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Peter K. Edwards, Jay R. Ebert, Gregory C. Janes, David Wood, Michael Fallon and Timothy Ackland

Context:

Matrix-induced autologous chondrocyte implantation (MACI) has become an established technique for the repair of chondral defects in the knee. MACI has traditionally required an open arthrotomy, but now lends itself to an arthroscopic technique, which may decrease the associated comorbidity of arthrotomy, potentially allowing for faster rehabilitation.

Objective:

To compare postoperative outcomes between arthroscopic and open arthrotomy techniques of MACI and present a case for faster recovery and accelerated rehabilitation after surgery.

Design:

Retrospective cohort study.

Setting:

Private functional rehabilitation facility.

Patients:

78 patients (41 arthroscopic, 37 open) treated with MACI for full-thickness cartilage defects to the femoral condyles.

Intervention:

According to surgeon preference, patients recruited over the same time period underwent MACI performed arthroscopically or via a conventional open arthrotomy. Both surgical groups were subjected to an identical rehabilitation protocol.

Main Outcome Measures:

Patient-reported (Knee Injury and Osteoarthritis Outcome Score, Short Form Health Survey, and visual analogue scale) and functional (6-min-walk test, 3-repetition straight-leg-raise test [3R-SLR]) outcomes were compared presurgery and at 3, 6, and 12 mo postsurgery. Active knee range of motion (ROM) was additionally assessed 4 and 8 wk postsurgery. MRI evaluation was assessed using magnetic-resonance observation of cartilage-repair tissue (MOCART) scores at 3 and 12 mo. The length of hospital stay was evaluated, while postsurgery complications were documented.

Results:

Significant improvements (P < .05) for both groups were observed over the 12-mo period for patient-reported and functional outcomes; however, the arthroscopic cohort performed significantly better (P < .05) in active knee-flexion and -extension ROM and the 3R-SLR. No differences were observed in MOCART scores between the 2 groups at 12 mo. Patients who received arthroscopic implantation required a significantly reduced (P < .001) hospital stay and experienced fewer postoperative complications.

Conclusions:

Arthroscopic MACI in combination with “best practice” rehabilitation has shown encouraging early results, with good clinical outcomes to 12 mo, reduced length of patient hospitalization, and reduced risk of postsurgery complications. This may have important implications for postoperative rehabilitation and a faster return to full function.

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Jay R. Ebert, Peter K. Edwards, Daniel P. Fick and Gregory C. Janes

Context:

Gluteus medius rehabilitation is of critical importance given its role in pelvic and lower limb stability, and the known link between gluteus medius weakness and many lower limb conditions.

Objective:

To systematically review the literature and present an evidence-based graduated series of exercises to progressively load gluteus medius.

Evidence Acquisition:

A systematic literature search was conducted in January 2016 to identify studies reporting gluteus medius muscle activity as a percentage of maximal volitional isometric contraction (MVIC), during rehabilitation exercises. Studies that investigated injury free participants were included. No restrictions were placed on the type or mode of exercise, though exercises that could not be accurately replicated or performed within an independent setting were excluded. Studies that did not normalize electromyographic activity to a side lying MVIC were excluded. Exercises were stratified based on exercise type and %MVIC: low (0% to 20%), moderate (21% to 40%), high (41% to 60%), and very high (> 61%).

Evidence Synthesis:

20 studies were included in this review, reporting outcomes in 33 exercises (and a range of variations of the same exercise). Prone, quadruped, and bilateral bridge exercises generally produced low or moderate load. Specific hip abduction/rotation exercises were reported as moderate, high, or very high load. Unilateral stance exercises in the presence of contralateral limb movement were often high or very high load activities, while high variability existed across a range of functional weight-bearing exercises.

Conclusions:

This review outlined a series of exercises commonly employed in a rehabilitation setting, stratified based on exercise type and the magnitude of gluteus medius muscular activation. This will assist clinicians in tailoring gluteus medius loading regimens to patients, from the early postoperative through to later stages of rehabilitation.