    Worn in the early postoperative period (0-6 weeks).

1 Lightweight metal hinge bars with multiple padded velcro straps to secure brace to patient’s thigh and lower leg.

2 Intended to limit range of motion by locking the brace at a specific ROM point, or within certain ROM limits through an adjustable dial at the hinges.

1 Designed to limit extension/flexion motion and varus and valgus stresses at the knee.

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a b c

  Postoperative bracing has been shown to have some benefits including decreased swelling, hemarthrosis, and pain compared to rehabilitation without a brace.

3,4 › Knee immobilizer or post-op. brace Proponents believe these braces help patients achieve knee extension, decrease pain, and protect the reconstructed knee from injury and excessive graft strain.

1

  Immediate postoperative bracing allows early weight bearing while protecting the knee from buckling due to severe quadriceps weakness and inhibition after surgery.

3 Once the patient obtains good quadriceps control with ability to perform a straight leg raise without an extension lag, use of the postoperative brace can be discontinued.

4

 Rehabilitative bracing has not been shown to have any effect on long-term outcomes. › Once adequate quadriceps strength for ambulation has returned, continued postoperative bracing is unnecessary.

3 › Clinical outcomes such as range of motion, laxity, and function do not appear to be affected by the use of rehabilitative braces.

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 Wright et al.

5 › › › Review of level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation,  11 included use of rehabilitative postop. bracing.

No study demonstrated a potentially worse outcome when bracing was not used immediately postoperatively.

 No increased rate of injury, pain, decreased ROM, or increased laxity compared to braced patients Only one study 6 demonstrated a potentially clinically significant finding.

 Improved knee extension following one week of locked extension bracing postoperatively

    Worn to potentially decrease the risk of reinjury when the patient returns to sport after surgery.

1 Wide variety of designs available as custom or off-the-shelf derotational braces for post-surgical ACL patients.

Consist of a rigid frame with hinge-post straps and Velcro straps.

2 Intended to limit anterior tibial translation and rotation at the knee joint.

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d e

 Functional brace use after ACL reconstruction may: 3,7 › › improve proprioception.

improve confidence in knee during return to play.

  Use of functional braces after ACL reconstruction is controversial.

1,3,7,8 Majority of studies have failed to show any long-term differences in pain 1 , ROM 1,3 , strength 3 , functional tests 3,7 , joint stability 7,8 , graft stability 1 , re-injury rates 1,8 , kinesthetic awareness 8 , or knee scores 3 compared to patients who did not use a functional brace during rehabilitation and return to play after ACL reconstruction.

 Rate of use by orthopedic surgeons 9 › Do you recommend functional braces for full return to activity?

Yes No Sometimes 17.6% (35) 2.9% (1) 1.2% (1) NORTH AMERICA (199) 37.2% (74) EUROPE (35) 31.4% (11) SOUTH AMERICA (85) 88.2% (75) 45.2% (90) 65.7% (23) 10.6% (9)

 Reports of recommended use of functional braces by US orthopedic surgeons have ranged from 58%- 63%.

9,10,11

 Studies to determine the effect of functional braces on re-injury rates after ACL rsurgery have many limitations.

› › Lack of power: high.

3 Re-injury rates overall after ACL reconstruction are low, so the number of patients needed to power a study on re-injury rate is very Wright 1 performed a review of Level I evidence to determine if there was appropriate evidence to support the use of functional braces after ACL reconstruction.

 12 randomized controlled trials found between years 1966-2005  All 12 had potential biases- 10 selection, 2 exclusion

   Sterett et al.

12 investigated the effect of functional bracing on subsequent knee injury in ACL reconstructed skiers.

Study performed over 2 years at large ski resort.

› All subjects were employees 820 subjects with ACL reconstruction performed ≥2 yrs. prior to data collection were given the option of using a functional brace during skiing activity, or going brace free.

› 257 braced, 563 non-braced

Sterett et al, 12  continued 61 new injuries recorded › › › 51 non-braced (8.9 injuries/100 knees/season)  25 required surgery 10 braced (4.0 injuries/100 knees/season)  3 required surgery Non-braced group was 2.74 times more likely to be injured than braced group.

 Use of a brace did not lower injury rate to that of a skier with no previous ACL injury (2.1%).

1. Wright RW & Fester GB. Bracing after ACL reconstruction: A systematic review. Clin Orthop Relat Res. 2007;455:162-8. doi: 10.1097/BLO.0b013e31802c9360

2. Beam JW. Orthopedic Taping, Wrapping, Bracing & Padding. 2 nd ed. Philadelphia, PA: F.A. Davis Company, 2012. 3. Albright JC & Crepeau AE. Functional bracing and return to play after anterior cruciate ligament reconstruction in the pediatric and adolescent patient. Clin Sports Med. 2011;30:811 5.doi:10.1016/j.csm.2011.06.001

4. Manske RC, Prohanska D, & Lucas B. Recent advances following anterior cruciate ligament reconstruction: Rehabilitation perspectives. Curr Rev Musculoskelet Med. 2012;5(1):59-71.

5. Wright RW, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: Part I: Continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg. 2008;21:217-24.

6. Melegati G, et al. The role of the rehabilitation brace in restoring knee extension after anterior cruciate ligament reconstruction: A prospective controlled study. Knee Surg Sports Traumatol Arthrosc. 2003;11:322-326.

7. Birmingham TB, et al. A randomized control trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. AJSM. 2008;36(4):648-655. doi: 10.1177/0363546507311601 8. Pezzullo DJ & Fadale PF. Current controversies in rehabilitation after anterior cruciate ligament reconstruction. Sports Med Arthrosc Rev. 2010;18(1):43-47.

9. Cook C et al. Continental variations in preoperative and postoperative management of patients with anterior cruciate ligament repair. Eur J Phys Rehabil Med. 2008;44(3):253-61.

10. Marx RG et al. Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy. 2003;19:762-70.

11. Wentzensen A & Hochstein P. Management of anterior cruciate ligament rupture: Indications, choice of procedure, timing, concomitant and aftercare. Zentralbl Chir. 1998;123:970-80.

12. Sterett WI, Briggs KK, Farley T, Steadman, JR. Effect of functional bracing on knee injury in skiers with anterior cruciate ligament reconstruction. AJSM. 2006;34(10):1581 5.doi:10.1177/0363546506289883

a. Use of Knee Braces in Comprehensive Knee Rehabilitation & Knee Pain Management. Availableat www.drbraceco.com

b. www.biodynamictech.com/po_kneebrace.html

c. Capitaldealsonline.com/store/the-bledsoe-rehab-knee-brace-regular-red-w-quicklok-hinge/ d. Rishiraj et al. Functional knee bracing and athletic performance. Journal of Foot and Ankle Research.2011, Available at www.lowerextremity review.com/article/functional-knee-bracing-and athletic-performance e. www.breg.com