Autologous Chondrocyte Implantation Postoperative Care and Rehabilitation

Clinical Sports Medicine Update
Autologous Chondrocyte Implantation

Postoperative Care and Rehabilitation
Science and Practice
Karen Hambly,*† PT, MCSP, Vladimir Bobic,‡ MD, FRCSEd, Barbara Wondrasch,§ PT,
ll ¶
Dieter Van Assche, PT, MSc, and Stefan Marlovits, MD, MBA
†
From the Department of Health and Human Sciences, London Metropolitan University,
‡
London, United Kingdom, Chester Knee Clinic, The Grosvenor Nuffield Hospital, Chester,
§
United Kingdom, the Academy for Physiotherapy of the General Hospital of Vienna, Vienna,
ll
Austria, the Department of Rheumatology, University Hospital Leuven, Leuven, Belgium,
¶
and the Department of Traumatology, Medical University of Vienna, Vienna, Austria
Autologous chondrocyte implantation is an advanced, cell-based orthobiological technology used for the treatment of chondral
defects of the knee. It has been in clinical use since 1987 and has been performed on 12 000 patients internationally; but despite
having been in clinical use for more than 15 years, the evidence base for rehabilitation after autologous chondrocyte implanta-
tion is notably deficient. The authors review current clinical practice and present an overview of the principles behind autologous
chondrocyte implantation rehabilitation practices. They examine the main rehabilitation components and discuss their practical
applications within the overall treatment program, with the aim of facilitating the formulation of appropriate, individualized patient
rehabilitation protocols for autologous chondrocyte implantation.
Keywords: rehabilitation; cartilage repair; autologous chondrocyte implantation (ACI); knee; patellofemoral; tibiofemoral
Intact articular surfaces are necessary for adequate joint 1987 and has been performed on more than 12 000 patients
function, as they enable smooth movement and protect the internationally. It has demonstrated significant and
joint against wear by reducing the coefficient of friction and durable benefits for patients in terms of diminished pain
by attenuating peaks of stress. However, damaged articular and improved function.1,23,113,114 Autologous chondrocyte
cartilage has a limited potential for self-repair, and restora- implantation has always been, and continues to be, very
tion of an adequate articulating surface remains a formi- strictly regulated; today it is the most widely researched
dable challenge. Controversy still exists as to whether clinical cartilage repair technique. Despite the fact that ACI
microfracture, autologous osteochondral grafting, or cul- has been in clinical use for more than 15 years, the evidence
tured autologous chondrocyte implantation (ACI) is the base for ACI rehabilitation is notably deficient. Consequently,
best repair technique and to which lesion each should be to date, guidance for ACI rehabilitation has been predomi-
applied. Numerous attempts to repair damaged articular nantly based on a combination of expert opinion, animal
cartilage have been met with similar problems: inability to studies, basic science, and clinical biomechanics. The objec-
produce hyaline cartilage, poor integration with the sur- tive of this article is to provide an overview of the current
rounding cartilage, and gradual deterioration of the repair understanding, issues, and areas of debate with regard to
tissue.2,24,137 ACI rehabilitation.
Autologous chondrocyte implantation is an advanced,
cell-based orthobiological technology used for the treatment
of chondral defects of the knee. This first orthopaedic
PROCEDURE AND VARIATIONS OF ACI
tissue-engineered procedure has been in clinical use since The classic autologous chondrocyte transplantation (ACT)
was described by Brittberg et al23 as the first generation of a
*Address correspondence to Karen Hambly, Department of Health and cell transplantation technique for cartilage repair, based on
Sciences, 166-220 Holloway Road, London, UK N7 8DB (e-mail: k.hambly@ the implantation of a suspension of cultured autologous chon-
londonmet.ac.uk). drocytes beneath a sealed periosteal cover. The technique is
No potential conflict of interest declared. characterized by the combination of 2 chondrogenic factors:
The American Journal of Sports Medicine, Vol. 34, No. 6
the implanted suspension of chondrocytes and the cam-
DOI: 10.1177/0363546505281918 bium cells of the periosteum.24 The surgical steps include
© 2006 American Orthopaedic Society for Sports Medicine arthrotomy, preparing the defect, periosteal harvest, suturing
1020
Vol. 34, No. 6, 2006 ACI Postoperative Care and Rehabilitation 1021
the periosteum over the defect, testing for water-tightness, mechanical axis to just beyond neutral when performing
application of fibrin glue sealant, chondrocyte implantation, a cartilage restoration procedure in the medial compart-
wound closure, and rehabilitation.100 This procedure has cer- ment of a varus knee. The use of an unloading brace should
tain disadvantages, including the potential leakage of chon- be considered for postoperative rehabilitation. For valgus
drocytes from defects, the dedifferentiation of a cellular angulation of a knee joint, a distal femoral osteotomy is
phenotype (because the cells are grown in monolayer before required to restore the mechanical axis to neutral. It is
implantation), the uneven distribution of cells, and the risk important to carefully plan a sequence of surgical and reha-
of periosteal complications.24,87,88 Early problems include bilitation options and to consider staging procedures if
periosteal graft detachment and delamination as well as needed.2
late periosteal hypertrophy.114 This article deals with the rehabilitation of cartilage
The second generation of ACI includes the use of a bilayer repair with cultured autologous chondrocytes, and from
collagen membrane instead of the periosteal flap. These this point onward, we will refer to all the different open
purpose-designed biomaterials are sutured over the prepared chondrocyte implantation techniques (ACI, ACT, MACI,
cartilage defect, and the cell suspension is injected under- MACT) as ACI.
neath. The use of a collagen membrane simplifies the surgi-
cal procedure and reduces the number of the incisions to 1,
thus reducing the overall surgical morbidity. Furthermore, PRINCIPLES OF ACI REHABILITATION
the complication rates of periosteal hypertrophy may be
reduced.54 Despite the fact that ACI is the most widely researched carti-
Further technological advances have led to the third lage repair technique, there are currently only 2 articles that
generation of ACI, which uses biomaterials seeded with specifically address rehabilitation protocols.8,14 Rehabilitation
chondrocytes as carriers and scaffolds for cell growth. This after ACI is a long and demanding process that presents
composite “all-in-one” tissue-engineered approach com- challenges to clinicians and patients alike. Autologous chon-
bines cultured chondrocytes with 3-dimensional biocom- drocyte implantation rehabilitation differs from other arti-
patible scaffolds for the purpose of generating new cular cartilage reparative or restorative procedures in 4
functional articular tissue. The 3-dimensional scaffolds pertinent ways: indication, surgical procedure, graft matura-
have been shown to contain the chondrocytes in the defect tion, and evidence base.
area and to support the maintenance of a chondrocyte-
differentiated phenotype.52,53,128 After debridement of the Indication
defect, the biomaterials with seeded cells are trimmed to
exactly match the defect size and are implanted without The ACI procedure is predominantly for larger lesions
the use of a periosteal cover or fixing stitches. In most tech- (>2 cm2),2 and this indication presents implications for reha-
niques, only fibrin glue is used for the fixation of the graft. bilitative joint loading and the potential for graft disruption,
Because there is no requirement for periosteal harvest or especially when lesions are poorly “shouldered.”85 Autologous
stitching the cover over the recipient site, a mini-arthrotomy chondrocyte implantation is also indicated as a secondary
technique can be used. Although the lack of firm fixation is treatment after 1 or more failed alternative cartilage repair
a concern, Marlovits and collaborators89 reported that the procedures, which has rehabilitative implications associated
implantation and fixation of a cell-scaffold construct with symptom duration and surgical morbidity.
(matrix-induced ACI [MACI]) in a deep cartilage defect of
the femoral condyle with fibrin glue and with no further Surgical Procedure
surgical fixation lead to a high attachment rate 34.7 days
after the implantation, as determined with high-resolution In contrast to other cartilage repair procedures, ACI is
MRI.89 currently a 2-stage procedure that is often undertaken
When planning to restore the articular defect, the surgeon with concomitant procedures, as previously highlighted. The
