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Document Title: Risberg-AJSM-Jan99.shtml
Article Title: The effect of knee bracing after anterior cruciate ligament reconstruction: A prospective, randomized study with two years' follow-up
Authors: May Arna Risberg, Inger Holm, Harald Steen, Jan Eriksson, Arne Ekeland.
Publication: The American Journal of Sports Medicine
ISSN: 03635465
Date: January/February 1999
(Figures included. Reference-denoting numbers appear in the same point size as document text.)
Volume: 27
Issue: 1
Page: 76
Key Words: Knee, brace, anterior cruciate, ACL ligament, anterior-drawer counteraction.
Comments: Risberg et al. found that, in the context of rehabilitation from standard tendon-graft ACL reconstruction, the benefits of functional bracing vary with how the braces are used. Improvement in Cincinnati Knee Score was noted in the braced group, albeit only at 3 months. Increased quadriceps-group atrophy was also correlated with brace use (although this is likely a result of the patients having been instructed to wear the bracing nearly continuously during the first 3 months postoperative...perhaps shortening this continuous-wear period would have been preferable, followed by a recommendation to wear the brace during any activity in which the knee could be forced sideways or hyperextended). The major problem with this study is that the functional bracing was continuously worn (or, more specifically, the patients were instructed to wear their bracing continuously for a couple of months) -- and this does not reflect the more-appropriate use of functional braces for knee-demanding activities only. Wearing any brace continuously, day after day, can of course cause muscular atrophy...but wearing a brace only during knee-strenuous activities will not cause such atrophy. Granted, a functional brace can be worn continually initially just after an ACL reconstruction, thus duplicating the function of a rehabilitative brace. But wearing any brace for months on end, all day and every day, is unnecessary. At the very least, extra exercises (both with and without bracing) should have been done during the continuous-brace-wear period, in order to avoid atrophy concerns.
In terms of overall results at final follow-up at 2 years, whether or not bracing was used was found to have no effect on knee laxity, range of motion, strength, functional abilities, or patient satisfaction. No evidence that bracing reduced the risk of new injury was observed; unfortunately, the study does not give any details regarding modes of any injuries, since the mode of injury (twisting, sideways forcing, hyperextension, etc.) plays a major role in whether or not a brace can provide protection. Consider that the authors describe the sports in which the patients originally injured their knees, but neglected to describe the forcing the knee was exposed to. Even though the study leaves the reader with the impression that neither group incurred any reinjuries, some table documenting this directly would have been nice. While it is always desirable for people to not reinjure their knees, note that the patients might simply have been fortunate to not have encountered any situations (such as contacting other players in various team sports) in which their knees might have been forced in such a way as to cause reinjury. A longer follow-up period, for example 5 years, would have been preferable. Also, note that this study only looked at the DonJoy GoldPoint brace, an off-the-shelf open-shell brace whose frame design has the same general attributes (most notably, a tendency to sit solely on the leg's soft tissues, hence an inability to grasp the tibial crest and also a tendency to shift on the leg with each leg-musculature activation) as the DonJoy Defiance. When extrapolating the findings of this study to other knee braces, these points must be borne in mind. Note, too, that in any given group of people, some individuals will likely have a leg shape that is incompatible with the use of off-the-shelf knee bracing; these individuals should be provided with custom-made bracing. It is unlikely that every brace-using person (30 people) in this study was truly well-fitted by the GoldPoint brace; this, in turn, may have impinged on the usefulness of the bracing. Consider that 7 out of the 30 braced-group patients had problems with eczema and discomfort, and therefore did not use the bracing for 3 months as instructed, and so it is plausible that they did not use the bracing subsequently during strenuous activities. Furthermore, no mention was made of the fitting procedures for the brace, and so it appears that the braces were merely given to the patients. It also seems that the braces were given to the patients without any explanation of the capabilities and limitations of bracing. In summary, although this study provides very useful insight, it is inappropriate to declare functional knee bracing useless in the context of ACL reconstruction simply on the basis of this study.
ABSTRACT
The purpose of this prospective, randomized, clinical trial was to evaluate the effect of knee bracing after anterior cruciate ligament reconstruction. Sixty patients were randomized into one of two groups: Patients in the braced group wore rehabilitative braces for 2 weeks, followed by functional braces for 10 weeks, and patients in the nonbraced group did not wear braces. Data were recorded preoperatively, and postoperatively after 6 weeks, 3 and 6 months, and 1 and 2 years. The following outcome measures were used: KT-1000 arthrometry, the Cincinnati knee score, goniometry to record range of motion, computed tomography to determine thigh atrophy, Cybex 6000 isokinetic testing to evaluate muscle strength, three functional knee tests, and a visual analog scale to evaluate pain. At all follow-up times there were no significant differences between the two groups with regard to knee joint laxity, range of motion, muscle strength, functional knee tests, or pain. However, the Cincinnati knee score showed that patients in the braced group had significantly improved knee function compared with patients in the nonbraced group at the 3-month follow-up, even though the braced group showed significantly increased thigh atrophy compared with the nonbraced group at 3 months.
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