Karen Hambly

Return to Sports Participation After Articular Cartilage Repair in the Knee: Scientific Evidence

Background Articular cartilage injury in the athletes knee presents a difficult clinical challenge. Despite the importance of returning injured athletes to sports, information is limited on whether full sports participation can be successfully achieved after articular cartilage repair in the knee. Hypothesis Systematic analysis of athletic participation after articular cartilage repair will demonstrate the efficacy of joint surface restoration in high-demand patients and help to optimize outcomes in athletes with articular cartilage injury of the knee. Study Design Systematic review. Methods A comprehensive literature review of original studies was performed to provide information about athletic participation after articular cartilage repair. The athletes ability to perform sports postoperatively was assessed by activity outcome scores, rate of return to sport, timing of the return, level of postoperative sports participation, and the continuation of athletic activity over time. Results Twenty studies describing 1363 patients were included in the review, with an average follow-up of 42 months. Return to sports was possible in 73% overall, with highest return rates after osteochondral autograft transplantation. Time to return to sports varied between 7 and 18 months, depending on the cartilage repair technique. Initial return to sports at the preinjury level was possible in 68% and did not significantly vary between surgical techniques. Continued sports participation at the preinjury level was possible in 65%, with the best durability after autologous chondrocyte transplantation. Several factors affected the ability to return to sport: athletes age, preoperative duration of symptoms, level of play, lesion size, and repair tissue morphology. Conclusion Articular cartilage repair in the athletic population allows for a high rate of return to sports, often at the preinjury level. Return to sports participation is influenced by several independent factors. The findings provide pertinent information that is helpful for the clinical decision-making process and for the management of the athletes postoperative expectations.

Current Concepts for Rehabilitation and Return to Sport After Knee Articular Cartilage Repair in the Athlete

Articular cartilage injury is observed with increasing frequency in both elite and amateur athletes and results from the significant acute and chronic joint stress associated with impact sports. Left untreated, articular cartilage defects can lead to chronic joint degeneration and athletic and functional disability. Treatment of articular cartilage defects in the athletic population presents a therapeutic challenge due to the high mechanical demands of athletic activity. Several articular cartilage repair techniques have been shown to successfully restore articular cartilage surfaces and allow athletes to return to high-impact sports. Postoperative rehabilitation is a critical component of the treatment process for athletic articular cartilage injury and should take into consideration the biology of the cartilage repair technique, cartilage defect characteristics, and each athletes sport-specific demands to optimize functional outcome. Systematic, stepwise rehabilitation with criteria-based progression is recommended for an individualized rehabilitation of each athlete not only to achieve initial return to sport at the preinjury level but also to continue sports participation and reduce risk for reinjury or joint degeneration under the high mechanical demands of athletic activity.

Factors Predictive of Outcome 5 Years After Matrix-Induced Autologous Chondrocyte Implantation in the Tibiofemoral Joint

Background: Matrix-induced autologous chondrocyte implantation (MACI) has become an established technique for the repair of full-thickness chondral defects in the knee. However, little is known about what variables most contribute to postoperative clinical and graft outcomes as well as overall patient satisfaction with the surgery. Purpose: To estimate the improvement in clinical and radiological outcomes and investigate the independent contribution of pertinent preoperative and postoperative patient, chondral defect, injury/surgery history, and rehabilitation factors to clinical and radiological outcomes, as well as patient satisfaction, 5 years after MACI. Study Design: Cohort study; Level of evidence, 3. Methods: This study was undertaken in 104 patients of an eligible 115 patients who were recruited with complete clinical and radiological follow-up at 5 years after MACI to the femoral or tibial condyles. After a review of the literature, a range of preoperative and postoperative variables that had demonstrated an association with postoperative clinical and graft outcomes was selected for investigation. These included age, sex, and body mass index; preoperative 36-item Short Form Health Survey (SF-36) mental component score (MCS) and physical component score (PCS); chondral defect size and location; duration of symptoms and prior surgeries; and postoperative time to full weightbearing gait. The sport and recreation (sport/rec) and knee-related quality of life (QOL) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used as the patient-reported clinical evaluation tools at 5 years, while high-resolution magnetic resonance imaging (MRI) was used to evaluate graft assessment. An MRI composite score was calculated based on the magnetic resonance observation of cartilage repair tissue score. A patient satisfaction questionnaire was completed by all patients at 5 years. Regression analysis was used to investigate the contribution of these pertinent variables to 5-year postoperative clinical, radiological, and patient satisfaction outcomes. Results: Preoperative MCS and PCS and duration of symptoms contributed significantly to the KOOS sport/rec score at 5 years, while no variables, apart from the baseline KOOS QOL score, contributed significantly to the KOOS QOL score at 5 years. Preoperative MCS, duration of symptoms, and graft size were statistically significant predictors of the MRI score at 5 years after surgery. An 8-week postoperative return to full weightbearing (vs 12 weeks) was the only variable significantly associated with an improved level of patient satisfaction at 5 years. Conclusion: This study outlined factors such as preoperative SF-36 scores, duration of knee symptoms, graft size, and postoperative course of weightbearing rehabilitation as pertinent variables involved in 5-year clinical and radiological outcomes and overall satisfaction. This information may allow orthopaedic surgeons to better screen their patients as good candidates for MACI, while allowing treating therapists to better individualize their preoperative preparatory and postoperative rehabilitation regimens for a best possible outcome.