must diagnose and correct any significant comorbidity: a staging of procedures therefore needs to be considered and
meniscal deficiency, ligament laxity, or mechanical malalign- planned to avoid competition between postoperative reha-
ment of the tibiofemoral or patellofemoral joint. Uncorrected bilitation protocols. After the arthroscopic biopsy, sufficient
meniscal deficiency and ligament laxity are a contraindica- time should be allowed before the cell implantation for the
tion to cartilage restoration procedures. Most lateral patella restoration of joint homeostasis. Initial autologous chon-
and trochlear cartilage restoration procedures should be drocyte culture time was 6 to 8 weeks, but this has already
combined with arthroscopic lateral release, preferably at the been halved to 3 to 4 weeks and has potential for further
time of chondral biopsy. The patellar realignment procedure, reduction with emerging tissue engineering technologies.
principally aimed at medialization of the patella to unload However, even without any concomitant procedures, a mini-
the newly restored articular surface, should be performed mum of 3 weeks is needed after arthroscopy148 to replace
at the time of open chondrocyte implantation. Medial lost synovial fluid, to allow portal wound healing, to allow
patellofemoral chondral lesions may be an exception to this recovery from analgesia/anesthetic, and to advance into
principle and may require patellar anteriorization. The role the remodeling/maturation phase of healing. The implan-
of the hinged patellar brace and incremental increase of tation stage is routinely performed via either open arthro-
knee flexion remains unclear. A high tibial osteotomy is tomy or mini-arthrotomy, resulting in greater surgical
required to correct the varus angulation of the lower limb trauma and mechanoreceptor disruption, all of which are
1022 Hambly et al The American Journal of Sports Medicine
likely to entail a longer rehabilitation process for return to than normal articular cartilage, or heterogeneous, with a
function compared with alternative arthroscopic cartilage layered or speckled pattern. However, Alparslan and coau-
repair procedures. thors4 found that a linear, fluid-like signal, either within the
ACI or at its junction with the subchondral bone, usually
Graft Maturation indicates tear of the periosteal cover or poor integration of
the graft, with in situ delamination. A small, cross-sectional
For optimal results, ACI rehabilitation needs to not only fol- qualitative study of the appearance of ACI on MRI found
low but also to facilitate the process of graft maturation. heterogeneous signal intensity to be common within the
Excessive or inappropriate loading of immature neocarti- graft site during the first 3 months, whereas at 1 year the
lage is therefore not advisable. However, the difficulty arises repair cartilage appeared more uniform. After contrast
in the longitudinal assessment of the maturation status of enhancement, grafts during the first 3 months showed het-
the graft. Graft remodeling and maturation can continue for erogeneous uptake of gadolinium–diethylenetriamine pen-
up to 3 years after ACI implantation,69 and the length of this taacetic acid (Gd-DTPA), whereas grafts between 3 months
process consequently has significant implications for the and 1 year showed very little enhancement. On MRI, the
timing and specifics of the rehabilitation protocol. repair tissue within the ACI site should ideally appear as
A broad timeline for maturation of the ACI graft has been thick as the adjacent native articular cartilage and should
proposed, based on studies in a dog model as well as clini- have a smooth articular surface that reproduces the original
cal observations such as second-look arthroscopy, MRI, and articular contour. When an osteochondral defect is present
patient symptoms.18,123 However, at this point, there is no preoperatively, however, the subsequent thickness of the
established and verified ACI graft maturation timeline. repair cartilage is usually thicker than that of native carti-
Canine studies have demonstrated that there are several lage, but the original articular contour is restored. The
stages to the healing process.19 The proliferative stage, margins of the graft should be continuous with the adjacent
which seems to last up to 6 weeks, is characterized by a native articular cartilage, with an indiscernible or linear
primitive cell response, with tissue fill of the defect. During interface. The signal intensity of the junction between the
the transition stage, the tissue is not firm or well inte- ACI and native cartilage may appear dark, indistinguish-
grated, and it feels very soft, almost liquid, when probed able from cartilage, or as bright as fluid. Interestingly, fluid-
with an arthroscopic probe. At this stage, a type II collagen like signal at these margins may be present with an intact
framework is produced along with the proteoglycans that surface and does not necessarily imply that a fissure is pres-
form the cartilage matrix. By 3 to 6 months, the tissue has ent, as long as the fluid-like signal does not extend beneath
usually firmed up, it has a gelatin-like consistency, and it is the remainder of the graft. The clinical significance, if any,
well integrated to underlying bone and adjacent cartilage. of the different signal intensities at the ACI margin is
Patients will start to experience good symptom relief dur- presently unknown.
ing this period. At 6 to 9 months, the neocartilage is putty- The subchondral bone plate beneath the ACI may appear
like. A remodeling and maturation phase occurs over time, either smooth or slightly irregular. If the ACI was performed
lasting as long as 2 years as matrix proteins crosslink and to repair an osteochondral defect, the level of the subchon-
stabilize in large aggregates and the collagen framework dral bone plate will be below that of adjacent areas, but the
reorganizes to integrate into the subchondral bone and to ACI repair tissue should still reproduce the articular con-
form arcades of Benninghoff. However, the process of tissue tour. Edema-like signal within the bone marrow subjacent
maturation that begins during the remodeling stage con- to the ACI site is an expected finding in the early postoper-
tinues long after this point. Excessive activity during this ative period. In mature grafts, however, the marrow signal
remodeling stage may cause repair tissue degeneration. intensity is usually normal or may demonstrate only mini-
Hence, the concept of a timeline of graft healing and remod- mal, linear bright signal on fat-suppressed images. It is still
eling is critically important during ACI rehabilitation.98 unclear when the subjacent bone marrow signal should
An increasingly effective, noninvasive method of assess- return to normal. Subchondral changes and edema of the
ing articular cartilage repair6,10,22,27 and, more specifically, underlying bone marrow are being reported increasingly
ACI graft maturation15 is advanced MRI. In particular, MRI frequently,5 and it is suggested that these are normal
can evaluate the degree of defect fill-in, the integration of responses to ACI and reflect graft remodeling and attach-
the neocartilage to the subchondral bone plate, and the ment to the subchondral bone.55 If that is the case, then from
status of the subchondral bone plate and bone marrow. The a rehabilitation perspective, it would be beneficial to know
signal intensity of ACI repair tissue is variable and may be when persistent changes are indicators of abnormal
heterogeneous. To our knowledge, no longitudinal studies responses to ACI, but this information is as yet unavailable.
showing the progression of the signal intensities in matur- Our experience has been that the presence of edema-like
ing ACI grafts have been performed. The clinical experience marrow signal beyond 12 months, or the progressive
of Alparslan and coauthors4 has shown that ACI grafts may increase in the quantity of edema-like marrow signal, may
have a relatively bright signal on fat-suppressed fast spin- herald a poor outcome.
echo images during the initial weeks after surgery (prolife- In addition, the influence of factors such as type of chon-
rative phase), and some areas of bright signal may persist for drocyte cover (periosteum or bilayer collagen membrane),
several months after the surgery (transitional phase).4 The the composition and biomechanics of scaffolds seeded with
mature, intact ACI repair tissue may appear similar in sig- chondrocytes (MACI, Hyalograft C, etc), and the concentra-
nal intensity to normal cartilage, mildly brighter or darker tion of growth factors, as well as the patient’s age, activity
TABLE 1
Comparative Analysis of Ranges in Parameters During Early-Stage ACI Rehabilitation Protocolsa
Patellofemoral Tibiofemoral
Minimum/Earliest Maximum/Latest Minimum/Earliest Maximum/Latest

