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ACL RECONSTRUCTION with AUTOLOGOUS CHONDRYOCYTE IMPLANTATION (Femoral Condyle) REHABILITATION GUIDELINE

•  The following protocol has been established as a reference for rehabilitation following autologous chondrocyte implantation of the femoral condyle. This is to serve only as a guideline. Individual cases will vary. The emphasis of this protocol is to preserve the stability of the surgical procedure and return the patient to an optimal level of function.

•  Although time frames have been established, it is more important that goals are reached at the end of each phase prior to progression to the next.

•  It is important to avoid excessive loading / weightbearing through the graft site to ensure proper healing. Take note of specific precautions mentioned in the protocol. Information regarding the location of the implantation site should be obtained from the surgeon.

•  Pain and swelling need to be carefully monitored throughout the rehabilitation process. If either occur, the activity needs to be identified and appropriately adjusted to lessen the irritation. Ignoring these symptoms may compromise the success of the surgery and the patient's outcome.

Early Phase - Day 1 to Week 12

Weight Bearing

Weeks 0 -  2

•  Non weight bearing for 2 weeks

•  Hinge brace locked at 0°.  Unlock for CPM and exercise only

Weeks 2 - 4

•  Partial weight bearing (30 - 40 lbs) with bilateral crutches

•  Important to avoid twisting/pivoting on involved knee while weight bearing.

•  Slowly open brace 20° at a time as patient gains quadricep control

•  Discard brace when quadriceps are strong enough to control the leg in straight leg raise (SLR) without extensive lag and involved leg shows stability with partial weight bearing

•  Consider aquatic therapy for gait training utilizing water's buoyancy factor to limit weight bearing. Incision will need to be healed

Weeks 4 - 6

•  Progress to one crutch if gait pattern normal and pain free with 2 crutches

•  Important to avoid twisting/pivoting on implanted knee

Weeks 6 - 12

•  Progress to full weight bearing (FWB) and discard crutches if pain free with minimal edema. Gait pattern should be normal

Range of Motion

CPM

•  Use 6 - 24 hours after surgery

•  Use in 2 hour increments for 8 - 10 hours/day

•  Can use CPM up to 6 weeks, important to use up to 4 weeks

•  Start with settings of 0 - 40/45°, increase 5 - 10° per day per patient comfort and edema

ROM Exercise

•  Active, active-assisted, and passive ROM techniques

•  Emphasize passive 0° extension, consider prolonged (10 minutes) prone knee extension, heel props supine and sitting, etc.

•  Active knee extension from 90 to 60 degrees weeks 1 and 2; progress to 90 to 45 degrees only at weeks 3 and 4 to avoid stress on patella tendon graft

•  Patella mobilization

•  Hamstring, gastrac/soleus and hip stretching

•  After week 2 may use stationary cycle for ROM only (very light resistance) with involved leg if ° obtained

Edema Control

•  Ice, elevation, edema modalities and edema massage as needed (no. non-steroidal anti inflammatory)

Strengthening

Weeks 1 - 2

•  Isometrics-quad sets, straight leg raises and hamstring isometrics, straight leg raises in four directions (hip flexion, extension, abduction, adduction). Do exercise in brace if quadricep control inadequate. Can add resistance above the knee

•  Consider use of biofeedback or electrical stimulation for muscle reeducation

•  Isometrics in varied knee positions-pain free

•  Begin active hamstring strengthening prone and standing

Weeks 2 - 6

•  Progress OS, SLR, hip strengthening as tolerated, can add resistance below the knee if quad control adequate

•  Begin progressive closed chain exercise starting with light resistance, i.e. supine leg press with Theraband, sled or shuttle and staying within weight bearing restriction

•  Consider Carticelâ graft site with closed chain activities:
- If anterior - avoid loading in full extension
- If posterior - avoid loading in flexion >45°

•  Consider aquatic therapy strengthening and conditioning

Weeks 6 - 10

•  Weight shifting activities if FWB

•  Progress bilateral closed chain strengthening in FWB if appropriate, i.e add shallow squats and shuttle

•  Progress hamstring strengthening - consider machine, weights, manual, isokinetic, concentric and eccentric resistance

Weeks 10 - 12

•  Isometrics with foot in fixed position at multiple angles, avoid position that would put stress on chondrocyte implantation

•  Progress bilateral closed chain exercises in pain free range using resistance less than person's body weight

•  Progress to deeper standing squats with correct positioning; avoid anterior tibial/knee movement to lessen sheer forces on the knee joint

•  Open chained knee extension 90 - 30° with proximal resistance

•  Continue hamstring strengthening (PRE's/machines, manual resistive exercises concentric and eccentric, stool scouts, isokinetic strengthening, etc.)

