"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"
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