Rehabilitation of Meniscus Repair and Transplantation Procedures

Chapter 30 Rehabilitation of Meniscus Repair and Transplantation Procedures

Timothy P. Heckmann, PT, ATC, Frank R. Noyes, MD, Sue D. Barber-Westin, BS

CLINICAL CONCEPTS 806

IMMEDIATE POSTOPERATIVE MANAGEMENT 807

BRACE AND CRUTCH SUPPORT 808

RANGE OF KNEE MOTION AND FLEXIBILITY 809

BALANCE AND PROPRIOCEPTIVE TRAINING 810

STRENGTHENING 811

CONDITIONING 814

RUNNING PROGRAM 816

PLYOMETRIC TRAINING 816

RETURN TO SPORTS ACTIVITIES 817

CLINICAL CONCEPTS

The postoperative program for meniscus repair and transplantation is shown in Table 30-1. The initial goal is to prevent excessive weight-bearing, because high compressive and shear forces can disrupt healing meniscus repair sites (especially radial repairs) and transplants. Variations are built into the protocol according to the type, location, and size of the meniscus repair and whether concomitant procedures (such as ligament reconstructions) are performed. The surgeon has the responsibility to inform the physical therapy team of details regarding the type of tear and the repair that was performed. Meniscus repairs with all-inside fixators have inferior holding strength, and commonly, only a few sutures are used. These repairs require more protection to allow for healing during the first 6 postoperative weeks. Inside-out meniscus repair techniques involve multiple vertical divergent sutures (see Chapter 28, Meniscus Tears: Diagnosis, Operative Techniques, and Clinical Outcomes) and have superior holding strength.

TABLE 30-1 Rehabilitation Protocol Summary for Meniscus Repairs and Transplants

Clinicians should be aware that meniscus repairs located in the periphery (outer third region) heal rapidly, whereas complex repairs that extend into the central third region tend to heal more slowly and require greater caution. In addition, modifications to the postoperative exercise program may be required if noteworthy articular cartilage deterioration is found during the arthroscopic procedure. This rehabilitation program has been used at the authors’ institution in hundreds of meniscus transplant and repair recipients, and the results of clinical investigations^3-5,⁷ demonstrate its safety and effectiveness in restoring normal knee motion, muscle, and gait characteristics.

Patients receive instructions before surgery regarding the postoperative protocol so they have a thorough understanding of what is expected after surgery. Patients are warned that an early return to strenuous activities including impact loading, jogging, deep knee flexion, or pivoting carries a definite risk of a repeat meniscus tear or tear to the transplant. This is particularly true in the first 4 to 6 months postoperatively.

The supervised rehabilitation program is supplemented with home exercises that are performed daily. The therapist routinely examines the patient in the clinic in order to implement and progress the appropriate protocol. Therapeutic procedures and modalities are used as required for successful rehabilitation. On average, patients require 11 to 16 physical therapy visits over 9 to 12 months to produce a desirable result.

Lateral and anteroposterior plain radiographs are obtained 1 week postoperatively to verify the position of the osseous component of meniscus transplants and at 6 to 8 weeks to verify healing and retention of the bony portion of the transplant within the slot or tunnels. Any onset of tibiofemoral joint line clicking or pain may indicate failure of the meniscus repair or transplant and should be noted immediately for consideration of refixation.

IMMEDIATE POSTOPERATIVE MANAGEMENT

Important early postoperative signs for the therapist to monitor include effusion, pain, gait, knee flexion and extension, patellar mobility, strength and control of the lower extremity, lower extremity flexibility, and tibiofemoral symptoms indicative of a meniscal tear (Table 30-2).

TABLE 30-2 Postoperative Signs and Symptoms Requiring Prompt Treatment

Postoperative Sign and/or Symptom	Treatment Recommendations
Continued pain in the medial or lateral tibiofemoral compartment of the meniscus repair or transplant	Physician examination, assess need for refixation or re-repair
Tibiofemoral compartment clicking, or a subjective sensation by the patient of “something being loose” within the tibiofemoral joint	Physician examination, assess need for refixation or re-repair
Failure to meet knee extension and flexion goals (see text)	Overpressure program, early gentle manipulation under anesthesia if 0°–135° not met by 6 wk postoperatively
Decreased patellar mobility (indicative of early arthrofibrosis)	Aggressive knee flexion, extension overpressure program, or gentle manipulation under anesthesia to regain full ROM and normal patellar mobility
Decrease in voluntary quadriceps contraction and muscle tone, advancing muscle atrophy	Aggressive quadriceps muscle strengthening program, EMS
Persistent joint effusion, joint inflammation	Aspiration, rule out infection, close physician observation

EMS, electrical muscle stimulation; ROM, range of knee motion.

