Rehabilitation before regenerative cartilage knee surgery: a new prehabilitation guideline based on the best available evidence
Focal cartilage defects are an increasingly relevant clinical problem especially in athletes. Cartilage regenerative surgery (CRS) including microfracture and autologous chondrocyte implantation (ACI) to treat such isolated cartilage defects in the knee joint has been well established in the last two decades. In contradiction to high-level evidence concerning the surgical technique, cell-related issues, and clinical results, the knowledge about the optimal rehabilitation process is still sparse although the importance of optimizing the rehabilitation process has recently led to new research focus in this field. The preoperative time frame may be used to start rehabilitation which may fasten the postoperative recovery and optimize clinical outcome (“Prehabilitation”—PREHAB). The aim of this article, therefore, was to review the available literature on prehabilitation concepts and to present a prehabilitation guideline for CRS patients based on the best evidence available.
A systemic literature research was conducted on rehabilitation for cartilage regenerative surgery as well as prehabilitation in knee joint procedures. From the available literature a prehabilitation concept was generated and tested in 10 ACI patients.
As the literature search found no studies addressing prehabilitation in CRS patients, an evidence-based PREHAB program has been compiled based on the available evidence from (a) studies addressing postoperative rehabilitation in CRS patients and (b) PREHAB studies on other knee procedures including TKA. This presented prehabilitation guideline has been tested in > 50 CRS patients and was found to be feasible as all of the patients showed a good compliance and were able to perform the protocol as suggested.
The presented PREHAB regimen may serve clinicians as a guideline for early rehabilitation of their CRS patients. Obviously, further research is mandatory to quantify its clinical effect and to demonstrate its cost-effectiveness and benefits in surgically treated patients.
KeywordsKnee injuries Knee osteoarthritis Articular cartilage Rehabilitation Resistance training
The authors are grateful to the two professional translators Carole Cürten and Duncan Cummins for language support as well as to the medical students Tanja Papke and Tasja Andrees for their support in improving the program and collegiality.
There is no funding source.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 3.Niemeyer P, Lenz P, Kreuz PC, Salzmann GM, Suedkamp NP, Schmal H, Steinwachs M (2010) Chondrocyte—seeded collagen type I/III membrane (ACT-CS) for autologous chondrocyte transplantation: Prospective 2-year results in patients with cartilage defects of the knee joint. Arthroscopy (in print) Google Scholar
- 6.Saris DB, Vanlauwe J, Victor J, Almqvist KF, Verdonk R, Bellemans J, Luyten FP (2009) Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med 37(Suppl 1):10S–19S. https://doi.org/10.1177/0363546509350694 CrossRefGoogle Scholar
- 12.Della Villa S, Kon E, Filardo G, Ricci M, Vincentelli F, Delcogliano M, Marcacci M (2010) Does intensive rehabilitation permit early return to sport without compromising the clinical outcome after arthroscopic autologous chondrocyte implantation in highly competitive athletes? Am J Sports Med 38(1):68–77. https://doi.org/10.1177/0363546509348490 CrossRefGoogle Scholar
- 13.Wondrasch B, Aroen A, Rotterud JH, Hoysveen T, Bolstad K, Risberg MA (2013) The feasibility of a 3-month active rehabilitation program for patients with knee full-thickness articular cartilage lesions: the Oslo Cartilage Active Rehabilitation and Education Study. J Orthop Sports Phys Ther 43(5):310–324. https://doi.org/10.2519/jospt.2013.4354 CrossRefGoogle Scholar
- 15.Loken S, Ludvigsen TC, Hoysveen T, Holm I, Engebretsen L, Reinholt FP (2009) Autologous chondrocyte implantation to repair knee cartilage injury: ultrastructural evaluation at 2 years and long-term follow-up including muscle strength measurements. Knee Surg Sports Traumatol Arthrosc 17(11):1278–1288. https://doi.org/10.1007/s00167-009-0854-5 CrossRefGoogle Scholar
- 16.Kreuz PC, Muller S, Erggelet C, von Keudell A, Tischer T, Kaps C, Niemeyer P, Hirschmuller A (2014) Is gender influencing the biomechanical results after autologous chondrocyte implantation? Knee Surg Sports Traumatol Arthrosc 22(1):72–79. https://doi.org/10.1007/s00167-012-2280-3 CrossRefGoogle Scholar
- 17.Kreuz PC, Muller S, Freymann U, Erggelet C, Niemeyer P, Kaps C, Hirschmuller A (2011) Repair of focal cartilage defects with scaffold-assisted autologous chondrocyte grafts: clinical and biomechanical results 48 months after transplantation. Am J Sports Med 39(8):1697–1705. https://doi.org/10.1177/0363546511403279 CrossRefGoogle Scholar
