Rehab program after microfracture surgery...

[Djaughe]

Sorry - If this info has already been posted. This link about the surgery.

Which sorta gives an indication what Amare will be doing fer the next 4 months...

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http://www.steadman-hawkins.com/knee_microfracture/recov.asp​

The rehabilitation program after microfracture is crucial to optimize the success of the surgical technique. The program is designed to promote the ideal physical environment in which the bone marrow cells can transition into the appropriate cartilage-like cell lines. When the ideal physical environment is combined with the ideal chemical environment produced by the marrow clot, a repair cartilage can develop that fills the original defect.

The specific rehabilitation program for each patient following a microfracture will vary depending upon the following factors:

• The location of the defect
• The size of the defect
• Whether any other surgical procedure, such as an anterior cruciate ligament reconstruction, was done at the same time as microfracture

Following are examples of some rehabilitation programs.

Rehabilitation Protocol for Patients with Chondral Defects on the Femur or Tibia

• The patient is started on a continuous passive motion (CPM) machine immediately in the recovery room. Ideally, the patient should use the machine for 6 to 8 hours every 24 hours. Range of motion is increased as tolerated until full range of motion is achieved with the machine.
• If a CPM machine is not used, the patient begins passive flexion/extension (straightening and bending) of the knee with 500 repetitions three times a day.
• The use of crutches, with only light touch-down weight allowed on the involved leg, is prescribed for 6 to 8 weeks. Patients with small defect areas (less than 1cm in diameter) may be allowed to put weight on the leg a few weeks sooner.
• Brace use is rarely recommended for patients with chondral defects on the femur or tibia.

Limited strength training also begins immediately after microfracture surgery.

• Standing one-third knee bends with a great deal of the weight on the uninjured leg begin the day after surgery.
• Stationary biking without resistance and a deep-water exercise program begin 1 to 2 weeks after surgery.
• After 8 weeks the patient progresses to full weight bearing and begins a more vigorous program of active knee motion.
• Elastic resistance cord exercises can begin about 8 weeks following surgery.
• Free weights or machine weights can be started when the early goals of the rehabilitation program have been met, but no sooner than 16 weeks after surgery.
• Patients must not resume sports that involve pivoting, cutting, and jumping for 4 to 6 months after a microfracture procedure. Full activity may be resumed once the physician has examined the knee and given approval for the patient to return to sports activity.

Rehabilitation Protocol for Patients with Patellofemoral Chondral Defects

• All patients treated with microfracture for patellofemoral defects must use a brace set for 0° to 20° of flexion for at least 8 weeks. It is essential to limit compression of the new surfaces in the early postoperative period, so that the maturing marrow clot will not be disturbed. The brace should be worn at all times except when passive motion is allowed.
• Patients are placed into a CPM machine immediately following surgery. The goal is to obtain a pain-free and full passive range of motion soon after surgery during those periods when the brace is removed.
• When the patient wears a brace, strength training is allowed, but only in the 0° to 20° range immediately after surgery in order to limit compression of the affected chondral surfaces. The joint angles of these patients are observed carefully at the time of surgery to determine where the defect makes contact with the opposing surface, either on the patella or on the trochlear groove of the femur. These areas are avoided during strength training for approximately 4 months.
• Patients are allowed to put weight on the involved leg as tolerated, but it must be limited to the angles of flexion that do not compress the treated surfaces. For this reason the patient must wear a brace locked in limited flexion.
• After 8 weeks, the knee brace is gradually opened to allow increased flexion of the knee, a process that takes about a month. Brace use is generally discontinued at about 12 weeks. Some patients, however, like to continue to wear the brace for strenuous exercise for a few more months up to about 6 months.
• After brace use is discontinued, strength training advances progressively.
• The doctor must examine the knee before the patient is released to full activity.

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[elindholm]

Whew, that's a relief. I was thinking it was serious.

 

[scoutmasterdave]

FWIW, microfracture surgery was used for Jason Kidd and Penny Hardaway. Let's all hope it doesn't rob Amare of his athleticism the way it did the other two...

 

[sunsfn]

Thanks for putting this on Djaughe.


You can not compare Penny to Amare. Penny had extensive knee problems before his operation.

However, I have not read what the surgery involved to Kidd involved.

