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Studies into conservative or decelerated rehab find it offers surprising benefits
Rotator cuff repair study found that delayed rehabilitation yielded 10% fewer retears.
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The search is on for safer, even decelerated rehabilitation protocols that might offer better outcomes than those achieved with more accelerated or aggressive rehab approaches.
Related to this trend, some clinicians are investigating possible risks with rehabilitating their patients more quickly.
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“In some cases, the definition of a surgical success may be dependent on the success of the rehabilitation,” said Allen A. Deutsch, MD. “Doctors should stay on top of their patients’ physical therapy and rehab programs.”
Deutsch suggested looking for detrimental signs indicating progress has stopped or slowed, and adjusting the rehab program, which he does following arthroscopic rotator cuff repairs. In his patients, concern for tendon retears, increased pain, early stiffness or swelling are among the changes that signal the rehabilitation may need to be adjusted.
Several studies supporting modified or more conservative rehab were on the program of the American Academy of Orthopaedic Surgeons (AAOS) 74th Annual Meeting.
For example, orthopedists who repair tendons and ligaments have examined new ways to effectively rehabilitate patients postoperatively and return them to full function more safely.
Soft tissue approaches
At the AAOS meeting, James S. Keene, MD, and colleagues, presented results of early motion in patients with quadriceps and patellar tendon repairs they protected with a “relaxing suture.” Keene told Orthopedics Today that protective suturing done with a No. 5 Ethibond suture is an improvement over wires used for a similar purpose in these repairs a few decades ago, because the wire had to be removed later to avoid skin and other soft tissue irritation.
“What’s different is … we’re using a nonabsorbable heavy suture, so you don’t see it on an X-ray and it’s not a problem under the skin,” Keene said.
Brace-free ambulation
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Image: Keene JS |
Researchers followed 50 tendon repair cases (20 quadriceps, 30 patellar tendons) to see whether patients could safely attain 120° flexion and brace-free ambulation at 6 weeks postop.
In the first 10 postoperative days, patients were full weight-bearing and began early limited (0° to 55°) motion. “The suture does break as you allow the person to do more motion after that 6-week period,” but it avoids the problems encountered with wires when they break, he explained.
Investigators used the relaxing suture in all patients regardless of tissue quality or how good they thought the repair was, always putting the relaxing stitch in to back up a repair. “We felt that by protecting it for that [initial] 6 weeks, it would be enough to safely permit early motion and promote tendon healing,” Keene said.
Patients achieved 120° flexion at 7.5 weeks and ambulated brace-free at 8.4 weeks on average. At 6 months, 40 patients had full and 10 lacked 3° to 10° of extension.
For the repairs, surgeons flexed the patients’ knees to 30° and then tightened and tied the suture, anchoring the backup suture differently in each tendon treated. For the quadriceps, they wrapped one end around the patella and then brought it back up through the quadriceps, proximal to the repair.
To get distal to the patellar tendon repair and anchor the back-up suture, surgeons placed it through the tibia via a drill hole, he said.
Thirty-five patients had excellent results, 15 demonstrated good results with average Lysholm scores of 92 points at their minimum 1-year follow-up (range 81-100 points).
Upper extremity option
In the upper extremity, Deutsch and colleagues found important benefits from decelerated postoperative rehabilitation for single-row arthroscopic rotator cuff repairs, another area where early rehab has come under increased scrutiny.
Accelerated rehabilitation evolved as the standard in these cases to prevent the stiff or “frozen” shoulders seen as a result of patients not moving early postop. But Deutsch told Orthopedics Today, “It is safe to slow down the rehab after cuff repair because there’s no risk of stiffness, and you can hopefully have the benefit of fewer retears.”
He treated 70 patients with rotator cuff tears via single-row arthroscopic repair, randomizing 37 to a standard and 33 to a decelerated protocol. The standard group began supine, passive, forward elevation exercise on postop day 7 and the decelerated group began the exercise at 4 weeks.
Deutsch and colleagues found no significant difference in range of motion at the latest follow-up. To date, they followed approximately 80% of patients to 1 year. Yet, at 6 months Deutsch saw a 10% difference in retear rate — 81% intact for the standard vs. 91% intact for the decelerated group.
“If there’s a trend toward more retears to occur in the standard group and more importantly no stiffness with the decelerated group, then there really didn’t seem to be any benefit to doing the standard protocol,” he said. “If there is a benefit to slowing down with no harm, it just makes sense to do it that way.”
Deutsch favors a customized approach to rehabilitation for arthroscopic rotator cuff repairs, since patients have unique sets of comorbidities, from age and occupation to tear size and tissue quality. “If you customize the program for … every patient, then … you’ll have fewer problems,” he said.
Since doing the study, he has delayed the start time for the supine passive forward elevation exercises to 6 weeks postop without a problem.
For more information:
- Guelich D, Mundanthanam GJ, Govea C, et al. Effects of rehabilitation on cuff integrity and range of motion following arthroscopic cuff repair. #P289. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.
- Keene JS, Kaplan LD, West J. Results of early motion and brace-free ambulation after quadriceps & patellar tendon repairs. #P498. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.
- Allen A. Deutsch, MD, orthopedic surgeon, Kelsey-Seybold Clinic, 2727 W. Holcolmbe, Houston, TX 77025; 713-442-0000; adeutschmd@aol.com. He is a consultant to Arthrex and Mitek.
- James S. Keene, MD, professor of orthopedic surgery, University of Wisconsin School of Medicine and Public Health, K3/705CSC, 600 Highland Avenue, Madison WI 53792; 608-263-1356; JSKeene57@aol.com. He has no financial disclosures related to his study.