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What is my Activity Level like after Cartilage Repair?
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What is my Activity Level like after Cartilage Repair?

Injury to joint (articular) cartilage is often associated with a significant reduction in joint function, and frequently results in a decrease in function and activities, particularly in high-demand athletic patients participating in impact sports.

Articular cartilage injuries may develop acutely (quickly) or chronically (over a long period), but have been shown to cause symptoms and limitations more than twice as often in active patients compared to the general population.

For patients in general, but particularly for athletes, the ability to be active and return to sporting activities presents the most important functional outcome following articular cartilage repair.

Since activity demands are different between different sports and level of sports participation, a detailed understanding of the severity of the individual athlete’s injury and the potential success rate of the therapeutic intervention is critical to optimise the recovery potential and manage realistic expectations.

Intended audience

This article is intended for anyone suffering from damage to their articular cartilage and their families who would like to find out about activity levels after cartilage repair, as well as anyone interested in cartilage problems.

How is activity measured after cartilage repair?

Many outcome scores have been developed and validated for evaluating function after articular cartilage repair. Of the various available outcome measures, the ICRS score (https://www.cartilage.org/index.php?pid=223), the International Knee Documentation Committee (IKDC) score, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) score are considered the very important ones in cartilage repair patients.

These patient-based, validated scores typically use standardised questionnaires with a series of questions. Based on the patient’s response, they allow calculation of a numeric score that indicates the patient’s overall function. Some of these scores include sub-scores that allow more specific evaluation of sport-related activities.

Besides the general scores, specific activity scores have been developed, such as the Tegner score that measures specific sports activities and the level that can be achieved on each score. Similarly, the Marx activity rating scale uses a patient’s ability to perform activities that are frequently included in sports to calculate a level of function.

All these validated scores can be helpful to compare and evaluate patients after cartilage repair procedures. While they provide important scientific information, these scores do not provide the patient with a relevant and practical measure of their postoperative joint function. For example, an ICRS score of 55 can be helpful for the clinician in comparing preoperative and postoperative function, but may not be a meaningful parameter for the treated patient.

In contrast, providing the patient with a percentage rate describing the likelihood of returning back to a known athletic activity, and even the expected level of sports participation compared to prior activity, gives the athletic patient a practical tool to evaluate their realistic expectations for surgery. It also provides useful data that can help with decision-making regarding surgical or non-surgical treatment, and for the evaluation of options for restoring articular cartilage.

What can patients expect in terms of recovery and activity after cartilage repair?

There are several factors that make it more likely that a patient can return to sports or previous activities.

The chances of a return to sport can vary between individuals, and age is a very important parameter, for example. Younger patients tend to do better, which is mostly due to their more active cellular metabolism and resultant better ability to generate new cartilage repair tissue within the treated articular cartilage defects. Some studies have shown that patients younger than 30-40 years will have higher activity levels and function after cartilage repair procedures, regardless of which technique is being used.

Pre-injury activity level also plays a significant role. Several studies have shown that higher activity levels before cartilage injury or cartilage surgery are associated with higher activity levels afterwards. More competitive athletes have a higher rate of return to sports than people who perform those same sports at a less competitive or recreational level. This is felt to result from different levels of motivation for return to sport, social situation, and access to rehabilitation resources that may vary between amateur and competitive or professional athletes.

Importantly, the fact that athletes at the more professional level can return to full activity and are able to endure extremely high impact loads in a wide range of sports after cartilage repair procedures is very encouraging, but again, this may be more a result of the professional athlete as a whole than a specific response to cartilage surgery.

Another very important parameter is how long the patient has had the cartilage injury before it was treated. Multiple studies now have shown that, if a patient has been injured for more than a year, the chances of returning to the same activity level is much lower than if they have had the injury for less than 12 months. This seems to be related to the development of a degenerative environment in the affected joints, which inhibits new cartilage regrowth. In addition, a long-term reduction in sports participation also plays a role.

Another factor that comes into play is the size of the cartilage defect. Small defects often are associated with more frequent return to normal athletic activity. The cut-off level that we have identified in some of our studies is that a cartilage defect less than 2–3 cm has a much better chance of successful repair. Larger defects are less likely to allow return to sport, but the success rate for larger defects is still encouraging.

In addition, the choice of cartilage repair technique can affect the ability to return to sport and likelihood for continued sports participation. Average rates of return to sports activity in the athletic population have been reported after autologous chondrocyte implantation (ACI) (74%), microfracture (68%), osteochondral autologous transfer (91%) and osteochondral allograft transplantation (88%). A recent systematic review of cartilage repair techniques demonstrated that athletes returned to the pre-injury level in 65% of cases after cartilage repair, with no significant difference between the individual techniques.