From Heckmann, T.; Barber-Westin, S. D.; Noyes, F. R.: Meniscal repair and transplantation: Indications, techniques, rehabilitation, and clinical outcome. J Orthop Sports Phys Ther 36:795–814, 2006.

Patients present to physical therapy on the 1st day after surgery on bilateral axillary crutches in a postoperative dressing with a long-leg brace locked in full extension. The postoperative bandage and dressing are changed to allow the application of thigh-high compression stockings and a compression bandage. Early control of postoperative effusion is essential for pain management and early quadriceps reeducation. In addition to compression, cryotherapy is critical in this time period. Patients receive a commercial cooling unit, which is used six to eight times daily at home. In the clinic, the use of various cryotherapy machines provide compression simultaneously with the cold program (Fig. 30-1).

FIGURE 30-1 A clinical cryotherapy machine that provides compression with the cold program (Game Ready, Berkeley, CA) is used in the initial postoperative period.

Patients are instructed to maintain lower limb elevation as frequently as possible during the 1st week. A portable neuromuscular electric stimulator may be helpful for quadriceps reeducation and pain management (Fig. 30-2). These devices are used six times per day, 15 minutes per session, until the patient displays an excellent voluntary quadriceps contraction.

FIGURE 30-2 A portable neuromuscular electric stimulator (EMPI, St. Paul, MN) is effective for quadriceps reeducation and pain management in the early postoperative phase.

The patient’s initial response to surgery and progression during the first 2 weeks sets the tone for the initial phases of the rehabilitation program. Common postoperative complications include excessive pain or swelling, quadriceps shutdown or loss of voluntary isometric contraction, range of motion (ROM) limitations, and saphenous nerve irritations for medial repairs. It is important to monitor patient complaints of posteromedial or infrapatellar burning, posteromedial tenderness along the distal pes anserine tendons, tenderness of Hunter’s canal along the medial thigh, hypersensitivity to light pressure, or hypersensitivity to temperature change. These abnormal symptoms or signs occur in early cases of complex regional pain syndrome (see Chapter 43, Diagnosis and Treatment of Complex Regional Pain Syndrome) and require immediate treatment.

BRACE AND CRUTCH SUPPORT

A long-leg postoperative brace is placed immediately after surgery following complex meniscus repairs or transplants. The brace is opened from 0° to 90°, but it is locked at 0° extension at night for the first 2 weeks. Thereafter, the brace is not routinely locked except in patients who cannot maintain 0° of extension. In these cases, the brace is locked at 0° extension as required during the day and night. The brace is used for 6 weeks. A brace is not routinely used after repair of a peripheral meniscus tear unless an all-inside fixator with only a few sutures is used for added protection.

Crutches with partial weight-bearing are recommended for the first 4 weeks in all cases. Weight-bearing is gradually progressed as shown in Table 30-1, and patients are encouraged to use a normal gait that avoids a locked knee and assumes normal flexion throughout the gait cycle. Patients who had a repair of a radial meniscus tear are kept non–weight-bearing for 4 weeks to protect the repair site.

RANGE OF KNEE MOTION AND FLEXIBILITY

Passive knee flexion and passive and active/active-assisted knee extension exercises are begun the 1st day postoperatively. Active knee flexion is limited to avoid hamstring strain to the posteromedial joint. ROM exercises are performed in the seated position initially from 0° to 90°. Flexion is gradually advanced to 120° by the 3rd to 4th week and 135° by the 5th to 6th week (Table 30-3). Patients who had extensive repairs may be required to limit ROM to 0° to 90° for the first 2 weeks. Knee motion exercises are performed three to four times daily until normal motion is achieved. Hyperextension is avoided in individuals who have had anterior horn meniscus repairs.

TABLE 30-3 Range of Motion, Flexibility, and Modality Usage after Meniscus Repair and Transplantation

Critical Points RANGE OF KNEE MOTION AND FLEXIBILITY

Begin passive flexion, passive and active-assisted extension exercises 1st day postoperative, 0°–90°.

Advance Flexion

• Goal 135° by 5–6 wk.

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