Introduction Introduction Introduction Introduction
Time to full 6 h postoperatively 12 wk 7 wk 12 wk

weightbearing
ROM goals for 6 wk 30° 120° 90° 130°
postoperatively
Orthoses No brace 6 wk locked 3 wk 8 wk
in full extension in unloader brace
CPM 2 h/d while 8-12 h/d 2 h/d while an 6-8 h/d
an inpatient (3-5 d) for 6 wk inpatient (3-5 d) for 6 wk
Patellar mobilizations Immediately 2 wk Immediately Not included
postoperatively postoperatively
Hydrotherapy 2 wk 4 wk 2 wk 4 wk
Cycling 4 wk 12 wk 2 wk 12 wk
a
For studies used, see references 8, 15, 29, 99, 120, 124, 138, 149, 154. ACI, autologous chondrocyte implantation; ROM, range of motion;
CPM, continuous passive motion.
level, and local nutrition all seem to be important to graft CLINICAL BIOMECHANICS
maturation but are still unclear and unsubstantiated.
An understanding of applied clinical biomechanics and an
appreciation of the forces and loads that will be exerted on
Evidence Base
the graft are essential in the design of an ACI rehabilitation
At present, the evidence base for ACI rehabilitation is in its program. The contact area (distribution and magnitude),
infancy. Prior experience of the evolution of procedures such contact load, and contact pressure during rehabilitation
as ACL reconstruction has shown that where the evidence should be considered to minimize the danger of damaging
base for rehabilitation is limited, fears of graft failure are the graft and to support the healing process by stimulating
paramount. This concern, in conjunction with the relative the graft physiologically in harmless positions. An extensive
minority of therapists with experience treating ACI review of clinical biomechanics is outside the scope of this
patients, is likely to be reflected in an overcautious article; for a review of patellofemoral and tibiofemoral biome-
approach to ACI rehabilitation at the present time. chanics, we suggest referring to McGinty et al,96 Grelsamer
To maximize the benefits of ACI surgery, it is essential for and Klein,51 and Martelli and Pinskerova.90 An overview of
patients to be well informed and educated and for them to the pertinent aspects in relation to ACI rehabilitation will
adhere to a specific rehabilitation program.1,2,48 Patient edu- now be presented.
cation, the management of patient expectations, and clear
goal setting are indispensable within ACI rehabilitation.
These values are reliant on a collaborative environment, BIOMECHANICS OF THE
with good communication between the surgeon, therapist, PATELLOFEMORAL JOINT
and patient.
The 2 primary goals for an ACI rehabilitation program The patellofemoral joint (PFJ) is a sellar joint composed of
are (1) local adaptation and remodeling of the repair and the patella and the underlying femoral trochlea. Passive
(2) return to function. The rehabilitative challenge is to opti- stabilization of the PFJ is created by the femoral condyles,
mize the achievement of these goals within an individualized the articular surfaces of the PFJ, the peripatellar retinac-
and progressive, yet safe, framework. The 3 main components ulum, and the medial and lateral patellofemoral liga-
of the rehabilitation program are (1) progressive weightbear- ments.32,96,134 The primary active stabilizer of the PFJ is
ing, (2) restoration of range of motion (ROM), and (3) enhance- the quadriceps muscle group; importantly, the sole dynamic
ment of muscle control and strengthening. restraint to lateral tracking is the vastus medialis obliquus
The repair site is at its most vulnerable during the first (VMO).51,84,96 Although normal functioning and stability
3 months after ACI. At this time, it is important to avoid of the PFJ are highly dependent on the appropriate bal-
impact as well as excessive loading and shearing forces. There ancing of these active and passive stabilizers,76,96 there are
is a consensus of opinion that weightbearing and ROM should additional influencing factors, including tibial and femoral
be restricted in early rehabilitation, but there is considerable rotations,51,76 gluteal muscle status, quadriceps anatomy,
variation across cartilage repair centers as to the extent and femoral trochlea anatomy, tibial tuberosity positioning,
duration of these restrictions, as highlighted in Table 1. and foot mechanics.51
TABLE 2
Summary of Patellar Articulation During Knee Flexion and Extension
Articulation Contact Area
Full extension Patella sits above femoral articular No patellofemoral contact with femur.
surface and rests on supratrochlear fat pad.
10°-20° Initial contact occurs between inferior

Joint contact area increases steadily with flexion.
patella and trochlea.
Mean contact area at 10° = 126 mm2; mean contact
30°-60° Middle surface of patella in contact with
area at 60° = 560 mm2.116
middle third of trochlea.
60°-90° Superior patella makes contact with trochlea. Contact area remains constant.
90°-135° Superior patella contact area splits into medial Controversial—research differs, with contact
and lateral contact areas that articulate with area either leveling off after 90° or continuing
the opposing femoral condyles. to increase with increasing flexion.54,81,110,116
135° Odd facet of patella contacts medial femoral condyle.
Full flexion Lateral femoral condyle fully covered by patella,
and medial femoral condyle nearly completely exposed.
The major function of the patella is to increase the so, the magnitude of the contact area also increases (Table 2).
mechanical advantage of the quadriceps mechanism and to This increased contact area helps to distribute compressive
minimize the concentration of stress by transmitting forces over a larger area, thereby reducing contact stress.
forces evenly to the underlying bone. In so doing, the Hence, the compressive forces imposed on the patellar artic-
patella allows flexion and extension to be undertaken with ular cartilage have to be considered in the context of the con-
reduced quadriceps force, resulting in lower stress across tact area over which they act.51,96,152 Therefore, PFJ stress is
the tibiofemoral joint.51,76,95 Other functions of the patella defined as the PFJRF divided by the area of contact between
are to protect the articular cartilage of the trochlea and the the articular surfaces of the patella and the femur.152
femoral condyles by providing a smooth sliding mechanism The 2 primary goals of ACI rehabilitation are best
for the quadriceps muscle with little friction.76 achieved by optimizing the PFJ contact area rather than
To optimize the distribution of forces and stresses, the decreasing the force,63,95,96 as this promotes better nutrient
patella has a large articulating surface, with the thickest exchange of the cartilage27,63,95 and decreases the pressure on
articular cartilage in the human body.51,76,95 The patellar the PFJ.
cartilage shows multiple facets in a pattern that is unique
to each individual, and it does not follow the contour of the BIOMECHANICS OF THE TIBIOFEMORAL JOINT
underlying subchondral bone.51 The articular surface of the
joint is congruent in the axial plane but not in the sagittal The tibiofemoral joint (TFJ) is a modified hinge joint that
plane, and the material properties of the patellar cartilage has recently been shown to have 6 degrees of freedom: flexion/
differ from those in the cartilage of the articulating extension with translation, axial rotation with translation,
trochlea.51,63 and varus/valgus angulation with translation.96,110 Flexion/
The articulations and contact area at various degrees of extension of the TFJ is a combination of rolling and gliding
knee flexion are pertinent to ACI rehabilitation because of of the articular surfaces, with a spin movement that helps
graft location; an overview is shown in Table 2. to maintain the joint congruency. During closed kinetic
The magnitude of the contact area decreases signifi- chain (CKC) extension, the femur rolls anteriorly and glides