Several second generation techniques have been developed, including matrix-associated (MACI) or scaffold-enhanced microfracture, and have been found to have similar rates for return to sport compared to the first generation techniques. Besides the ability to return to sport, the ability to continue to play presents another important outcome parameter. While excellent durability of athletic activity was observed in 87% of athletes treated with ACI after 52 months, continued sports activity was more limited after treatment using microfracture or osteochondral autograft in athletes.

What can patients expect from a rehabilitation programme?

Rehabilitation can vary depending on the repair technique used and whether a cartilage repair procedure is done alone. Often, cartilage repair techniques are combined with another procedure, such as an anterior cruciate ligament (ACL) reconstruction or an osteotomy, which address associated knee pathology such as instability or malalignment.

If the associated pathologic factors responsible for developing the cartilage problem in the first place are not corrected, the cartilage repair will often be limited and less successful. The associated procedures can have an effect on patient rehabilitation. In general, if a patient has an isolated defect, the most important aspect is to educate them that recovery will be slow.

Usually there will be some limitation of weight bearing for between 2 and 6 weeks after the procedure depending on the defect characteristics and repair technique. Gradual progression guided by an experienced physical therapist familiar with cartilage repair procedures is critical.

Further reading
  • Flanigan DC, Harris JD, Trinh TQ, et al . Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc. 2010;42(10):1795-801.
  • Gudas R, Gudaite A, Pocius A, Gudiene A, Cekanauskas E, Monastyreckiene E, Basevicius A. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012 Nov;40(11):2499-508.
  • Kon E, Filardo G, Berruto M, Benazzo F, Zanon G, Della Villa S, Marcacci M. Articular cartilage treatment in high-level male soccer players: a prospective comparative study of arthroscopic second-generation autologous chondrocyte implantation versus microfracture. Am J Sports Med. 2011 Dec;39(12):2549-57
  • Kreuz PC, Steinwachs M, Erggelet C, et al. Importance of sports in cartilage regeneration after autologous chondrocyte implantation: a prospective study with a 3-year follow-up. Am J Sports Med. 2007;35(8):1261-1268.
  • Krych A, Robertson C, Williams, RJ. Return to Athletic Activity After Osteochondral Allograft Transplantation in the Knee. Am J Sports Med 2012 40:5: 1053-59
  • McAdams T, Mithoefer K, Scopp J, Mandelbaum B, Articular Cartilage Repair in Athletes. Cartilage 2010, 1(3): 165-176.7.Mithoefer K. Complex articular cartilage restoration. Sports Med Arthrosc. 2013 Mar;21(1):31-7.
  • Mithoefer K, Della Villa S, Silvers H, Ricci M, Hambly K. Current Concepts of Rehabilitation and Return to Sport after Articular Cartilage Repair in the Athlete. J Orthop Sports Phys Ther 2012; 3:254-273.
  • Mithoefer K, Steadman R. Microfracture in the Football (Soccer) Player: A case series of professional athletes and systematic review. Cartilage 2012; 3:18S-24S.
  • Mithoefer K, Peterson L, Saris D, Mandelbaum B. The Evolution and Current Role of Autologous Chondrocyte Transplantation for Treatment of Articular Cartilage Injury in Football Players. Cartilage 2012; 3:31S-36S.
  • Mithoefer K, Gill TJ, Williams RJ, Cole BJ, Mandelbaum BR. Clinical Outcome and Return to competition after microfracture chondroplasty in the athlete’s knee. Cartilage 2010, 1:113-20.
  • Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum, BR. Return to sports participation after articular cartilage repair in the knee. Am J Sports Med 2009, 37 Suppl 1:167S-176S.
  • Mithoefer K, McAdams TR, Scopp J, Mandelbaum BR. Emerging Options for Treatment of Articular Cartilage Injury in the Athlete. Clin Sports Med 2009; 28:25-40
  • Mithoefer K, Williams RJ, Warren RF, Wickiewicz TL, Marx RG. High-Impact Athletics after Knee Articular Cartilage Repair: A Prospective Evaluation of the Microfracture Technique. Am J Sports Med 34(9): 1413-1418; 2006.
  • Mithöfer K, Minas T, Peterson L, Yeon H, Micheli LJ. Functional Outcome of Articular Cartilage Repair in Adolescent Athletes. Am J Sports Med 2005 33(8):1147-1153.
  • Mithöfer K, Peterson L, Mandelbaum B, Minas T. Articular Cartilage Repair in Soccer Players with Autologous Chondrocyte Transplantation: Functional Outcome and Return to Competition. Am J Sports Med 2005, 33(11):1639-1646.
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