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ADVANCES IN MEDICINE

impact, excessive loading and shearing forces. There is a consensus of agreement that weight-bearing and ROM should be restricted in the early rehabilitation but there is considerable variation across carti- lage repair centres in the extent and dura- tion of these restrictions.

Low impact sports and exercise such as swimming, cycling and golf can usually be resumed within six months but a return to higher impact activities such as racquet sports, team sports, martial arts and run- ning should not be attempted until at least one year post operation. There are rela- tively few studies that have looked at return to sport following ACI. One recent study looked at soccer players who had undergone ACI treatment and found that 71% of players reported good to excellent results and 83% of the competitive players returned to soccer (6).

Chondrocytes are exquisitely sensitive to mechanical loading forces and basic sci- ence indicates that intermittent, cyclical dynamic loading may act as a positive stimulus to the optimisation of graft mat- uration and remodeling. This raises the rehabilitative dilemma of ‘protection ver- sus function’. There is a general agreement that the graft needs to be protected yet the level of stress needed to disrupt or delaminate the graft has not yet been quantified. Likewise it is also acknowl- edged but similarly not quantified, that there is a requirement for a ‘healthy’ level of stimulus for optimal graft maturation and remodeling.

There is a noticeable deficiency of an evi- dence base for ACI rehabilitation recom- mendations although there are now sever- al prospective studies underway in Europe but it will be several years before the results are available for utilisation in applied practice. Key issues to be consid- ered in ACI rehabilitation are whether there is too heavy a focus on graft protec- tion at the expense of range of movement and reduced function and to assess the potential for an ‘accelerated’ ACI rehabili- tation programme.

In October 2004 a workshop on cell-based cartilage repair rehabilitation will be tak- ing place in the UK. The primary objective of the workshop is to obtain a consensus on the baseline and optimal requirements for minimally restrictive, safe and progres-

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sive rehabilitation. Guidelines will be pro- duced following the workshop and these will form the basis for a follow up article focusing on rehabilitation in sportEX medi- cine in 2005.

THE FUTURE? There is considerable interest in further enhancing this new technology and there are now third generation ACI techniques being trialled using arthroscopic proce- dures with gels and biological scaffolds and future generations may well include gene therapy. The application of this tech- nology is being expanded to include other synovial joints and it is in early clinical use in the hip and talus whilst in vitro work is taking place into the application of ACI techniques for the repair intervertebral discs.

THE AUTHOR Karen Hambly, BSc, MCSP, is a chartered physiotherapist and graduate sports scien- tist with a special interest in rehabilitation and return to sport following cell-based articular cartilage repair procedures. She has also completed her Diploma in Sports Medicine. Author address for correspon- dance: info@rehabmatters.com

References

1. Willers C et al. A current review on the biolo- gy and treatment of articular cartilage defects (part I and part II). Journal of Musculoskeletal Research 2003;7(3 and 4):157-181 2. Hjelle K, Solheim E et al. Articular cartilage defects in 1,000 knee arthroscopies. Arthroscopy 2002;18(7):730-734 3. Curl WW, Krome J, Gordon ES et al. Cartilage injuries: a review of 31,516 arthroscopies. Arthroscopy 1997;13(4):456-460 4. Aroen A, Loken S, Heir S et al. Articular car- tilage lesions in 993 consecutive knee arthro- scopies. American Journal of Sports Medicine 2004;32(1):211-215 5. Saxon L, Finch C, Bass S. Sports participation, sports injuries and osteoarthritis implications for prevention. Sports Medicine 1999;28(2): 123-135 6. Mithofer K et al. Treatment of full-thickness articular cartilage lesions of the knee in high- demand athletes with autologous chondrocyte transplantation. Orthopaedic Journal at Harvard Medical School 2002(July) 7. Cain EL, Clancy WG. Treatment algorithm for osteochondral injuries of the knee. Clinics in Sports Medicine 2001;20(2):321-342 8. Johnson D. Articular Cartilage Update. American Academy of Orthopedic Surgeons 70th Annual Meeting New Orleans, USA, 2003 9. Unverferth KL, Minas, T. Surgical management of isolated chondral defects. Current Opinion in Orthopaedics 2002;13:1-8 10. Newman AP. Articular Cartilage Repair. American Journal of Sports Medicine

1998;26(2):309-324 11. Shelbourne KD, Jari S, Gray T. Outcome of Untreated Traumatic Articular Cartilage Defects of the Knee: A Natural History Study. Journal of Bone and Joint Surgery (American) 2003;85(90002):8-16 12. Knutsen G, Engebretsen L, Ludvigsen TC et al. Autologous chondrocyte implantation com- pared with microfracture in the knee. A ran- domized trial. Journal of Bone and Joint Surgery (American) 2004;86(3):455-464 13. Coleman H et al. Treatment of isolated artic- ular cartilage lesions of the medial femoral condyle. A clinical and MR comparison of autol- ogous chondrocyte implantation vs. microfrac- ture. Ortopedia Traumatologia Rehabilitacja 2002;4(Supplement 1) 14. Brittberg M, Lindahl A, Nilsson A et al. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. New England Journal of Medicine 1994;331(14):889-895 15. Minas T. Autologous chondrocyte implanta- tion in the arthritic knee. Orthopedics 2003;26(9):945-947 16. Haddo O, Mahroof S, Higgs D et al. The use of chondrogide membrane in autologous chon- drocyte implantation. Knee 2004;11(1):51-5 17. NICE. Guidance on the use of autologous cartilage transplantation for full thickness defects in knee joints. Technology Appraisal Guidance - No 16, 2000 18. Abstract Book. 5th Symposium of the International Cartilage Repair Society; 2004 May 26-29 2004; Gent/Belgium. ICRS 19. Peterson L, Brittberg, M., Kiviranta, I et al. Autologous chondrocyte transplantation: biome- chanics and long-term durability. American Journal of Sports Medicine 2002;30(1):2-12 20. Peterson L, Minas T, Brittberg M et al. Two- to 9- year outcome after autologous chondro- cyte transplantation of the knee. Clin Orthop Rel Res 2000;374:212 - 234 21. Bobic V. Magnetic resonance imaging of articular cartilage defects and repair. IASKOS: Current Concepts 2000 22. Gold GE et al. What’s new in cartilage? Radiographics 2003;23(5):1227-42 23. McCauley TR, Disler DG. Magnetic resonance imaging of articular cartilage of the knee. Journal of the American Academy of Orthopaedic Surgery 2001;9(1):2-8 24. Minas T. ACI in the patellofemoral joint of the knee transplantation. 5th ICRS Symposia. Gent/Belgium, 2004 25. Bailey A et al. Rehabilitation after Oswestry autologous-chondrocyte implantation: the OsCe11 Protocol. Journal of Sport Rehabilitation 2003;12(2):104-118 26. Blackburn TA. Updating Autologous Chondrocyte Implantation Knee Rehabilitation: Orthopedic Tech Review, 2003. 27. Gillogly SD, Voight M, Blackburn T. Treatment of Articular Cartilage Defects of the Knee with Autologous Chondrocyte Implantation. Journal of Orthopaedic Sports Physical Therapy 1998;28(4):241-251 28. Wondrasch B, Marlovits S. Rehabilitation protocols after matrix associated autologous chondrocyte transplantation: Variation accord- ing to the defect localisation. 5th International Cartilage Repair Society Symposium 2004

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