cantly in passive compared to active flexion,104 whereas the posteriorly on the tibia plateau. In the last 30° of extension,
contact area significantly increases with weightbearing.13 there is a medial rotation of the femur, the “screw home”
The magnitude of the contact area can also be influenced by mechanism. In an open kinetic chain (OKC) extension, the
tibial and femoral rotations.76 Men have larger absolute con- kinematics of the joint is vice versa in relation to the moving
tact areas than do women, but there is no significant gen- tibia. The femoral condyles roll posteriorly and glide anteri-
der difference when normalized to patellar dimensions.13 orly during flexion in a CKC system, with a conjunct lateral
The patellofemoral joint reaction force (PFJRF) is equal rotation of the femur at the beginning of the movement. In
and opposite to the resultant of the quadriceps tendon ten- OKC flexion, the kinematics of the joint is vice versa in
sion and the patellar tendon tension.51,96,152 Thus, the com- relation to the moving tibia.
pressive force is a measurement of patellar compression The movement of the lateral compartment differs from
against the femur and is influenced by the knee angle and that of the medial because of the difference in shape of the
patellar positioning as well as the quadriceps force.96,152 With femoral condyles. In the medial compartment, the magni-
increasing knee flexion, the PFJRF increases, but as it does tude and distribution of the contact area change because
the amount of rolling and gliding is equal. There is no graft.28,51 In the OKC exercises, forces are low near full
significant change in the contact area in the lateral compart- extension (25°-0°) and at 90° of flexion. Extending from this
ment, as rolling exceeds gliding in a ratio of 1.7 to 1.58,64,90,110 position, the joint reaction force increases until early flexion
The kinematics of the joint is initiated, guided, and limi- (25°).28,51,96 Therefore, OKC exercises are most safely carried
ted mainly by the cruciate ligaments but also by muscles out from 25° to 90° of flexion. But as it has already been
and capsular structures. Injury to one of these structures mentioned, the rehabilitation should be focused on func-
or loss of function leads to altered arthrokinematics, which tional activities, and therefore CKC exercises should be
may be deleterious to the menisci and cartilage.41,144 emphasized.
During normal activities, the joint contact forces (shear Because of the “roll-and-glide” mechanism, the TFJ
and compressive forces) that are produced are attenuated demonstrates different kinematics between OKC and CKC
by several structures of the joint. Shear forces are pri- exercises compared to the PFJ, and this difference results
marily restrained by the cruciate ligaments. Compressive in altered TFJ shear and compressive forces.96 Excessive
forces are mostly attenuated by the menisci and the carti- tibiofemoral shear forces and compressive forces may be
lage.27,63,96 Excessive shear and compressive forces can be deleterious for the ACI graft. To reduce the risk of abnormal
deleterious to the menisci and the cartilage. A number of shear forces, one of the most important requirements for
studies have measured these forces41,110,144,157; the exact ACI are intact cruciate ligaments. Even with functional cru-
level of musculoskeletal loading is influenced by a number ciate ligaments, OKC exercises produce higher tibiofemoral
of interindividual factors such as weight, gender, move- anterior and posterior shear forces than do CKC exer-
ment coordination, and the activity being undertaken.144 cises40,96; CKC exercises produce significantly higher com-
More pertinently, it is currently unknown at what magni- pressive forces and increase muscular cocontraction, which
tude compressive and shear forces become injurious to lead to greater joint stability. Tibiofemoral shear forces
structures such as the menisci and cartilage.41 decrease in CKC systems; hence, the risk of damage to the
To develop a safe and effective ACI rehabilitation pro- graft is reduced.96,144
gram, shear forces have to be minimized, and the size and The selection and progression of CKC and OKC exercises
location of the defect have to be known because during sev- in ACI rehabilitation are dependent on the surgical tech-
eral activities only parts of the femur/tibia are articulat- nique, lesion location and size, concomitant intra-articular
ing.90,110 For example, the posterior aspect of the medial injury, healing stage, and patient compliance. The CKC
femur condyle contacts the tibia between 90° and 120°63; exercises can be performed in a greater ROM, emphasizing
therefore, appropriate loading in positions between 0° and functional activities of daily living, but they alone may
80° might not be injurious for a graft in this area. not provide an adequate stimulus for optimal quadriceps
strengthening. Performing OKC exercises in a small ROM
increases quadriceps muscle torque and thus leads to
OPEN KINETIC CHAIN VERSUS CLOSED
better functional outcome. Therefore, rehabilitation after ACI
KINETIC CHAIN EXERCISES should include both OKC and CKC exercises, with ranges of
movement based on the size and location of the ACI graft.
In recent years, the clinical use of CKC exercises has
increased, as they are assumed to be more functional than
OKC exercises.96 Additionally, CKC exercises have also been ACTIVE AND PASSIVE MOVEMENTS
shown to involve multijoint action, muscular cocontraction,
and a normal proprioceptive input.51,139 In contrast, OKC Controlled early resumption of activity can promote
exercises have been described as nonfunctional, lacking in restoration of function, whereas prolonged immobilization
joint proprioception and synergistic muscular cocontrac- has been shown to delay recovery and adversely affect nor-
tions, and producing a decreased joint compressive force mal tissues.25,148 Therefore, mobility after ACI should be
component in conjunction with increased joint shear rapidly restored. To protect the graft in the early postoper-
forces.51,116,142 ative stage, a short period of partial immobilization is nec-
To ensure optimal healing of the ACI graft after surgery, essary, often with use of orthoses. The duration and degree
peak compressive forces and shear forces should be avoided. of partial immobilization are dependent upon the size and
A common opinion is that OKC exercises produce higher localization of the transplanted area.
patellofemoral compressive forces than do CKC exercises In conjunction with partial immobilization, restrictions
and activities.51,116,142 However, because of the complicated in weightbearing are also generally advocated, although
biomechanics of the PFJ, it is not sufficient to solely differ- there is considerable variability in the implementation
entiate between OKC and CKC modes, as the localization of of partial weightbearing (PWB) across cartilage repair
the graft will influence the rehabilitation program. In CKC centers (Table 1). A particular issue concerns weightbearing
exercises, the joint reaction force on the PFJ increases as the recommendations for patellar repairs. In these cases, it can
knee flexes from 0° to 90° and then decreases from 90° to be argued that if a patient is braced in full extension, there
120°. The CKC exercises are therefore safest in the range will be no contact with the femoral articular surface, and
from 0° to 45°, especially if the graft is on the proximal therefore, there will be no need to restrict weightbearing
aspect of the patella.28,51 In full extension, there is no while mobilizing.51,95,96 When weightbearing restrictions
patellofemoral contact (Table 2), so straight-leg raises in all are advised, it is important to check levels of weightbear-
positions are safe and produce no abnormal stress on the ing on a regular basis and to educate the patient regarding
as active knee extension involves quadriceps contraction