Rehabilitation after Articular Cartilage Repair of the Knee in the Football (Soccer) Player

Background: Participation in football can put both male and female players at an increased risk for knee osteoarthritis. There is a higher prevalence of focal chondral defects in the knee of athletes compared to nonathletes. The management of chondral defects in the football player is complex and multifactorial. Objective: The aim of this study is to provide an overview of the current strategies for rehabilitation after articular cartilage repair of the knee in the football player. Design: A review of current literature and the scientific evidence for rehabilitation after articular cartilage repair of the knee. Conclusions: Articular cartilage repair has been shown to allow return to sport but rehabilitation timescales are lengthy. Successful rehabilitation for a return to football after articular cartilage repair of the knee requires the player to be able to accept the load of the sport. This necessitates a multidisciplinary approach to rehabilitation, especially in the transition from therapy to performance care. It should be recognized that not all players will return to football after articular cartilage repair. The evidence base for rehabilitative practice after articular cartilage repair is increasing but remains sparse in areas.

Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organizations International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to meniscus and articular cartilage lesions. J Orthop Sports Phys Ther. 2018;48(2):A1-A50. doi:10.2519/jospt.2018.0301.

Current Concepts in Cartilage Management and Rehabilitation

Special Issue: Current Concepts in Cartilage Management and RehabilitationGuest Editors: Jennifer S. Howard, Jay R. Ebert, and Karen Hambly

Return to running following knee osteochondral repair using an anti-gravity treadmill (P03-581)

Objectives: The purpose of this study was to assess the impact of an anti-gravity treadmill return to running programme on self-efficacy and subjective knee function following knee osteochondral surgery. Methods: Two otherwise healthy female endurance runners who had undergone knee osteochondral surgery were recruited. Patient A was 9 months post-surgery for a left knee femoral cartilage grade 3–4 defect 3 cm2. Patient B was 11 weeks post-surgery for a partial lateral menisectomy and chondroplasty. An anti-gravity treadmill was usedto manipulate loading during a graduated phased return to running. Self-efficacy was evaluated using the Self-Efficacy for Rehabilitation outcomes scale (SER) and the Knee Self-Efficacy Scale (K-SES). Subjective knee function was evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS). Results: The programmes resulted in improvements in SER (Patient A 57%; Patient B 18%) and K-SES present (Patient A 89%; Patient B 33%) and K-SES future (Patient A 65%; Patient B 33%). Only the KOOS Sport/Rec (Patient A and B) and the Quality of Life (Patient B) subscales showed clinically important improvements. Conclusions: The programmes resulted in improved knee and rehabilitation self-efficacy and subjective knee function following osteochondral repair of the knee. These case reports illustrate the importance of considering self-efficacy in individualising rehabilitation after knee osteochondral surgery and highlights the potential role for anti-gravity treadmills in enhancing self-efficacy and subjective knee function in preparation for a return to sport.

Chapter 16 – Postoperative Cartilage Repair Rehabilitation

Cartilage Surgery: An Operative Manual by Mats Brittberg, MD and Wayne Gersoff, MD is your guide to applying the most recent advances in cartilage repair, and performing cutting-edge surgical procedures. An internationally diverse collection of authors offers a global perspective on timely topics such as cartilage biologics. Clinical pearls, operative video clips, and detailed, full-color intraoperative photographs offer step-by-step guidance on essential techniques. You can access the full content and videos online at expertconsult.com, and the videos are included on a bound-in DVD.