 

[thegrahamcrackr]

FWIW, microfracture surgery was used for Jason Kidd and Penny Hardaway. Let's all hope it doesn't rob Amare of his athleticism the way it did the other two...

And Webber.


But the situation is different. Those guys were missing a lot of tissue, and in Penny's case it was bone on bone. The scar tissue created was supposed to be a replacement, and it isn't as strong as the natural stuff.

Amare's scar tissue is just to support the stuff he already has.

 

[Chaz]

We have to remember also this procedure did have to repair any ligament damage. As far as all that goes it seems he is healthy.

I tend to think that means his explosiveness will return.

Will he be the same? Probably not. Of course I expected him to be different this year compared to last anyway. Who is to say he won't be better?

 

[JCSunsfan]

Patients with small defect areas (less than 1cm in diameter) may be allowed to put weight on the leg a few weeks sooner.

I assume this is where the "4 months" rather than 4-6 months difference is.

Also, recovery time seems to be shortening for alot of procedures. ACL's used to be a year minimum, and now guys are returning in 6 months.

 

[thegrahamcrackr]

I assume this is where the "4 months" rather than 4-6 months difference is.

Also, recovery time seems to be shortening for alot of procedures. ACL's used to be a year minimum, and now guys are returning in 6 months.

Got to love medical advancements!

Also, BC said that it had something to do with the location on the knee as well.

 

[arthurracoon]

Got to love medical advancements!

Also, BC said that it had something to do with the location on the knee as well.

Probably not as much pressure there.

 

[cards 24-7-365]

This is an excellent thread, thanks for postin this Djaughe:

I have worked with people who have had this procedure as I am in the sports medicine field (athletic trainer, like Aaron Nelson and Johnny O). To me 4 months is rushing it - as you can see from Steadman's rehab protocol that weight training, pivoting and cutting are not permitted until 4-6 months. The non weight bearing period of 4-6 weeks will cause severe atrophy of the hip, thigh and calf musculature - so to get that strength back will take in my estimation 2-3 months after weight lifting, running, cutting and jumping are allowed = 6-9 months. That is if (a big if) there are no set backs.

The other thing that is disturbing about these chondral defects is that often they are not associated with another injury or episode of injury (ex. twisting or hyperextending the knee). For some reason these injuries just seem to happen. From my experience, it is frequent that athletes who have one chondral defect on one knee often end up having a similar injury on the other knee. And even more often it seems that the first microfracture procedure does not "fill in" all the way and another prcedure is needed (remember we are not replacing apples with apples, this procedure causes scar tissue to fill in the defect) - everyone reacts differently. This is what happened to Wadsworth and Swann. Harpring has had 2 microfractures already. And yet some athletes come back and play for many years without complication - Rod Woodson, Bruce Smith.

If I were the Suns I would not put that 4 month expectation out there as it is likely IMO, that Amare will not return in that time frame. Why not use the "out for an undetermined time" phrase and if he comes back this year it is gravy.

Either way, good luck Amare - you will be missed by not only Suns fans but all basketball fans.

 

[Djaughe]

....this procedure causes scar tissue to fill in the defect) - everyone reacts differently. This is what happened to Wadsworth and Swann. Harpring has had 2 microfractures already. And yet some athletes come back and play for many years without complication - Rod Woodson, Bruce Smith...

Have you heared of a 22 year old getting this procedure?


btw...I thought this article was interesting - I never knew K.J. had this done...

Microfracture surgery results vary
By Mike Tulumello, Tribune
October 12, 2005

The difference in outcomes for microfracture surgery can be as different as the performances of Kevin Johnson and Penny Hardaway. Hardaway seemed to get so-so results from his muchpublicized microfracture surgery in May 2000.

He played in only four games in the 2000-01 season, before bouncing back to have a decent year in ’01-’02 (12.0 points, 4.4 rebounds, 4.1 assists.)

Then he was slowed down by a variety of muscle injuries and eventually was traded to New York, where he has been injury prone as well.

But Johnson underwent an unpublicized microfracture procedure in the early 1990s and then enjoyed outstanding success, said Dr. Richard Emerson, the former Suns doctor who helped perform the operations on the two players.

Johnson’s operation was successful even though microfracture was considered more of an exotic procedure in the early 1990s (Emerson isn’t sure what year the operation took place).

Johnson’s surgery was performed after the Suns bowed out of the playoffs, and he didn’t miss any time the next season.