that results in high compressive forces on the patella.51,103 To
avoid damaging shear forces in the early stages of rehabili-
tation, active movements of the knee should be performed in
a controlled manner. This procedure necessitates a compre-
hensive program of education and instruction for the patient.
First, there is a need for close guidance to ensure correct
application of the exercise modality. Second, advice on acti-
vities of daily living is essential, as many such activities can
provoke excessive shear forces. Good patient understanding
and movement control are priorities for optimal care of the
healing process in the early stages of rehabilitation.
In summary, active ROM exercises have been shown to be
beneficial to increase ROM and to stimulate the healing
process.27,63,150 However, it is imperative that the location and
size of the lesion are considered and that the patient pro-
gresses through the ROM exercises in a controlled manner.
CONTINUOUS PASSIVE MOTION
Continuous passive motion (CPM) is commonly used in

postoperative rehabilitation of knee disorders to minimize
the adverse effects of immobilization and to positively influ-
ence the healing process. Immobilization of synovial joints
results in compositional alterations of articular cartilage:
decreased synthetic activity of chondrocytes, decreased
proteoglycan content, and reduced water content. In addi-
tion, immobilization results in biomechanical changes,
including decreased cartilage stiffness and decreased carti-
Figure 1. Assessment of the degree of partial weightbearing lage thickness.27,63,131,148,150 Generally, immobilization leads
for a patient on crutches using a set of scales. to decreased ROM of the joint, followed by an adaptation
process of all the articular structures to the immobilized sit-
uation. Thus, early mobilization after surgical procedures in
the correct amount of weight. A practical way for the synovial joints is advocated to prevent the consequences of
patient to monitor weightbearing is to use a set of weigh- immobilization, such as stiffness and adhesions, through
ing scales, as shown in Figure 1. passively moving the joint without jeopardizing the healing
To enhance the graft healing process, a controlled increase process.
of ROM through passive and active movements is indicated. The biological approach for the use of CPM for cartilage
Repetitive movement intensifies the synovial fluid flow over lesions and its positive effects on the healing of full-thickness
the repaired site and enhances local diffusion. Moreover, defects in articular cartilage have been mainly reported by
repetitive movement over a significant range induces inter- Salter.129-132 Salter et al132 described a more rapid metapla-
mittent changes of intra-articular pressure.107,112 Several sia of the healing tissues within the defect from undifferen-
studies report stimulation of chondrocyte activity induced by tiated mesenchymal tissue to hyaline articular cartilage
intermittent pressures.62,155 Generally, it is thought that the with CPM than with either immobilization or intermittent
chondrocyte response to mechanical stimulation contributes active motion. Williams et al153 showed that a period of inter-
to the maintenance of the articular cartilage homeostasis. mittent active motion followed by CPM may protect and
Besides the biomechanical aspects of movement, hormonal stimulate repair of the articular cartilage matrix. O’Driscoll
factors such as enzymes, growth factors, and cytokines play a and Giori107 proposed the use of CPM as a means to pump
key role in reparative signaling for the involved joint cells blood and edema fluid away from the joint until the swelling
and structures.74,83,146 In addition, ROM exercises promote no longer develops.
general circulation, can prevent adhesions, and bring relief Used postoperatively after periosteal transplantation in
of pain.25 patients with full-thickness patellar cartilage defects, CPM
Muscular activity increases both the joint contact area and shows good results and outcomes, especially compared to the
the joint reaction forces, resulting in the production of higher results and outcomes of patients treated only with active
joint forces with active movements. It is therefore suggested motion.3,82 Postoperative CPM after periosteal transplanta-
that active movements, in which the ROM implicates high tion has also shown enhanced cartilage repair tissue that
joint reaction forces, should be increased at a slower rate grossly, histologically, and biochemically resembled articular
than passive ROM. For instance, after a PFJ repair, knee cartilage.3,108,132 The effect of CPM on ROM is controversial.
extension is first introduced passively during ROM exercises, Investigations comparing CPM with active motion exercise
after total knee arthroplasty have not shown any significant Relative rest is recommended for the first 48 hours up to
difference in the improvement of knee mobility.11,26,70 7 days postoperatively.147 To restore homeostasis, a combina-
However, these studies were based on total knee arthroplasty, tion of rest and mobilization is necessary.68,147 As long as mov-
and it is unlikely that the results are comparable to ACI. ing around in an upright position induces swelling and pain,
Continuous passive motion is regularly used in rehabili- bed rest is advised. Mobilizations should be continued.94,107
tation after ACI (Table 1); however, to date, there are no Cryotherapy goals during acute care are to lower tissue
published investigations showing the effects of CPM on temperature, slow metabolism, decrease secondary hypoxic
graft healing or ROM after ACI. Studies advocate the use injury, reduce edema formation, facilitate exercise, and
of CPM for 6 to 8 h/d to optimize cartilage repair.16,63,100,136 speed time to recovery.71 Cryotherapy facilitates pain reduc-
The ROM in which CPM is performed is dependent upon tion by slowing nerve conduction velocity and reducing
the size and location of the transplanted area, as it is edema formation.72 Immediately after knee surgery, there is
important to avoid high shear forces that could be detri- an increase in intra-articular temperature.92 However, the
mental to the graft. temperatures reported postoperatively do not seem to affect
chondrocyte viability.158 Postoperative ice application has
been shown to decrease intra-articular temperature152 and
ORTHOSES has also demonstrated significantly decreased pain scores
and the number of times analgesia is administered.109
Guidelines for ACI rehabilitation frequently mention the The rationale for extended postoperative cryotherapy is
use of orthoses (Table 1), which are used to prevent exces- more questionable. Cooling increases knee joint stiffness
sive compressive forces over the ACI graft and to facilitate and reduces knee joint position sensitivity.145 These findings
function in the first stages of rehabilitation: are important in ACI rehabilitation programs that involve
exercise immediately after a period of cooling. A combina-
• Postoperative braces can be used to prevent tion of excessive ice applications and progressive CPM can
movement ranges. In so doing, they assure that increase joint stress and could lead to stress-induced
weightbearing is performed in a nonarticulating ROM. hemarthrosis. Because of decreased pain perception, a fur-
• Functional unloader braces partially unload a ther disturbance of homeostasis during “forced” passive
specific joint compartment. In addition, some are mobilization is also possible.147 In the later phases of ACI
able to follow the physiological movement of the rehabilitation, cryotherapy may have a positive effect in
joint via a specific polyaxial rotation unit.93 speeding up the return to participation in sporting activi-
ties60; however, the relatively poor quality of studies is an
The recommendation for bracing after a patellar or objective concern.
trochlear repair is generally a postoperative brace (Table 1). Compression is effective in preventing extra-articular
In this way, safe ranges of motion can be closely guarded. swelling.71 Compression should be applied continuously
The maximum length of time that is recommended for brac- and evenly with an elastic wrap.
ing patellofemoral repairs is 6 weeks (Table 1). Elevation should be standard practice in postoperative
In terms of bracing for tibiofemoral repairs, there are ACI management. Elevation improves venous drainage and
2 schools of thought. The first advises initial postoperative hence facilitates the reduction of edema and swelling.147 The
bracing for a minimum of 3 weeks, after which an unload- correct level of elevation is for the limb to be above the heart.
ing brace can be considered for large uncontained lesions Stabilizing the joint allows the local musculature to
or concomitant osteotomy correction. The second school of relax and prevents further injury while allowing wound
thought advises the use of a functional unloading brace healing, return of homeostasis, and scar formation.147
right from the outset. Driesang and Hunziker35 showed
high delamination rates of tissue flaps used in articular
repair; the functional unloading brace is advocated to pre-
vent early loss of these flaps.35,67 The maximum length of PROPRIOCEPTION AND NEUROMUSCULAR
time that is recommended for bracing tibiofemoral repairs FUNCTION
is 8 weeks (Table 1).
Neuromuscular re-education and retraining are critical
components in the restoration of functional joint stability,
ACI AND PRICES yet they are often undervalued within the rehabilitation
program. Neuromuscular function broadly involves the
The combination treatment of protection, rest, icing detection of afferent input via mechanoreceptors: the pro-
(cryotherapy), compression, elevation, and stabilizing is cessing of a response to the stimulus in the central nervous
commonly known as the PRICES protocol.68 The PRICES system and the initiation of an efferent reaction to main-
protocol has a key role to play in immediate ACI postoper- tain balance, stability, and mobility.77 Rehabilitation can
ative care. assist in the restoration of proprioception, but high-level
Protection of the operated joint is necessary to prevent studies are scarce.57,75,78
graft failure. Protection can be accomplished by patient Proprioceptive deficits in the knee have been observed
instruction, close guidance the first days postoperatively, in conjunction with a number of common injuries and sur-
and several rehabilitation modalities.68 gical interventions, including osteoarthritis (OA),12,61,135
patellofemoral pain syndrome (PFPS),9 before and after

ACL reconstruction,10,45,46 and total knee arthroplasty.7,47
Interestingly, it would seem that proprioceptive loss after
injury, surgery, or joint degeneration is not localized to the
affected joint. Studies looking at proprioception between
operated and nonoperated legs,47,125 OA and non-OA
knees,135 and ACL-injured and non–ACL injured knees119
have found reduced proprioception in the contralateral
unaffected limb as well as the expected reduction in the
affected limb.
Currently, there are no published studies that have
researched preoperative and postoperative proprioception
and neuromuscular control in patients with local articular
cartilage damage of the knee. However, the mere fact that a
surgical intervention has taken place will mean that there
will be some degree of proprioceptive loss postoperatively.61,81
It is also likely that open procedures result in a greater degree
of proprioceptive loss than do arthroscopic procedures
because of an increased level of disruption to joint mechanore-
ceptors.45,56 The effects of the size and location of an articular
cartilage lesion on proprioception are not known. Moreover,
the influence of symptom duration on a patient’s preoperative
level of proprioception as well as the postoperative time
needed and potential for full restoration are in question.
It is important for the ACI rehabilitation program to
address proprioceptive and quadriceps activation deficits
in a dynamic, functional manner. Quality of neuromuscu-
lar control should be a main feature throughout the reha-
bilitation program. Three windows of opportunity exist for
the ACI patient to address proprioceptive losses, and these
present in the preoperative stage, between the arthro-
scopic biopsy and the ACI surgery, and after surgery.
Neuromuscular rehabilitation needs to be adequately
addressed in each of these stages. Current ACI rehabilitation
guidelines generally do not cover neuromuscular rehabilita-
tion sufficiently, or they even exclude this important area
of rehabilitation altogether.
The focus of neuromuscular-control rehabilitation is the Figure 2. Example of bipodal proprioception exercise using
retraining of coordination patterns via feedback and feed- an inflatable disc.
forward control systems in a functional, dynamic, and pro-
gressive manner. This process involves varying movement
speed from slow movements that target the feedback
system in the early stages of rehabilitation through pro-
gressions to fast movements that focus more on retraining • slow to fast movements;
the feed-forward system in the later stages of rehabilita- • introduction of unstable base (eg, mats,
tion. The exercises should be performed throughout the unidirectional/multidirectional wobble boards,
full available ROM and should ideally be performed on trampet, and gym balls) (Figure 2);
both the affected and the nonaffected limbs because of • introduction of resistance and/or center of gravity
the likely decreases in proprioception in the contralateral shift (eg, from light to heavy elastic resistance band);
limb.47,119,125,135 • introduction of distractions (eg, throwing, catching,
Specific exercises for neuromuscular rehabilitation reaching, turning); and
after ACI should be addressed on an individual basis in • introduction of sport- and occupation-specific drills.
line with any weightbearing or ROM restrictions that may
be in place. Generally, proprioceptive challenges tend to be In addition, it is essential that more functional, dynamic
introduced through balance training and progressed in the tests are incorporated into the rehabilitation program.
following ways: These tests involve working with the patient on the qual-
ity of his or her neuromuscular control in activities such as
• 2-legged to 1-legged stance; descending stairs, gait, rising from chairs, and in the later
• eyes open to shut; stages, running, hopping, and jumping.
HYDROTHERAPY of the joint receptor feedback disruption that is an inevitable

