From the
Cincinnati Sportsmedicine and Orthopedic Center and the Deaconess Hospital, Cincinnati,
Ohio.
This work was funded by the
Cincinnati Sportsmedicine Research and Education Foundation and by a grant from Bledsoe
Brace Systems.
The authors thank Jennifer V.
Riccobene for her expert technical assistance.
ABSTRACT
We studied a brace design to
decrease loads on the medial tibiofemoral compartment in knees with chronic pain and
arthrosis to determine if pain symptoms decreased, function improved, and dynamic gait
characteristics altered during walking. Eighteen patients with symptomatic medial
compartment arthrosis were fitted with a commercially available brace. All were evaluated
after an average of 9 weeks of brace wear, and 13 patients were evaluated after 1 year of
brace wear. The Cincinnati Knee Rating system and additional pain scales were used to
analyze symptoms and functional limitations. Nine subjects underwent a dynamic gait
analysis and were compared with a control group of 11 normal subjects matched for age and
walking speed.
The brace was worn an average
of 7 hours a day, 5 days a week. Following 9 weeks of brace wear, statistically
significant improvements were found for all pain parameters, and these improvements
continued at the 1 year evaluation. Before brace wear, 78% had pain with activities of
daily living, but after the first evaluation, only 39% continued to have such pain, and at
the second evaluation, only 31% were so affected. Before brace wear, patients had a
walking tolerance of 51 minutes prior to the onset of pain symptoms. At the first
evaluation, patients could walk138 minutes without pain, and after 1 year, they could walk
107 minutes without pain. Before brace wear, 78% rated their overall knee condition as
fair or poor whereas at the first evaluation, only 33% continued to provide this rating.
No differences were found in the dynamic gait parameters measured with and without the
brace.
While this did not provide the
dramatic improvements in symptoms, function, and patient satisfaction obtainable after
high tibial osteotomy, it did help the majority of patients. If the goal of brace use is
to buy a short amount of time for patients who cannot undergo or wish to avoid osteotomy
or knee arthroplasty, then bracing appears to offer a reasonable alternative for
short-term pain relief and improved function.
Many patients develop medial
tibiofemoral compartment knee arthrosis due to varus malalignment, prior medial
meniscectomy, trauma, or other less-defined reasons. Treatment goals of such individuals
are to decrease pain symptoms, allow maintenance of reasonable activities, and prolong the
period until joint arthroplasty is required. In the younger active patient with varus
malalignment and early symptomatic medial arthrosis, our recommendation is to perform a
valgus-producing osteotomy to decrease medial compartment loads, diminish symptoms, and
improve function.
In a prospective study of 41
patients who underwent osteotomy, 88% were satisfied a mean of 58 months postoperatively
and would undergo the operation again, and 78% felt their knee condition was improved by
the operation.1 We1 and others2 have noted that improved
preoperative planning and a precise surgical technique combined with immediate
postoperative motion decreased the morbidity and complication rate and increased the
predictability of valgus-producing osteotomy.
A number of patients with
medial compartment arthrosis and varus malalignment are not candidates for osteotomy or
knee arthroplasty. These are individuals who simply may refuse these procedures from an
economic standpoint, who are unwilling or unable to miss work for the operation, or who
are of an advanced age desiring to buy few years prior to these procedures. In these
instances, the use of a brace designed to diminish medial compartment loads, along with
appropriate anti-inflammatory or pain medication when indicated and judicious activity
modification, may decrease pain and increase function. In the past few years, a number of
commercial braces have been introduced in to the clinical treatment of patients with
medial compartment arthrosis.
This study prospectively
followed a consecutive group of patients who used one type of brace designed to diminish
medial compartment loads and improve function. All patients were assessed after 9 weeks
and 1 year of brace wear to determine symptoms, functions, and patient satisfaction. A
dynamic gait analysis also was performed, recording motions of the lower extremity and
ground reaction forces with and without the selected brace, to determine if abnormal or
improved alterations in gait dynamic resulted.
MATERIALS AND
METHODS
Subjects. Inclusion
criteria for this study were persistent chronic medial tibiofemoral compartment pain that
affected sports or daily activities, arthroscopic or radiographic documentation of medial
compartment arthrosis, and varus osseous alignment. Over a 2-month period, 19 patients who
met this criteria consented to participate. One additional patient who presented with
diffuse knee pain and lateral instability also was included in the study to determine the
brace’s ability to alleviate diffuse pain. Inclusion
criteria for this study were persistent chronic medial tibiofemoral compartment pain that
affected sports or daily activities, arthroscopic or radiographic documentation of medial
compartment arthrosis, and varus osseous alignment. Over a 2-month period, 19 patients who
met this criteria consented to participate. One additional patient who presented with
diffuse knee pain and lateral instability also was included in the study to determine the
brace’s ability to alleviate diffuse pain.
