Marty Huegel PT, M Ed

1
Rehabilitation Following Microfracture Surgery

• Marty Huegel PT, M Ed
• Director of ReQuest Physical Therapy
• Director of Rehabilitation University of Florida
  Athletic Association
• Gainesville FL

2
Good Basic References

• JOSPT Volume 28 Number 4 Oct 1998
• JOSPT Volume 36 Number 10 Oct 2006
• Special IssuesArticular Cartilage

3
General Concepts

• Understanding Biology of degradation and Repair
  Factors
• Location and size of lesion
• Procedure
• Concomitant procedures
• ACL
• Meniscus

4
Rehabilitation

• Literature not clear
• Motion
• Weight bearing vs. non weight bearing
• Timing
• Various Protocols

5
What Does the Science Tell US

• Motion
• The effects of immobilization on the
  characteristics of articular cartilage current
  concepts and future directions
• B Vanwanseele, E Lucchinetti, E Stussi.
  Osteoarthritis and Cartilage 2202 10, 408-419
• Animal models studied extensively, stress
  deprivation is not good
• Humans?
• Following Microfracture?

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What Does the Science Tell US

• Motion
• With or without loading
• Immobilization without compression
• Atrophy and thinning of articular cartilage
• Multiple authors
• Immobilization with intermittent compression
• Causes reverse
• What about following Microfracture ???

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What Does the Science Tell US

• Weight Bearing, Compression
• Loading may be more important than motion
• Joint movement in the absence of loading was
  associated with cartilage atrophy
• Palmoski et al, Arthritis Rheum 23 325-334. 1980
• Unloaded
• Chondrocytes are sensitive to mechanical stimuli
• Timing of loading
• Following unloading cartilage is less stiff and
  less capable of tolerating high loads graded
  return
• What about following Microfracture ???

8
Motion and Loading Summary

• In normal's loading appears essential
• Safe loading is yet to be defined
• No load, reduced load and excessive load appear
  detrimental to cartilage health
• Consider rate, quantity and purpose of loading
• Animal studies suggest intermittent rather than
  continuous stress promotes beneficial changes and
  absence of motion is detrimental
• What about with Microfracture????

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Shear vs. Compression Forces

• Effect of Biomechanical Conditioning on
  Cartilaginous Tissue Formation in Vitro S
  Waldman et al, JBJS Vol 85A, Supplement 2 2003
• In Vitro tissue engineering has not allowed for
  mechanical stresses
• Chondrocytes were grown on ceramic substrates and
  subjected to brief periods of compression or
  shear
• Results Shear stimulation elicited the greatest
  effect
• Chondrocytes may respond differntly to different
  modes of forces

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Goals of Any Cartilage Procedure

• Replace damaged cartilage with hyaline or
  hyaline-like tissue
• Reduce patient symptoms
• Return patient to a productive level of function
• Allow future treatment options should they be
  necessary
• Senior Author Cole, Basic Science and treatment
  Options for Articular Cartilage Injuries JOSPT,
  vol 36, number 10 Oct 2006. p 717

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What does the Literature tell us

• Gill TJ et al Chondral defect repair after the
  Microfracture procedure a non human primate
  modal. Am J Sports Med 2005, 33680-685
• Defects were created in an area of minimal weight
  bearing and treated with Microfracture in
  primates
• Defects were evaluated at 6 and 12 weeks
• 6 weeks limited chondral repair with ongoing
  resorption of subchondral bone
• 12 weeks defects completely filled with more
  mature cartilage and bone repair
• Suggests weight bearing restrictions should be
  greater than 6 weeks

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Rehabilitation Protocols

• Gill
• Medial or Lateral Femoral Condyle
• TTWB 15 first 6 weeks post-op
• CPM comfortable ROM
• Progress to full weight bearing as tolerated at 6
  weeks, AROM
• Return to jumping cutting sports at 4 months
• Patella lesion
• WBAT 30 deg ROM in brace
• CPM 10-90 8 hours/day

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Steadman 2008

• Femoral Condyle or Tibial Plateau Lesions
• 0-8 weeks CPM 30-70, 6-8 hours for 8 weeks and
  TDWB x 8 weeks. Quad sets, SLR
• 2 weeks cycle spinning no resistance up to 45
  min/day, deep water running
• 9-16 weeks wean off crutches, cycle, treadmill,
  elliptical progressive. Closed chain elastic cord
  resistance at 12 weeks
• 17-24 weeks pain free loaded exercises,
  progressive running, single plane agilities
  progressing to multi-plane
• 25-36 sports specific, no return to pivoting,
  cutting jumping sports for 6-9 months

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HSS 2006

• CPM 6 hours day. 6 weeks NWB
• Cycling at 2 weeks
• Concomitant ligament or meniscus surgery does not
  alter program
• Cutting and pivoting at 5 months
• Patella full wt bearing 0-30 deg
• OKC 3-4 months

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Results

• 1994 Rodrigo Defect graded on a 1-5 (1 normal
  cartilage, 5 exposed subchondral bone scale.
• Second look arthroscopy
• 46 pts who complied with CPM rated 2.6
• CPM non-compliance rated 1.6
• Seems to implicate importance of CPM

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Results

• 1997 Steadman
• 1200 pts subjective 3-5 yr follow-up
• 75 less pain
• 20 unchanged
• 5 worse
• Negative predictors
• chronicity
• age
• failure to use CPM

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Results

• Steadman 2003
• NFL football players
• 25 pts
• 4.5 r follow-up
• Lysholm 52-90
• Tegner 5-9
• 76 returned to play averaging 4.6 seasons

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Results

• 2000 Passler
• 162 pts
• 4.4 yr follow-up
• 78 improved
• 18 unchanged

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Results

• 2005 Miller Steadman
• Bipolar lesions and lesions 400 mm2, and pts
  with absent menisci less improvement than smaller
  focal lesions with intact menisci

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Results

• 2004 Knutsen
• Microfracture vs. ACI
• 80 pts
• Prospective, randomized
• 2 yr second look w/ biopsy
• Both groups improvement
• Tegner, Lysholm
• SF 36 better with Microfracture
• Histology
• Comparable
• Suggests comparable results w/ Microfracture
  being less expensive and simpler

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Results

• 2005, 2006 Gudas
• Microfracture vs. OATS
• 57 age 24.3 competitive athletes randomized
• HSS and Int Cartilage Repair Society ratings
• OATS 96 good to excellent
• Microfracture 52
• Histology and MRI results superior w/ OATS
• However Rehab protocol did not include CPM and
  allowed wt bearing at 4 weeks

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Results

• 2006 Mithoefer (HSS)
• High Impact Athletes
• 68 good to excellent results
• After initial improvement scores declined in 47
• Results were better in athletes
  surgery

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Results What Matters in Rehab?

• 2005 Marder
• Case control study
• Compared CPM and non-weight bearing vs. No CPM
  and full weight bearing
• Small defects
• No difference in outcome
• Lesions were small and well shouldered
• Larger lesions would allow compression of the
  infill material with weight bearing

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So what do we know about the Microfracture
Procedure and follow-up Rehab?

• Replace damaged cartilage with hyaline or
  hyaline-like tissue?
• Yes but we are unsure of how rehab affects
  outcome
• Reduce patient symptoms?
• Yes, most protocols use pain as a guideline once
  weight bearing and weight bearing exercises begin
• Return patient to a productive level of function?
• Most studies indicate about 75, more difficult
  with age, BMI and larger lesions
• Allow future treatment options should they be
  necessary?
• Minimally invasive, all options remain on the
  table

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Thank You