consequence of surgical intervention. The proposed thera-
Exercises in water allow early active mobilization and early peutic benefits of electrotherapy include pain reduction,
loading and improve neuromuscular performance, espe- increased ROM, reduced edema, enhanced voluntary muscle
cially during the initial phase of a rehabilitation pro- recruitment, and the promotion of cartilage healing.
gram.118 The reduction in gravity under water decreases However, research remains limited and is often restricted
the detrimental effects of weightbearing and the impact to animal studies, and to date, the effect of electrotherapy
forces on joint structures during movement,117,118 enabling on chondrocytes and their maturation in vivo is largely
ROM exercises to be performed in a functional position unknown.
with a reduced risk of high shear forces under compression.
Factors such as water depth and flow will also influence the
Therapeutic Ultrasound and Laser
loading demands on the knee joint, so it is important to
base the rehabilitation program on the general principles of Low-intensity pulsed therapeutic ultrasound (TUS)30,36
hydrotherapy. and low-level laser therapy86,127,133 have been proposed as
Exercises under water produce lower EMG activity dur- providing appropriate stimuli for the acceleration of chon-
ing isometric and dynamic conditions when compared to drogenesis. However, it has yet to be demonstrated that
similar exercises on dry land,118 and therefore, joint forces these therapies can stimulate articular cartilage regenera-
are lower. For this reason, hydrotherapy in ACI rehabilitation in vivo.
tion, including strengthening, proprioception training, and
functional activities, is beneficial. Investigations show that
an early and intensive application of hydrotherapy for
Interferential Therapy
improving coordination and strength during rehabilitation Interferential therapy (IFT) has been shown to have sig-
is advisable.44 In addition, moving in water endows the nificant effects in reducing postoperative pain, increasing
patient with a “feeling of freedom,” as they can walk with- ROM, and reducing edema after knee surgery.65 However,
out crutches and move around without restriction. This is there are issues regarding functionality, efficiency of ther-
an important psychological advantage. apy time, and clinician dependence.
MANUAL THERAPY AFTER ACI Transcutaneous Electrical Nerve Stimulation

Two conceptual approaches to manual therapy need to be The effectiveness of transcutaneous electrical nerve stimu-
mentioned within ACI rehabilitation: the clinical investiga- lation (TENS) as a pain-relieving modality has been stud-
tion and the application of manual techniques to re-establish ied in a range of populations with variable outcomes. On
physiological regulation. The ability to define passive move- one hand, several studies have found TENS to be effective
ment disorders in a joint, the localization of swelling, the in decreasing pain after knee surgery,6,66 but other studies
involvement of anatomic structures, temperature, and so have found no significant benefit in pain reduction.20 A
on, are not only necessary for good clinical practice but review of the role of TENS concluded that it had no place
also for a comprehensive tailoring of the rehabilitation.147 in the treatment of acute postoperative pain, as it was not
Manual therapy as an independent application of manual an effective analgesic.97
techniques for general knee disorders is questionable. Arthrogenic muscle inhibition (AMI), and specifically
However, the combination of manual therapy with exercises quadriceps inhibition after knee surgery, has been well docu-
and specific manual techniques for the enhancement of mented.143,156 Recovery of voluntary control of quadriceps
ROM prove to be more effective than exercises alone.33,106 function is an important aspect of ACI rehabilitation and
Manual therapy is often cited as being used to facilitate the should be addressed as early as possible after surgery with
restoration of local function, and ACI rehabilitation proto- isometric quadriceps setting exercises. Transcutaneous elec-
cols often mention gentle manual mobilization techniques trical nerve stimulation has been proposed as a treatment
to prevent parapatellar soft tissue formation (Table 1). Few modality for AMI on the basis that it competes with the type
references are made in the protocols to specific techniques 1 afferent nerve fibers that carry the mechanoreceptor feed-
to facilitate accessory movements, as in the use of passive back. One study has shown a small increase in voluntary
anterior glides to the tibia8 or lateral rotation of the tibia quadriceps activations after TENS in knee surgery patients,6
where there is a limit to TFJ extension, although they prove but a more recent study found that TENS failed to disinhibit
to be effective in facilitating immediate muscle control.31,61 vastus medialis and decrease AMI after knee joint effusion.59
ELECTROTHERAPEUTIC MODALITIES Neuromuscular Electrical Stimulation

AND EMG BIOFEEDBACK
An alternative strategy to address AMI utilizes the produc-
The role of electrotherapeutic modalities in postoperative tion of involuntary muscle contractions by neuromuscular
ACI rehabilitation is controversial. In the first few weeks electrical stimulation (NMES) (Figure 3). Neuromuscular
after ACI, rehabilitative exercises are often difficult to per- electrical stimulation has been found to be effective in
form, not only because of edema and pain but also as a result reducing quadriceps extensor lag49 and in strengthening
TABLE 3
Overview of the Key Biomechanical Features
of Cycling and Rowing Exercise Modalities
Cycling Ergometer Rowing Ergometer
Nonweightbearing/low impact Nonweightbearing/low impact

Sagittal plane Sagittal plane
Closed kinetic chain exercise Closed kinetic chain exercise
Unilateral leg action Bilateral leg action
Mean range of knee Mean range of knee flexion
flexion 30°-110° in 1 0°-130° in 1 rowing stroke
pedal revolution
Minimum 100° of knee No minimum degree of
flexion required knee flexion required
Maximum knee flexion Maximum knee flexion
controlled by saddle height controlled by length of slide
Figure 3. The use of neuromuscular stimulation to produce
High repetitions per minute Low repetitions per minute
isometric involuntary muscle contraction. (60-90 rpm) (16-30 spm)
the quadriceps after knee arthroplasty140 and ACL recon- knee flexion angle at which the peak load is exhibited is
struction.43 However, it is important to note that voluntary therefore required for each proposed exercise modality.
muscle strengthening has been found to be just as effective Exercise modalities should complement but not replace
as NMES.80,111 We therefore suggest that NMES is a useful functional movement retraining (eg, stairs).
adjunct to the primary exercise program in ACI rehabilita-
tion and acknowledge that there may be an increased role Cycling
for NMES in those patients who are poorly motivated, have
long-term muscle weakness, and/or are slow responders. In comparison with other activities of daily living such as
walking or stair climbing, the maximum load-moments on
EMG Biofeedback the knee joint in cycling are small.37 An overview of the per-
tinent biomechanical features of cycling is presented in
Electromyographic biofeedback has been used as a tool to Table 3. Increases in the cycling workload result in a signifi-
re-educate patients in voluntary quadriceps contraction cant increase in knee load-moments and compressive and
through the provision of feedback about the quality of their shear forces, but increases in the pedaling rate do not
muscle contraction. Results have shown that EMG biofeed- appear to affect the maximum knee load-moment.37 It is
back used with muscle strengthening enhances quadriceps therefore possible to introduce stationary cycling at an early
recruitment after arthroscopy,79 arthroplasty,141 and ACL stage as long as resistance is minimal and there is sufficient
reconstruction.34 ROM to allow a complete pedal revolution (Table 3).
Along with the correct selection of resistance, another
important factor in cycling that needs to be considered is
EXERCISE MODALITIES saddle height because of its direct influence on knee flex-
ion angles, as shown in Figure 4.37 If the saddle height is
There is currently no ACI-specific evidence base to directly too low, increased PFJRFs occur,38 especially if combined
support the frequency, intensity, type, and timing of exer- with too high a gearing; TFJ load-moments decrease with
cise modalities during rehabilitation. Recent studies have increasing saddle height.39 Too high a saddle height, often
advocated the avoidance of certain ranges of knee move- as a consequence of insufficient available range of knee
ment, for example, active knee flexion between 40° and flexion, results in frontal plane rocking from the pelvis and
70° in the early stages after patellofemoral ACI.24 However, hip, which is unfavorable for rehabilitation in terms of con-
virtually all exercise modalities, including common activi- trol and muscle activation patterns. High saddle heights
ties such as walking, cycling, and rowing, involve a knee are a predisposing factor for an increased risk of develop-
flexion/extension pattern within this range. ing iliotibial band friction syndrome (ITBFS), especially if
The incorporation of exercise modalities into ACI reha- knee ROM is not full.42 An increase in saddle height for a
bilitation programs may be better considered in terms of short postoperative period is unlikely to significantly pre-
minimizing joint stress as opposed to the complete avoid- dispose a patient to ITBFS because the condition is pre-
ance of specific ranges of movement. This result can be dominantly due to overuse. However, if the saddle height is
achieved through the selection, introduction, and progres- increased to initially accommodate restrictions in knee
sion of exercise modalities that are appropriate for the graft ROM, then it is important to normalize the saddle height
age, size, and location. An understanding of the variations in parallel with the restoration of knee ROM to reduce the
in the magnitude and direction of loads at the knee and the future risk of problems such as ITBFS.
A B
Figure 4. Stationary cycling showing range of knee flexion from bottom dead center (A) to top dead center (B) at correct saddle-height
positioning.
Analysis of the effect that changing the direction of in which the hip can apply a greater extensor moment than
pedaling has on knee joint biomechanics has shown that the knee in the power phase of the pedal revolution at low
reverse pedaling requires quadriceps muscle activity in workloads.50 Proportionally, the amount of work done by
ranges of greater knee flexion compared with forward pedal- knee flexion is significantly higher in recumbent cycling
ing22 and that the vastus medialis is more active in reverse compared with upright cycling.122 Reiser et al121 found no
pedaling.22 Tibiofemoral compressive loads have been shown changes in the tension/compression forces at the knee but did
to be lower in reverse pedaling, especially near peak exten- find that posterior shear forces were significantly reduced in
sion of the knee.105 However, PFJRFs have been found to be recumbent cycling. These findings indicate that recumbent
significantly higher in reverse pedaling compared with for- cycling is a useful exercise modality in ACI rehabilitation
ward pedaling.21,105 On the basis of this evidence, reverse and that there may be advantages in using recumbent
pedaling may be considered for TFJ rehabilitation to reduce cycling as a progression or alternative to upright cycling.
loading on the knee but should not be advocated for PFJ reha-
bilitation because of the increases in loading on the knee joint. Rowing Ergometer
Recumbent Cycling Similarities exist between cycling and rowing (Table 3) that
support the inclusion of rowing as an exercise modality for
Recumbent cycling is an increasingly common activity in lower limb rehabilitation. However, there are differences
gymnasiums and fitness centers. Overall, general muscle between the 2 exercise modalities that have implications for
moments are similar between upright and recumbent ACI rehabilitation program design. In cycling, knee flexion
cycling, but importantly, the magnitudes of the general mus- has to be 100° before a full pedal revolution can be achieved;
cle moments at low workloads are lower during recumbent in contrast, there is no such biomechanical constraint in
cycling.50 This condition is due to the body being in a position rowing. Rowing has a number of distinct advantages over
A C
Figure 5. Ergometer rowing without using a handle at (A) the