•  Progressive resistive exercises (PRE's) for gastrac/soleus, hips an upper quadrant

•  Consider multi-hip for involved side unilateral weight bearing/balance/stabilization training

Cardiovascular/Walking Activities

•  Choose at least one for 25 - 40 minutes 3 times/week: Cycle with uninvolved extremity; swimming with straight leg kick only; upper body ergometer

•  Treadmill: Weeks 7-8 if FWB, forward and backward walking at slower pace. Emphasis on proper gait pattern

•  Weeks 8-12: stationary bike; stair master in limited arcs of motion; treadmill with incline 2-3° to reduce loads, may progress speeds; rower with shortened arcs of motion

Functional/Balance Activities

•  Weeks 8-12: balance training on involved leg -- eyes open, eyes closed if motor control adequate; consider balance/tilt board, Baps, ball throws, etc.

Goals to be Met at the End of Early Phase

•  Full ROM

•  Minimal/slight edema level

•  Pain free tolerance to Transitional Phase exercise with adequate stability, motor control

•  Minimal occasional pain only

Transitional Phase - Week 13 Through Month 6

Range of Motion

•  Maintain full active/passive ROM, patella mobility and surrounding muscular flexibility (quads, hamstrings, gastrac/soleus, abductors and adductors)

Strengthening

•  Advance bilateral and unilateral closed chain exercise (consider step-ups (low step), emphasize concentric/eccentric control)

•  Continue to progress hamstring strengthening as per early phase

•  May begin full ROM active knee extension strengthening monitoring signs of patella femoral irritation

Cardiovascular/Walking Activities

•  Continue cardiovascular training (Stair master, biking, swimming)

•  Treadmill - may progress to faster speeds to achieve mild impact tolerance

Balance/Functional Training

•  Progress balance/proprioceptive training (i.e., ball throws or T Band resistance in unilateral stance, etc.)

•  Consider slide board

•  Consider sport cord lateral drills

•  Utilize ACL functional/sport brace for balance activities per MD recommendations

Goals to be Met at the End of Transitional Phase

•  Minimal pain ROM

•  >80% quadricep and 90% hamstring strength

•  Minimal pain free status, no edema

Mid Phase - Month 7 Through Month 9

Strengthening

•  Advance strength training - increase resistance and decrease reps, emphasize single leg loading

Cardiovascular Training

•  Continue per Transitional Phase endurance training

•  Emphasize sport specific conditioning if within activity guidelines-see below

Functional/Balance Training

•  Initiate light plyometric activity at 9 months (vertical, horizontal jumping, bilateral lateral jumping etc); emphasis on eccentric control with landing. Progress as tolerated and per motor control to diagonal and unilateral plyometric training

Walking/Weight Bearing

•  Utilize pain/swelling as guideline; if either occur, reduce impact activities

•  Initiate light jogging on treadmill utilizing slight incline; start with 2 minute walk, 2 minute jog

Final Phase - Month 10 Through Month 18

Walking/Weight Bearing

•  Initiate impact training

•  Initiate light jog on treadmill utilizing slight incline; start with 2 minute walk, 2 minute jog, etc.

Strengthening

•  Advance training with heavier weights and fewer repetition to increase size/mass of muscles

•  Emphasize single leg loading and loading in full weight bearing

Function/Cardiovascular Training

•  A progressive running and agility program should be incorporated beginning with straight plane running with increasing speeds

•  Cutting drills should begin with slow “S” cutting with progressive speeds; if stable, sharper “V” cutting may be incorporated with sport specific drills

•  High impact activities (basketball, tennis, etc.) may begin at 16 months if pain free

•  Return to sports may vary according to individual MD guidelines

Side Notes
Depending on the individual surgeon, the following may be considered prior to return to sports or work:

•  KT 2000 Testing to assess ligament stability

•  Isokinetic testing for strength assessment

•  Functional ACL bracing

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