Cartilage & Meniscal Rehab Consensus Protocols Announced

A global panel of almost 50 orthopedic clinical experts sponsored by Össur, a global leader in non-invasive orthopedic equipment headquartered in Iceland, recently developed the first ever Consensus Document on Cartilage and Meniscal Rehabilitation Protocols “for patients recovering from knee cartilage-related injuries, including contained and uncontained cartilage defects, and meniscal repair or transplantation.”

The recommendations detailed in the Consensus Document were gathered at the 1st Global Cartilage Expert Consensus Meeting last Fall held at Foothill Ranch, California. Prof. Jörg Jerosh of Johanna-Etienne Hospital, Neuss Germany chaired the meeting.

During the two-day meeting, the clinicians discussed important developments in cartilage and meniscal repair techniques, and the potential of future therapies like “stem cells for treating cartilage injuries, and the importance of alignment in cartilage repair.” They also developed “treatment recommendations for patients recovering from cartilage or meniscal repair procedures.”

One of the presenters at the meeting was pioneering orthopaedic surgeon, Robert LaPrade, M.D. of the Steadman Clinic in Denver, Colorado. He discussed the golden standard of care in performing osteoarticular allograft.

“A meeting like this is very important because we had several generations of surgeons here,” LaPrade said.

“Some of us were involved in the infancy of the ACI [autogenous cartilage implantation] procedure. We have seen some patients have problems with post-operative rehabilitation by not using bracing. For the newer generation of surgeons to be able to see how we treat patients and use that as part of their practice could help them advance their care of patients.”

LaPrade explained to OTW the process of gathering an expert consensus. He said, “Due to the feedback we gathered with a structured and standardized questionnaire and keynote lectures given by key opinion leaders, before the workshops we had a strong foundation for the discussion among the experts. Following the face to face discussion in the workshops, the experts drafted a recommendation for rehabilitation which was finally consented within a Delphi Round following the meeting. So, at the end we were able to agree on a detailed recommendation with clear guidance for our colleagues.”

All the recommendations include suggestions on weight-bearing, range of motion (ROM), bracing and physical therapy.

Contained Lesions Guidelines

The panel’s recommendations for contained lesions, detailed here, were divided into four treatment phases over about 13 weeks.

For rehabilitation after marrow stimulation and surface restoration of a contained cartilage lesion, the panel advised physicians to employ a protocol of progressive weight-bearing from complete immobilization during the first two weeks, to partial weight bearing during Phase II (Weeks 3-6).

They didn’t advise full weight-bearing until after 13 weeks post-op. In addition, the panel suggested that non-impact cardio activities be avoided until 12 weeks, and to prohibit running until around 24 weeks after the procedure.

For patients recovering from surface reconstruction (osteochondral auto/allograft) of a contained cartilage lesion, the panel called for full weight-bearing by week 3 and blood flow restriction therapy during the first two phases (Weeks 1-6).

The panel also supported the use of an unloading knee brace like Össur’s Rebound Cartilage brace, both during immobilization and while the patient slowly regains full range of motion and weight-bearing.

Poorly Contained Lesions

The panel’s recommendations for patients with poorly contained or larger cartilage lesions, detailed here, also includes a four-phase rehabilitation period, but this time over 26 weeks.

Physio therapy, the panel said, should consist of “passive motion, edema control, patella mobilization, quad activation and cryotherapy” during the first 6 weeks after the surgical repair of a poorly contained cartilage lesion. In addition, in Phase III (Week 7-12) patients could benefit from stationary bike exercises and hydrotherapy, and from neuromuscular training and a home exercise program during Phase IV (Weeks 13-26).

They indicated as well that the patient should wear an Immobilizer/ROM brace during first 6 weeks (Phase 1 & 2) and then switch to an Unloader during Phase III and IV.

Meniscal Repair

The biggest concern when it comes to meniscal repair, according to this panel of experts, was the increased risk for developing osteoarthritis in younger patients because of the lack of a consensus on the best rehabilitation protocols for meniscal tears, including a bucket handle tear, a radial meniscal tear, and a lateral/medial meniscal root tear.

For rehabilitation of meniscal tears, they outlined five phases of recovery lasting about 26 weeks. In the early phases of rehabilitation, they warned against doing deep squats and suggested that loaded squats should only be performed when the patient has free range of motion again.

The panel also suggested isometric exercises and cryotherapy in the beginning until more activity can be tolerated. For these patients, an Unloader brace was also recommended.

The panel of orthopedic experts also emphasized that patients should not resume plyometric and any sport-specific training until after week 26. And that patients recovering from a repair of a radical meniscal tear or the repair of a lateral/medial meniscal root tear with fixation should be weaned off their crutches by week 12 post-op. All the suggested guidelines can be found here.

A Major Milestone

LaPrade talked to OTW about why having a consensus on cartilage and meniscal rehabilitation is so crucial right now.

He said, “Over the last decade clinical data on cartilage and meniscal repair have been gathered extensively. Whereas surgical techniques have changed to enhance clinical outcomes, rehabilitation protocols have varied significantly. Especially the ‘return to play’ or ‘return to work’ aspects within the management of knee cartilage or meniscal lesions—therefore, we felt that the time had come to develop a global consensus on the rehabilitation following cartilage and meniscal repair.”

LaPrade emphasized, “The recommendations are not really product related—as an example we recommended that knee immobilizers or post-OP ROM braces be utilized in some cases—but as Össur offers the only knee unloader brace with dynamic force straps being indicated specifically for cartilage and meniscal injuries, we mentioned the Rebound Cartilage brace specifically.”

He added, “Össur is also committed to invest in biomechanical and clinical data—just a couple of weeks ago biomechanical data on the reduction of medial meniscal strain with the use of the Rebound Cartilage was published—demonstrating the value of the brace for meniscal repairs.”

Overall, he said, “We—as a group of global experts—agreed on indications and arrived at surgical procedure related consensus for rehabilitation following cartilage and meniscal surgery. This is a huge milestone because we had endless discussions in many other groups before. It was important that Össur was able to bring so many experts together and conduct such a meeting which reached consensus on this issue.”