B start of drive, (B) mid-drive, and (C) the end of drive.
Whole-body vibration, in which the patient undergoes

a sensory bombardment, has recently become a popular
training modality for gaining strength.126 However, the
lack of research concerning cartilage tissue repair, the
overload in a sustained exercise position, and the exact
effect of different training parameters are all reasons for
not implementing whole-body vibration in the early stages
of rehabilitation after ACI at this time.
RETURN TO SPORT AFTER ACI
Rehabilitation after ACI is widely recognized as being lengthy,

with maximum improvement in knee symptoms taking as
cycling: active flexion and extension in the ACI limb can be long as 3 years after surgery.69 This is a pertinent factor to
assisted by the non-ACI limb, there is greater proximal sta- consider because of the level of impact that the duration of the
bilization, and loads are applied bilaterally. The relatively rehabilitation has on the time out of sport. Only 1 multicenter
slower movement speed of the rowing action facilitates study to date has researched return to sport after ACI.101,102
improved neuromuscular control for early-stage rehabili- Mithöfer et al101,102 studied the ability of 45 soccer players
tation, but the higher movement speed of cycling is likely to return to soccer in a 40-month (±4 months) follow-up
to be more of an advantage in later-stage rehabilitation. period after ACI. They found that despite 72% of players
Anecdotally, rowing tends to be introduced at a later stage reporting good to excellent knee function, only 33% were able
in ACI rehabilitation than is cycling (Table 1), but it is often to return to soccer.101,102 What is unclear is whether the two
introduced as a full-range, unrestricted activity.8,124 With thirds of players who did not return to soccer were clinically
adequate attention to the minimization of joint stress via unable to return to play or whether they either chose to
stroke rate and pace guidance, “no handle” ergometer row- switch to a lower-impact activity or opted not to return to
ing could be introduced earlier than stationary cycling and sport at all. The definition of “ability to return to sport” and
could feasibly be utilized as an “active” progression after the relevance of current outcome measures to sporting par-
CPM (Figure 5). ticipation require further exploration and clarification.
Younger age and shorter preoperative duration of symptoms
Other Exercise Modalities were also shown to significantly improve the ability to return
to soccer.101,102 However, this improved potential to return to
Other low-impact exercise modalities commonly available soccer could well be due to a greater influence of psychosocial
in fitness centers include elliptical trainers, cross-trainers, factors and changing life priorities rather than to physiolog-
ski trainers, and stair climbers. These modalities have the ical properties such as healing and chondrocyte maturation.
advantage of being CKC activities; however, clinical biome- Bowen et al,16 in their article on return to play after chon-
chanical data are limited, and the implications for loading on dral injuries to the knee, highlighted the fact that the suc-
the knee joint are not fully understood. A major consider- cess of rehabilitation is multifactorial and recognized that
ation is the potential lack of synchronization between the psychosocial factors such as patient motivation were impor-
hip and knee joints that could increase the transfer of forces tant contributors. Drawing heavily on self-determination
to the knee and subsequently increase the stress that is theory, it is proposed that the type of motivation for return-
placed upon the knee joint. ing to sport (internal vs external) is an important factor,
not only in determining whether the athlete does return TABLE 4

