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
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
Weeks 6 - 12
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
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
Mid Phase - Month 7 Through
Month 9
Strengthening
Cardiovascular Training
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
Strengthening
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:
|