"It worked well," Emerson said. "He was very motivated."

In Hardaway’s case, Emerson said: "I never thought Penny wasn’t motivated. Penny eventually came back. But it took longer than everyone would have liked."

Hardaway eventually needed a second operation six months later and ended up missing almost the whole season.

How well the procedure works depends on the body’s ability to respond after the operation.

"You say a prayer and ask the body to do its job," Emerson said.

Players can get five to eight years of performance out of a microfracture, he said. "But you just don’t know how long it’s going to last. It’s just an unknown."

Along with Hardaway’s experience, microfracture surgery got a bad name locally when two prominent Cardinals players — Eric Swann, a former star, and Andre Wadsworth, a first-round draft pick — underwent the surgeries and never returned to form.

The purpose of microfracture surgery is to generate a type of cartilage to serve as a cushion for the knee, so that bone isn’t rubbing on bone.

"It’s not a big reconstruction, like Tom Gugliotta," Emerson said, referring to his operation on the Suns forward, who blew out his knee in March 2000. "It’s technically straightforward."

However, microfracture is not a long-term solution because the surgery does not create true cartilage.

"There’s a three- to fiveyear time frame before it starts to deteriorate, but hopefully with this procedure we’re helping to ****** that natural progression," Emerson said.

As for Amaré Stoudemire, Emerson said, "Microfracture is certainly an acceptable treatment in this kind of injury."

In the cases of Swann and Hardaway, both athletes had a history of knee problems before undergoing the surgery, which can affect the recovery process. Swann had several surgeries. Hardaway had two operations on his left knee as a player in Orlando.

Other NFL players have fared well with the procedure, including superstar lineman Bruce Smith.

Just last year, running back Stephen Davis of the Carolina Panthers underwent the procedure in November. He returned 10 months later, in the Panthers’ final exhibition game on Sept. 1. In five regular season games, Davis has carried the ball 91 times for 292 yards, a 3.2-yard average, and seven touchdowns.

- Craig Morgan contributed to this report.

 

[cards 24-7-365]

Have you heared of a 22 year old getting this procedure?

Yes, microfracture is common in many people who have chondral defects. The most troubling thing about this injury to are:

a) Nothing else in the knee is injured - so why did it happen? Like Dr. Carter said, in most other people a chondral defect is associated with a knee injury like a ligament tear. But in this case, there was no other damage - to me it is disturbing because there is no reason for it to happen. In the case of a guy like Wadsworth - who was young (24-25) but probably 40-50 lbs heavier - If I recall correctly, I think he had similar surgeries in both knees and never really had a history of knee problems before his first microfracture. Makes me think that some athletes may be predisposed to these types of conditions - again, this is speculation on my part I haven't read any research to indicate that some are predisposed to chodral defects.

b) The microfracture procedure does not replace the chondral cartilage (which is the shiny, white cartilage that covers the end of a bone - check it out next time you eat chicken wings ) with chondral cartilage - it replaces it with a scar tissue or more of a bony fibrocartilage which will never have the same smoothness and other characteristics that the chondral cartilage had. So anatomically speaking, the knee will never be the same. That is why if you google microfracture surgery you will find that the the surgery often has to be repeated in about 5 years to maintain it's efficacy. Unfortunately, at this time it is the best solution technologically.

 

[thirty-two]

Whew, that's a relief. I was thinking it was serious.

i know i am way late, but that cracked me up.

 

[Djaughe]

...a) Nothing else in the knee is injured - so why did it happen? Like Dr. Carter said, in most other people a chondral defect is associated with a knee injury like a ligament tear. But in this case, there was no other damage - to me it is disturbing because there is no reason for it to happen. .....

Yer scaring me...

 

[elindholm]

Thanks a lot for the perspective, cards 24. We're learning a great deal about this situation.

 

[Djaughe]

Thanks a lot for the perspective, cards 24. We're learning a great deal about this situation.

lol...methinks if I was amare...I'd have been pissed after waking up....

 

[SweetD]

I wanted to learn more about the knee and were Amare's injury is. So here are some of the picutures I found.

