David Menche M.D.
Autologous Chondrocyte Transplantation Of The Femoral Condyle | Print |
Patients who have undergone an Autologous Chondrocyte Transplantation of a femoral condyle need to understand the biological healing that is taking place in there knee after surgery. The repair process can take 1-2 years to fully mature and therefore precautions must be adhered to in order to protect the repair. The good news is that if patients have a successful result at two years almost 100% of patients will continue to have good to excellent results for many years to come.

The first week post-operatively is a real rest week. Patients should be at home with their ice and continuous passive motion [CPM] machines.The CPM machine may be started the day after surgery depending on the pathogolgy seen at the time of the surgery and the quality of the repair. During the first 2-3 weeks the range of motion [ROM} should be limited to 0-40 degrees. If the CPM hurts the knee, the range of motion should be lowered to tolerance. If it still hurts, do not use the machine and call the office. The ice machine can usually be on 24/7 as long as there is no discomfort.

You will be in a knee immobilizer or brace for the first 4-6 weeks or until you can control your quadriceps muscle well. In addition, you will be on crutches non-weight bearing usually for 6 weeks. Progressive weight-bearing will be increased over the next 6 weeks. Be aware -These are general guidelines which will be modified according to your specific situation.

Obtaining extension [full straightening] of the knee is your primary goal after surgery. In order to achieve this goal place pillows underneath the heel. This simple position will encourage full straightening of the knee. DO NOT PUT A PILLOW UNDERNEATH THE KNEE even if it feels better. ROM should be obtained actively or with active assistance. Nobody should be pushing on your knee hard to achieve motion without first consulting with me.

Until you have full range of motion (FROM) and no swelling do not think that more walking, standing or stair climbing will ultimately enhance the function of your knee. That is a myth. The above activities early on have a potential for overloading your knee and causing more pain and swelling.

Focus on your therapy program which initially will encourage range of motion and strengthening in a controlled, supervised manner. As you progress, I will encourage return to full activity as tolerated.

Stretching should be provided by one-on-one supervision in the therapy center and done on a daily basis at home. The therapist should instruct you on a home program before you attempt to perform these exercises at home. Remember, initially these exercises are to be performed actively or with gentle active assistance.

Strengthening should only be performed in a very slow manner. Initially, one should start with a multi-angle isometric program (tightening the muscles). You can progress to a PRE with very light weights only (progressive resistive exercise program i.e. lifting weights)after 6-12 weeks if tolerated i.e no pain or increased swelling in the knee as well as th surgeon's permission. When lifting weights, lift the weight over a 10 second time period and lower the weight over 5 seconds. If pain develops during any part of the range of motion, inform the therapist. The therapist will have 3 options.

1) To lower the weight and continue the exercise through a full range of motion.
2) To avoid the range of motion which is painful
3) To stop the exercise totally.

As mentioned, the exercises should initially be performed with very light weights. The goal should be to perform one set for 12-15 repetitions. Patients should stay on a light PRE program for the first 6 months. Afterwards, you may progress as tolerated. Ideally, at that time one should perform one set of 6-8 repetitions. Upon the last repetition the patient will have total muscle fatigue but absolutely no pain in the joint i.e. in an open knee extension exercise the you will attempt to raise your leg but it just won’t go. There is no pain but the muscle is totally fatigued. When you have been able to complete a set as described above try increasing the weight 5%-10%. Exercises should be performed for all muscle groups of both lower extremities.

PRIMARY GOALS PRECAUTIONS
1. Achieve FROM actively and active assisted
2.  No swelling
3.  Obtain full strength
4. Protect cartilage repair
Knee immobilizer worn full time except while on CPM for the first 6-12 weeks, limit aerobic activity only for warm-up and cool down until full ROM, no swelling and adequate strength is achieved.

ADVERSE SIGNS AND SYMPTOMS

  1. Increased knee pain >24 hours
  2. Increased knee swelling that is not reduced with ice and elevation
  3. Increased redness, localized skin temperature and/or drainage or bleeding from surgical site.

PHASE 1- ACUTE PHASE- LIMITED ROM AND SWELLING

WEIGHT BEARING ROM BRACE EXERCISE
Non-weight bearing for first 6 weeks. Usually full weight bearing @9-12 weeks. Obtain AROM 0-90degrees @2-3 weeks. 120 degrees@ 5-6 weeks. FROM @ 12 weeks.
Immobilizer
4-6 weeks
1. Multi-angle isometrics
2.  Patellar mobility
3. Aquatic therapy
4. muscle re-education

PHASE 2 - RETURN TO FULL FUNCTION

CRITERIA TO ENTER PHASE 2 - MUST BE CLEARED BY PHYSICIAN
1) FROM
2) No pain or effusion
3) Satisfactory clinical exam

EXERCISE
1) Continual stretching and strengthening exercises. Progress to PRE program using very light weights and performing the exercises slowly. At six months progress to unrestrictred PRE program if no contra-indication.
2) Increase functional aerobic activity level specific to the patient’s functional goals i.e. do not aggressively utilize the elliptical if the patient’s goals are to increase their everyday walking
3) Walking program can be initiated after 12 weeks if in Phase 2 and cleared by physician.
4) Straight running not to begin before 9 months
5) Cutting can begin after 1 year
6) Progress to sport-specific skill training as required after 15 months
7) Avoid plyometrics that are not sport-specific