Active Motion
                 Resisted Motion
                 Functional Activity
Principles of Treatment
 Intermediate - Return to Activity Phases
     Resistance Training
        Coincides with advancement to full wt. bearing
             Light resistance: 3-4 sets of 25 reps

             Heavier resistance may not be indicated

     Return to Activity
        Low impact activities
             9 to 12 months

        High impact activities
             More than a year

             Not all patients are candidates



Principles of Treatment
 Tibiofemoral Joint
     Biomechanical Factors
        Shear
        Compression
     Functional Activity
     Therapeutic Exercise

TFJ Biomechanical Factors
 Shear
    OKC knee extension has anterior tibial glide in the Last 40 degrees of knee ext.
        Posterior glide was present after 40 degrees
        Proximal pad placement and faster velocities decrease the anterior glide
         Grood et al, J Bone Joint Surg 1984;66A:725-734
         Yack et al, Am J Sports Med 1993;21:49-54
         Wilk et at, Am J Sports Med 1996;24:518-527

TFJ Biomechanical Factors
 Shear
    CKC has increased shear compared to OKC
        squat and leg press
   Wilk et at, Am J Sports Med 1996;24:518-527

TFJ Biomechanical Factors
 Shear
    Screw-Home Mechanism causes increased shear (tibial external rotation)
    Lat. Compartment > Med. Compartment
TFJ Biomechanical Factors
 Compression
    Lat. Compartment
        Lateral has less surface area
    Medial Compartment
        Medial has greater compression than the lateral
        Medial has greater surface area to distribute the load


TFJ Biomechanical Factors
 Meniscectomy creates an increase in load
 Load bearing surface area decreases after Meniscectomy

TFJ Biomechanical Factors
 The weight bearing zone most likely to have articular cartilage degenerative change is
  the 30 to 60 degree position.
  Rosenberg, et al, JBJS 1988;70-A:10 1479-1488

Functional Activities
 During gait the amount of loading on each compartment varies
    LE Alignment
    Adjacent joint position
      and ROM

Functional Activities
 LE Alignment – Single limb stance
    Med. Compartment > Lat. Compartment

Functional Activities
 Adjacent joint position and ROM
    Static stance
    Joint ROM assessment


Functional Activities
 Gait
    When is the Medial Compartment Loaded?
        Highest loads occur at the beginning and end of stance phase of gait
            Heel strike (less muscle activity)

        Foot is not fully pronated and unable to fully attenuate shock
Functional Activities
 Gait Analysis
    Frontal Plane (anterior view)
        calcaneal/tibial angle
        femoral/tibial angle
    Sagittal Plane (side view)
        knee flexion angle/ankle dorsiflexion
    Transverse Plane (anterior view)
        tibial/femoral rotation


Therapeutic Exercise
 Passive ROM
    “one rep per day”
 Active ROM
    neuromuscular integration
 Resisted ROM
    Arcs of motion
    High reps and low weight
    CKC

Therapeutic Exercise
 Resisted ROM
    Arcs of Motion
       Surgical location


Therapeutic Exercise
 High Reps and Low Weight
    Describe that patients with OA of the knee may not tolerate resistance training
     greater than 80% of 1 repetition maximum (RM)
        Suggest 60% of 1 RM as a guide for patients with OA
     Jan M-H, et al. Investigation of clinical effects of high- and low-resistance training
     for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther
     2008;88:427-436

Therapeutic Exercise: CKC
 “I’m easily satisfied with the very best”
   Winston Churchill

Therapeutic Exercise: CKC
 Control the tibia
    Medial Compartment
       Knee valgus position is preferred
    Lateral Compartment
       Knee varus position is preferred
Therapeutic Exercise: CKC
 Unilateral Activities
    Balance training is critical
    Strength training is commonly contraindicated
Outcome Studies
 Osteochondral Allografts
    Graft stability is key in long-term viability of the articular cartilage
     Gross, et al. Cliln Ortho Rel Res 2008;466:1863-1870

Outcome Studies
 Osteochondral Allografts
    13 of 16 patients would repeat the procedure
    KOOS
       Pain 80.6
       ADL 93.4
      Lahav, et al. J Knee Surg 2006;19:169-173

Outcome Studies
 Osteochondral Allografts
    Good to excellent results
       Femoral condyle 93%
       Tibia plateau 65%
       Patellofemoral 76%
        Bugbee WD. J Knee Surg 2002;15:191-195

Outcome Studies
 Osteochondral Autografts
    Good to excellent results
       Femoral condyle 92%
       Tibial plateau 87%
       Patellofemoral 79%
        Hangody L, Fules P. J Bone Joint Surg Am 2003;85 (suppl 2) 25-32

Conclusions
 Numerous factors are involved in the design of a rehabilitation program following
  Osteochondral Auto/Allograft surgery
 Key Factors
    Surgical Procedure
    Examination-based Approach
       Patient’s response to surgery

       Radiographic evidence of healing

       Knee joint biomechanics



Conclusions
 Articular Cartilage Rehabilitation is a Science and an Art!
                                      THANK YOU

								
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