Quality and Variability of Online Physical Therapy Protocols for Isolated Meniscal Repairs

Abstract

Objectives:Patients are attempting to access healthcare content online at a precipitously increasing rate given the efficiency and ease of modern search engines. The purpose of this study was to assess the quality and variability found across isolated meniscal repair rehabilitation protocols published online. Methods: Web-based meniscal repair physical therapy protocols from U.S. academic orthopaedic programs available online were included for review. The first 10 protocols identified by the Google search engine for the term "meniscal repair physical therapy protocol" were also included as these will be the most commonly encountered by patient searches. Exclusion criteria comprised treatment of concomitant injuries and protocols aimed at pediatric patients. A comprehensive custom scoring rubric was created to assess each protocol for presence or absence of various rehabilitation components, as well as their timing. Results: Twenty protocols were included from 155 U.S. academic orthopaedic programs for a total of 30 protocols. Only one protocol (5%) recommended a pre-operative rehabilitation program and no protocol recommended continuous passive motion post-operatively. Twenty-six protocols (86.6%) recommended immediate post-operative bracing with an average 5.0 (range 3 to 8) weeks of brace use. Twenty-three of these protocols (88.5%) specifically mentioned locking of the brace during ambulation. Twelve (40.0%) protocols permitted immediate weight bearing as tolerated (WBAT) post-operatively, while the remaining protocols permitted WBAT at an average 4.0 (range 1 to 7) weeks post-operatively. There was considerable variation in range of motion (ROM) goals with most protocols (73.3%) initiating immediate PROM to 90°. Full ROM was mentioned in 22 (73.3%) protocols and permitted at an average of 5.2 (range 1 to 7) weeks. The types of strength and proprioception exercises specifically recommended in each protocol were extremely diverse. In regard to modalities recommended for return to basic activity, stationary biking was the most commonly employed (90.0%) at an average 4.6 (range 1 to 7) weeks post-operatively. Agility and pivot training were permitted at an average of 12.5 (range 7 to 28) and 19.3 (range 11 to 28) weeks, respectively. Only five protocols (16.7%) employed functional testing during the rehabilitation process as a marker for return to athletic activities, with 14 (46.7%) protocols failing to mention return to practice or competition as a goal for meniscal repair rehabilitation. Conclusion: There is a paucity of evidence-based treatment modalities employed during physical therapy following isolated meniscal repair. The results of this study indicate that only a minority of academic orthopaedic programs publish meniscal repair physical therapy protocols online and that within these protocols there are significant disparities. These variations reflect the lack of consensus regarding the best-practice components of meniscal repair rehabilitation which can lead to confusion among patients, therapists and...

Rehabilitation Variability Following Femoral Condyle and Patellofemoral Microfracture Surgery of the Knee

“…Current literature suggests partial, or touch-down, weight-bearing for femoral condyle lesions for 6 to 8 weeks postoperatively, with advancement to full weight-bearing between 9 and 16 weeks. 8,12,28 For patellofemoral lesions, present literature supports partial, or touch-down, weight-bearing immediately postoperatively, weight-bearing as tolerated at 0 to 2 weeks postoperatively, and promotion to full weight-bearing between 9 and 16 weeks. 8,12,28 As it stands, the online protocols analyzed in our investigation report timelines slightly differ from those present in literature.…”

“…8,12,28 For patellofemoral lesions, present literature supports partial, or touch-down, weight-bearing immediately postoperatively, weight-bearing as tolerated at 0 to 2 weeks postoperatively, and promotion to full weight-bearing between 9 and 16 weeks. 8,12,28 As it stands, the online protocols analyzed in our investigation report timelines slightly differ from those present in literature. Schmitt et al .’s systematic review on outcomes following articular cartilage surgery proposed that rather than using time as a factor for weight-bearing progression, clinical signs indicating joint overload, such as effusion or muscle strength/deficits, may serve as more reliable criteria for decision making.…”

“…Using a methodology previously outlined by several studies on variability in rehabilitation protocols, 23,27-31 publicly available online rehabilitation protocols from academic orthopedic surgery programs in the United States were reviewed. Programs were identified from the Electronic Residency Application Service (ERAS).…”

“…Academically focused protocols were specifically selected to minimize potential bias and variability obtained through online search engines. A web-based query was performed (www.Google.com) using the search term “[Program/affiliate hospital/affiliate medical school name] microfracture rehabilitation protocol.” 27-29,31 Protocols designed for pediatric patients, those pertaining to concomitant procedures (ACL reconstruction, meniscal repair or debridement, osteochondral autograft and osteochondral allograft transfer system), protocols not associated with academic orthopedic surgery programs and those lacking details about specific elements of the rehabilitation, such as time points for the initiation and progression of protocol elements, were excluded from final review. Protocols that did not provide specifics on the type of articular cartilage restoration procedure performed were also excluded.…”

“…The quality and variability of postoperative rehabilitation protocols for anterior cruciate ligament (ACL) reconstruction, 23 medial patellofemoral ligament reconstruction, 27 meniscal repair, 28 proximal hamstring repair, 29 Achilles tendon repair, 30 and ulnar collateral ligament 31 reconstruction have been previously assessed with significant heterogeneity found between recommended rehabilitation protocols. Similarly, the present investigation sought to assess the variability of online postoperative patellofemoral and femoral condyle microfracture rehabilitation protocols published by academic orthopedic surgery programs in the United States.…”