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[SweetD]

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[SweetD]

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[SweetD]

Very Detailed and Techy

INTRODUCTION
Soccer is the most popular sport worldwide with about 200 million currently registered active players. (1) The frequency of soccer injuries is estimated at 10-35 per 1000 hours of competition, with the majority occurring in the lower extremities. Knee injuries account for 15-40% of soccer-related injuries. (2,3)

While numerous studies have described injuries of the cruciate ligaments and menisci in soccer players, little information is available on articular cartilage injuries in these highdemand athletes. (4) This lack of data is surprising since the prevalence of acute and chronic articular cartilage lesions in the cruciate-deficient knee is well documented. 5,6 The lack of available data on cartilage lesions in soccer players is not completely understood, but may be related to the limited treatment options available for these injuries in the past. Levy and coworkers have recently confirmed the increasing frequency of isolated chondral injuries in collegiate, professional and worldclass soccer players. They concluded that the observed increase resulted from both the growing popularity of the sport and the increased awareness of chondral injuries due to emerging new techniques for cartilage repair. (4)

In full-thickness injuries to the articular cartilage, disruption of the articular surface occurs without concomitant violation the subchondral bone, which precludes access to the subchondral vasculature. Since no bleeding occurs, the avascular cartilage can only promote repair via a transient increase in mitotic and metabolic activity in the surviving chondrocytes bordering the defect. Due to this limited response, the newly synthesized matrix is nearly always insufficient to fill the defect and restore the articular surface. Laboratory studies have shown that because of the qualitative and quantitative deficiencies in the spontaneous repair tissue, the newly formed matrix deteriorates quickly with loading of the joint surface. (7) Clinically, this leads to progression of the lesions, with pain, swelling, catching of the joint, and a dramatic reduction of the patient’s quality of life and ability to participate in athletic activities. (8)

Repair of articular cartilage has been difficult due to the pathophysiology and molecular biology of cartilage tissue, and traditional treatment methods have not produced reliable and lasting results. (9,10) The treatment of articular cartilage lesions in the knee has recently gained considerable interest due to the development of new techniques. The successful repair of articular cartilage lesions of the human knee by autologous chondrocyte transplantation was first reported by Brittberg in 1994. (11) Recent follow-up data demonstrates excellent results with the use of this technique up to eleven years. (12,13) However, an evaluation of autologous chondrocyte transplantation in high-demand athletes, such as soccer players, has not yet been performed.

METHODS

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Figure 1:
The Outerbridge classification of articular cartilage lesions: Grade 0: Normal Cartilage, Grade I: Superficial Softening, Grade II: Fibrillation, Grade III: Fissuring Grade IV: Loss of all Cartilage Layers and Exposure of Subchondral Bone

Soccer players with acute or chronic articular cartilage lesions were treated with autologous chondrocyte transplantation at Brigham and Women’s Hospital, Boston, MA, Santa Monica Orthopedic Sports Medicine Foundation, Los Angeles, CA and Gothenburg Medical Center, Gothenburg, Sweden. The athletes were examined and completed functional outcome questionnaires preoperatively and at defined postoperative intervals. Data analysis included gender, associated injuries, skill level, previous injuries or trauma, and clinical symptoms. Intraoperative data was collected from operative notes and available intraoperative video recordings and photographs to determine anatomic location, defect size and grade. Articular cartilage lesions were graded using the most widely accepted depth classification system described by Outerbridge (Figure 1). (14)

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Figure 2: Procedure of Autologous Chondrocyte Transplantation including cartilage biopsy, procurement, culture of chondrocytes, and re-implantation under fibrinsealed periosteal flap.

Autologous chondrocytes were harvested from a nonweightbearing area of the knee joint. The cells were then cultured and multiplied in vitro followed by reimplantation after 3-4 weeks. At implantation, the cultured chondrocytes were placed under a periosteal flap covering the articular cartilage defect and sealed with a thin fibrin layer (Figure 2). Local growth factors stimulate the chondrocytes to produce an extracellular cartilage matrix that closely resembles hyaline cartilage. Results of a recent multicenter study demonstrated good to excellent results in up to 92% after 2-11 years following autologous chondrocyte transplantation. 12,13 Rehabilitation was performed according to previously described protocols. (15)

Functional outcome was evaluated by use of scientifically established knee rating systems including the Modified Cincinnati Knee Score, Western Ontario McMaster Index WOMAC), and Knee Society Score. Data analysis was performed by standard statistical methods using established commercially available software (SSPS Inc. , Chicago, IL, USA). Differences were considered significant at a probability level of 95% (P<0.05).