but also in the outcome of the return.115 Recent studies that Postoperative Timelines for ACI Rehabilitation Based on
have considered re-entry into sport after career-threatening Biology of Healing and Corresponding Therapy Goals,
injuries have shown that reinjury concerns are significantly Modalities, and Criteria for Progressiona
implicated in the prevention of an athlete returning to
sport73,115 (N. Walker, unpublished data, 2005). Emotional PHASE I: RECOVERY AND PROTECTION (WEEKS 0-4)
response to athletic injury should be considered in connec- Biology: cell attachment, inflammation, and proliferation
tion with return-to-sport goals for ACI patients, both preop-
eratively and postoperatively. Therapy goals
• Protect healing tissue from load and shear forces and allow
After total knee replacement, advice to patients that high-
cell adherence
impact activity may jeopardize their surgery outcomes can • Restore joint homeostasis (for relative rest situation)
result in changes in postoperative activity.17 Consideration • Prevent adhesions
of the impact that advice from the surgeon, therapists, other • Restore full passive knee extension
patients, significant others, and general information sources • Gradually increase pain-free knee flexion
may have on postoperative activities is an important factor • Ensure safe transfers at home and for transportation
that is underrecognized and poorly evaluated. • Regain quadriceps control
With the uncertainties that surround ACI rehabilitation Modalities
at present, the general consensus of opinion among cartilage • Education/coaching
repair centers appears to be that ACI surgery should be tar- • Cryotherapy, elevation, and compression
geted on the reduction of symptoms and on improving func- • Continuous passive motion
tional daily activities rather than as a method of returning to • Active ROM exercises (joint circulation exercises: ankle
high-level sports participation for competitive athletes with pumps, heel slides, hip extension and abduction)
chondral damage. General recommendations are that low- • Weightbearing control with crutches for ADL
impact sports and exercise such as swimming, cycling, and • Bracing (postoperative or functional unloading)
golf can usually be resumed within 6 months.8,15,120,124,138,149 as indicated
• Quadriceps setting
Recommendations for timescales for a return to higher-
• Patellar mobilization
impact activities such as racquet sports, team sports, martial • Biofeedback and electrical muscle stimulation as indicated
arts, and running range from an earliest postoperative
return at 12 months up to 18 months.# However, there is con- Criteria for progression to next phase
siderable variation between people, so return to sports after • Minimal pain and swelling, able to perform daily joint
ACI should be based on the key criteria that circulation exercises
• Surgical incisions healed
• Full passive knee extension and voluntary quadriceps
• the patient’s graft is able to withstand the specific activity
demands of their chosen sport, and • Active, pain-free knee flexion of 90°
• the patient has been rehabilitated to a point at which • Earliest time for progression to next phase: 4 weeks
they are able to safely return to sports involvement. postoperatively
Where a return to sport is planned, it is important that PHASE II: INAUGURATION (WEEKS 4-8)
sport-specific activities are included as functional progres-
sions within the rehabilitation program. Biology: cell differentiation and start of maturation phase
Therapy goals
• Restore joint homeostasis (for daily joint circulation
ACI REHABILITATION PROGRAMMING exercises)
• Increase pain-free ROM (local stretching of the joint
Rehabilitation after ACI is a process and, as such, the staging capsule is acceptable)
and progression of individual rehabilitation elements need to • Maintain full extension
be considered with respect to the primary goals of local adap- • Ensure safe transfers at home and for transportation
tation and remodeling of the repair and of return to function. • Gradually increase weightbearing for protection of repair
A generic ACI postoperative rehabilitation program based • Gain quadriceps control in safe, multiangle CKC exercises
on the current understanding of the biology of graft healing
Modalities
and on the corresponding therapy goals, modalities, and cri-
• Education/coaching
teria for progression has been proposed by us and is shown in • Active ROM exercises (joint circulation exercises: heel
Table 4. Time frames have been indicated, but we do not rec- slides, stationary rowing [no resistance], or bicycle
ommend the adoption of a rigid timetable, as the proposed [minimal resistance])
phases are not mutually exclusive, and considerable variation • Balance for control of weightbearing for ADL (with brace if
exists between people. Modifications to the rehabilitation indicated)
program may be necessary based on defect size, location, age, • Continued bracing (postoperative or functional unloading)
previous activity level, concomitant surgical procedures, and as indicated
• Quadriceps isometric multiangle control and coordination
• Quadriceps setting
#
References 8, 15, 29, 99, 120, 138, 149. (Continued)
TABLE 4
• Increase lower-limb strength through FROM in CKC
(Continued)
• Gradually increase training load and volume
• Maintain joint circulation exercises (3 or more times/wk)
• Gluteus maximus, medius, and minimus retraining
• Patellar and soft tissue mobilization Modalities
• Biofeedback and electrical muscle stimulation as indicated • Education/coaching
• Hydrotherapy for gait coordination and joint circulation • Active ROM exercises with light resistance in safe ranges
exercises • Balance exercises in challenging postures (balance,
trampoline, flip boards, sport- and occupation-specific)
Criteria for progression to next phase
• Feed-forward and feedback exercises for coordination
• Minimal pain and swelling and voluntary quadriceps activity
in multidirectional open tasks
• Full passive knee extension
• Hydrotherapy for gait coordination and endurance
• Active, pain-free knee flexion of >110°
• Strength training (light resistance over repaired zone
• Ability to perform daily joint circulation exercises
and full resistance over other areas)
for at least 30 minutes within homeostasis
• Earliest time for progression to next phase: 6 weeks Criteria for progression to next phase
postoperatively • No pain or swelling after intense low-impact exercises
• Full, pain-free ROM
PHASE III: MATURATION (WEEKS 8-12) • Able to perform daily joint circulation exercises for at least
60 minutes within homeostasis
Biology: cell differentiation and maturation • Earliest time for progression to next phase: 12 weeks
Therapy goals postoperatively
• Restore joint homeostasis (for light functional exercises)
• Gain full, active, pain-free ROM (local stretch of the joint PHASE V: FUNCTIONAL ADAPTATION (WEEKS 26-52+)
capsule is acceptable)
Biology: maturation and integration
• Ensure safe transfers at home and for transportation
• Gradually increase weightbearing for protection of repair Therapy goals
• Increase quadriceps strength in safe, multiangle • Restore joint homeostasis (for impact exercises longer than
CKC exercises 30 minutes)
• Regain quadriceps control in FROM CKC exercises • Ensure safe dynamic postures
• Gradually increase ADL • Aim for unrestricted ADL
• Regain optimal coordination for walking, stair • Gradually increase lower-limb strength in range of repair
climbing/descending, and transfers (OKC and CKC)
• Maintain training intensity, load, and volume
Modalities
• Maintain joint-circulation exercises (daily)
• Education/coaching
• Prevent future damage/injury
• Active ROM exercises (no resistance over repaired zone and
• Continually improve comfort and confidence in knee
light resistance in safe ranges)
• FWB control in exercise conditions (balance, mat, Modalities
sport- and occupation-specific) • Education/coaching
• Weaning off bracing and/or crutches • Active ROM exercises: light resistance, full range
• Feed-forward exercises for coordination • Balance exercises in challenging, coordinative tasks
in multidirectional tasks (balance, trampoline, flip boards)
• Quadriceps settings • Hydrotherapy for general endurance
• Gluteus maximus, medius, and minimus retraining • Sport-specific agility training (unidirectional, noncontact)
and strengthening • Strength training (full resistance over repaired zone)
• Patellar and soft tissue mobilization
• Biofeedback and electrical muscle stimulation as indicated Criteria for progression to next phase
• Hydrotherapy for gait coordination and endurance • No pain or swelling after impact exercises longer than
30 minutes
Criteria for progression to next phase • Full, pain-free ROM
• Minimal pain and swelling • Graft is able to withstand the specific demands of the
• Full passive knee extension and voluntary quadriceps activity activity, as assessed by sport-specific functional testing
• Active, pain-free knee flexion of >110° • Patient is motivated to return to sport
• Able to walk 1-2 miles or stationary bicycle/rowing • Earliest time for progression to next phase: 26 weeks
(light resistance) for 30 minutes within homeostasis postoperatively
• Earliest time for progression to next phase: 10 weeks
postoperatively PHASE VI: RETURN TO SPORTS (WEEKS 26-78+)
PHASE IV: INTEGRATION (WEEKS 12-26)
Therapy goals
• Restore joint homeostasis (for specific sports activities)
Therapy goals • Maintain safe dynamic postures
• Restore joint homeostasis (for intense low-impact exercises) • Aim for unrestricted sport (at same or lower level)
• Ensure safe static postures • Restore symmetry, including lower-limb strength and flexibility
(Continued) (Continued)
TABLE 4 “accelerate” ACI rehabilitation programs to reflect these

(Continued) developments in orthopaedic tissue engineering. However, to
optimize ACI rehabilitation for the benefit of future patients,
• Increase training intensity, load, and volume there is an urgent need for further studies to form the foun-
• Prevent further damage/injury dations of the evidence base for ACI rehabilitation.
• Restore confidence in knee
Until the time an evidence base is available, clinicians
• Restore competition fitness
involved in ACI rehabilitation will have to continue depend-
Modalities ing on knowing precise surgical details (defect location and
• Education/coaching size and concomitant procedures) and to have an understand-
• Active ROM exercises: unrestricted resistance, full range
ing of chondrocyte maturation, clinical biomechanics, and the
• Sport-specific agility training (multidirectional, contact)
principles of exercise programming and functional progres-
• Balance exercises in challenging, sport-specific
coordinative tasks sions. Such knowledge requires the adoption of a coordinated
• Hydrotherapy for cardiovascular fitness approach between basic scientists, surgeons, and therapists.
• Pre-sports conditioning (circuits)
• Functional strength training
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Autologous Chondrocyte Implantation Postoperative Care and Rehabilitation

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Clinical Sports Medicine Update

Autologous Chondrocyte Implantation

Minimum/Earliest Maximum/Latest Minimum/Earliest Maximum/Latest

Time to full 6 h postoperatively 12 wk 7 wk 12 wk

Articulation Contact Area

10°-20° Initial contact occurs between inferior

as active knee extension involves quadriceps contraction

CONTINUOUS PASSIVE MOTION

Continuous passive motion (CPM) is commonly used in

patellofemoral pain syndrome (PFPS),9 before and after

HYDROTHERAPY of the joint receptor feedback disruption that is an inevitable

MANUAL THERAPY AFTER ACI Transcutaneous Electrical Nerve Stimulation

ELECTROTHERAPEUTIC MODALITIES Neuromuscular Electrical Stimulation

Cycling Ergometer Rowing Ergometer

Nonweightbearing/low impact Nonweightbearing/low impact

Figure 5. Ergometer rowing without using a handle at (A) the

Whole-body vibration, in which the patient undergoes

RETURN TO SPORT AFTER ACI

Rehabilitation after ACI is widely recognized as being lengthy,

not only in determining whether the athlete does return TABLE 4

TABLE 4 “accelerate” ACI rehabilitation programs to reflect these

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