- 18.Kreuz PC, Steinwachs M, Erggelet C, Lahm A, Krause S, Ossendorf C, Meier D, Ghanem N, Uhl M (2007) Importance of sports in cartilage regeneration after autologous chondrocyte implantation: a prospective study with a 3-year follow-up. Am J Sports Med 35(8):1261–1268. https://doi.org/10.1177/0363546507300693 CrossRefGoogle Scholar
- 20.Slemenda C, Heilman DK, Brandt KD, Katz BP, Mazzuca SA, Braunstein EM, Byrd D (1998) Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women? Arthritis Rheum 41 (11):1951–1959. https://doi.org/10.1002/1529-0131(199811)41:11%3C1951::AID-ART9%3E3.0.CO;2-9 CrossRefGoogle Scholar
- 24.Bennell KL, Kyriakides M, Metcalf B, Egerton T, Wrigley TV, Hodges PW, Hunt MA, Roos EM, Forbes A, Ageberg E, Hinman RS (2014) Neuromuscular versus quadriceps strengthening exercise in patients with medial knee osteoarthritis and varus malalignment: a randomized controlled trial. Arthritis Rheumatol 66(4):950–959. https://doi.org/10.1002/art.38317 CrossRefGoogle Scholar
- 28.Cronin B, Johnson ST, Chang E, Pollard CD, Norcross MF (2016) Greater Hip extension but not hip abduction explosive strength is associated with lesser hip adduction and knee valgus motion during a single-leg jump-cut. Orthop J Sports Med 4(4):2325967116639578. https://doi.org/10.1177/2325967116639578 CrossRefGoogle Scholar
- 31.Mazieres B, Thevenon A, Coudeyre E, Chevalier X, Revel M, Rannou F (2008) Adherence to, and results of, physical therapy programs in patients with hip or knee osteoarthritis. Development of French clinical practice guidelines. Jt Bone Spine 75(5):589–596. https://doi.org/10.1016/j.jbspin.2008.02.016 CrossRefGoogle Scholar
- 40.McKay C, Prapavessis H, Doherty T (2012) The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study. J Injury Funct Rehabil 4(9):647–656. https://doi.org/10.1016/j.pmrj.2012.04.012 CrossRefGoogle Scholar
- 42.Heir S, Nerhus TK, Rotterud JH, Loken S, Ekeland A, Engebretsen L, Aroen A (2010) Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery. Am J Sports Med 38(2):231–237. https://doi.org/10.1177/0363546509352157 CrossRefGoogle Scholar
- 43.Felson DT, Gross KD, Nevitt MC, Yang M, Lane NE, Torner JC, Lewis CE, Hurley MV (2009) The effects of impaired joint position sense on the development and progression of pain and structural damage in knee osteoarthritis. Arthritis Rheum 61(8):1070–1076. https://doi.org/10.1002/art.24606 CrossRefGoogle Scholar
- 44.Hirschmuller A, Andres T, Schoch W, Baur H, Konstantinidis L, Sudkamp NP, Niemeyer P (2017) Quadriceps strength in patients with isolated cartilage defects of the knee: results of isokinetic strength measurements and their correlation with clinical and functional results. Orthop J Sports Med 5(5):2325967117703726. https://doi.org/10.1177/2325967117703726 CrossRefGoogle Scholar
- 46.Aagaard P, Andersen JL, Dyhre-Poulsen P, Leffers AM, Wagner A, Magnusson SP, Halkjaer-Kristensen J, Simonsen EB (2001) A mechanism for increased contractile strength of human pennate muscle in response to strength training: changes in muscle architecture. J Physiol 534(Pt. 2):613–623CrossRefGoogle Scholar
- 53.Behm D, Colado JC (2012) The effectiveness of resistance training using unstable surfaces and devices for rehabilitation. Int J Sports Phys Ther 7(2):226–241Google Scholar
- 56.Andersen LL, Magnusson SP, Nielsen M, Haleem J, Poulsen K, Aagaard P (2006) Neuromuscular activation in conventional therapeutic exercises and heavy resistance exercises: implications for rehabilitation. Phys Ther 86(5):683–697Google Scholar
- 58.Pollock ML, Gaesser GA, Butcher JD, Desprs J-P, Dishman RK, Franklin BA, Garber CE (1998) ACSM position stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 30(6):975–991Google Scholar
- 67.Nagano Y, Ida H, Akai M, Fukubayashi T (2011) Effects of jump and balance training on knee kinematics and electromyography of female basketball athletes during a single limb drop landing: pre-post intervention study. Sports Med Arthrosc Rehabil Ther Technol 3(1):14. https://doi.org/10.1186/1758-2555-3-14 CrossRefGoogle Scholar
- 68.Steffen K, Emery CA, Romiti M, Kang J, Bizzini M, Dvorak J, Finch CF, Meeuwisse WH (2013) High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomised trial. Br J Sports Med 47(12):794–802. https://doi.org/10.1136/bjsports-2012-091886 CrossRefGoogle Scholar
- 69.Barengo NC, Meneses-Echavez JF, Ramirez-Velez R, Cohen DD, Tovar G, Bautista JE (2014) The impact of the FIFA 11 + training program on injury prevention in football players: a systematic review. Int J Environ Res Public Health 11(11):11986–12000. https://doi.org/10.3390/ijerph111111986 CrossRefGoogle Scholar