RESULTS
Over 20 amateur soccer players were treated with autologous chondrocyte transplantation (ACT). Range of player age at the time of transplantation was 14-43 years. There was minimum 6 month follow-up. Roughly one half of players presented with ACL deficiency or history of previous ACL reconstruction. The predominant symptom was pain, and catching or locking was noted in just under half of the patients studied. Lesions varied in size from 1.5 to 20 cm2. Almost half of the lesions were located on the medial femoral condyle, with lateral femoral condyle, lateral tibial

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Figure 3. Arthroscopic view demonstrating a contained full-thickness defect of the articular cartilage of the lateral femoral condyle in a soccer player before (left) and after treatment with autologous chondrocyte transplantation (right).

plateau, trochlear, and patellar lesions also noted. Single lesions predominated (Figure 3). Additional procedures included high tibial osteotomy, ACLreconstruction, meniscal repair, and tibial tubercle osteotomy. Seventy percent of all players rated their results as good or excellent by overall clinical evaluation. The rate of good or excellent results was higher in players with single cartilage lesions or defects located on the medial femoral condyle. Modified Cincinnati scores, Western Ontario MacMaster (WOMAC) Scores, and Knee Society Scores all improved significantly. No association was found between the functional outcome and gender, age, defect location, defect size, defect number, or presence of anterior cruciate ligament deficiency. Failure of the repair occurred in under 15 percent of patients. Graft delamination was noted in one patient.

DISCUSSION
Autologous chondrocyte transplantation has been described as a successful technique for the restoration of full-thickness articular cartilage lesions in the knee by several investigators. (9-12) Recent data indicates excellent long-term durability of articular cartilage restoration and persistence of improved knee function up to eleven years after surgery. (13) Besides autologous chondrocyte transplantation, other techniques for repair of articular cartilage defects have been used successfully such as microfracture (16,17) and osteochondral mosaicplasty (18). While the mosaicplasty and microfracture technique has been evaluated in athletes (18,19) an assessment of autologous chondrocyte transplantation in the athletic population has not yet been performed.

The soccer population was chosen to test the effect of autologous chondrocyte transplantation since the increased risk for development of knee osteoarthritis in this high-demand athletic population is well documented, particularly at the elite level. (20-23) A recent consensus conference on osteoarthritis at the National Institute of Health (NIH) demonstrated a relative risk of 4.4-5. 3 for knee osteoarthritis in soccer players. (24) This fivefold increased risk for gonarthrosis likely results from the high joint stresses associated with repetitive joint impact and torsional loading from rapid deceleration motions, frequent pivoting, and player contact. Besides chronic cartilage degeneration, acute injuries to the articular cartilage of the knee can have a profound impact on the player’s career, representing the most common cause of permanent disability. (25) Thus, management of chondral lesions in the knee in this high-demand population may play a crucial role in limiting or preventing severe long-term sequelae. (26)

Acute or chronic injuries of the anterior cruciate ligament were reported in approximately half of our patients. This is consistent with the previously described high incidence of soccer-related anterior cruciate ligament (ACL) injuries. Anterior cruciate ligament injuries are associated with articular cartilage lesions in 40-70% and these lesions are frequently located on the femoral condyle. (5) Accordingly, the articular cartilage lesions in soccer players in our study presented primarily as isolated lesions of the medial or lateral femoral condyle. In contrast to previous studies,(12) no significant differences were observed between players with isolated or multiple lesions, but this may be related to the relatively low number of athletes with multiple articular cartilage defects in our study population. The percentage of good to excellent results in soccer players falls within the previously reported range of 65-92% good to excellent results for autologous chondrocyte transplantation in the general patient population. (12,13) As observed in previous studies of this technique, isolated lesions of the femoral condyle in soccer players were associated with better outcomes.

SUMMARY
Our data indicates that the early results from repair of fullthickness articular cartilage lesions in high-demand athletes are comparable to the results reported for microfracture (19) or osteochondral mosaicplasty (18). The current results represent a preliminary report of an ongoing study. Further investigation is under way to determine the long-term functional outcome and ability to return to competition in this highly demanding sport. Long-term evaluation will help to determine whether restoration of articular cartilage lesions in the knee in soccer players can effectively reduce the high incidence of osteoarthritis in soccer players.