All patients were fitted with
a brace according to the manufacturer’s specifications (Bledsoe Brace Systems, Grand
Prairie, Tex). The brace was designed to decrease loads on the medial tibiofemoral
compartment using a dual-hinged adjustable strut fixed to the brace shell at the calf and
thigh (Fig 1). Patients were told to wear the brace for as many hours and for as many days
of the week as they wished.
| fig 1 (not yet available) |
| Fig 1: Photograph of the brace design. The brace was used according to
the manufacturer's specifications. |
Two patients who were
noncompliant with the study protocol and used the brace for only 1 hour a day for less
than 2 weeks were deleted from the study. This left 18 patients (14 men and 4 women) with
a mean age of 41 years (range: 21 to 78 years). All had a chronic medial compartment pain
ranging from 8 to 396 months (mean: 137 months) prior to the initiation of this study.
All patients had undergone
multiple operative procedures, including multiple arthroscopies. Twelve patients also had
partial or total medial meniscectomies, three had high tibial osteotomies, three had
anterior cruciate ligament reconstructions, and one had a lateral reconstruction. Nine
patients had sustained the original injury during an industrial accident, seven during
sports activities, and one during activities of daily living. One patient did not sustain
a specific injury. Seven patients were completely disabled from their occupations due to
arthrosis symptoms.
Evaluation. A
comprehensive interview was administered before brace wear, after the initial follow-up
evaluation (mean: 9 weeks), and after the final follow-up evaluation (mean: 46 weeks).
Five of the 18 patients discontinued use of the brace after the first follow-up
evaluation. One patient elected to undergo high tibial osteotomy even though the brace had
been effective in reducing pain symptoms, one patient had a lateral and posterolateral
ligament reconstruction after the brace had been ineffective in reducing pain, one patient
felt that medication was more effective in pain relief than the brace, and two patients
stated that the brace was not effective enough to continue the study. Therefore, 13
patients completed the second follow-up evaluation. All patients completed questionnaires
and were interviewed for the assessment of symptoms, sports activities, occupational
activities, and functional limitations according to the Cincinnati Knee Rating System.3,4
To assess pain symptoms, a
visual analogue scale was used in which a score of 1 indicated no pain and 10 indicated
severe pain. Walking tolerance was determined by asking patients how many minutes they
could walk without incurring significant pain. Pain with walking was analyzed further on a
scale of 1 to 5, with 1 indicating mild pain and 5 indicating excruciating pain. Patients
indicated the number that best described their pain after 30 and 60 minutes of mall
shopping. The location of the pain was documented as either medial, lateral, anterior, or
generalized. Finally, patients were asked if none, some, or significant pain relief was
provided by only the brace, by only medication, or by both the brace and medication.
Patients completed a
self-assessment of the overall condition of their knee on a scale of 1 to 10 where scores
of 1 and 2 indicate a poor knee; 3 and 4, a fair knee; 5 and 6, a good knee; 7 and 8, a
very good knee; 9 and 10, a normal knee. The scale was completed at the pre-brace and both
follow-up evaluations.
At the two follow-up
evaluations, patients were asked to provide an n average of the hours a day and days per
week that the brace had been worn. They were asked if the brace helped a great deal and
was used frequently, if it provided some help and was worthwhile to wear, or if it had
been no help at all. Problems encountered with brace wear were documented and included
slipping, pain, skin irritations, or any other complaint. All of the patients’
comments were recorded by an interviewer other than the physician who prescribed the
brace.
In 18 patients, the appearance
of the articular cartilage was determined during a prior operative procedure performed
closest in time to the initiation of brace wear according to our previously described
system.5 In six patients, the classification was accomplished within 6 months
of brace wear; in four patients, between 7 and 12 months; in four patients, between 1 and
2 years; and in four patients, after 2 years.
Surface abnormalities were
categorized as normal, grade I (softening), grade II (fissuring and fragmentation), or
grade III (exposed bone). Each category then was divided into a subtype A or B depending
on whether the depth of the lesion was less than or more than one half of the depth of the
surface. For this study, a lesion was classified as abnormal if it was grade IIA, IIB, or
III and had an area of at least 15 mm in diameter.
Radiographs (standing
anteroposterior 45 , lateral, and merchant views) taken prior to initiation of brace wear
were assessed for any tibiofemoral joint space narrowing. Narrowing was classified as
either none or mild, moderate (loss of less than one half of the total joint space) or
severe (loss of one half or more of the total joint space). In 13 patients, radiographs
were available within 6 months of brace wear; in 1 patient, between 7 and 12 months; in 3
patients, between 1 and 2 years; and in 1 patient, after 2 years.
Gait Analysis Gait
analysis tests were performed on nine of these patients at the Cincinnati Sportsmedicine
and Deaconess Hospital facility using the GaitLink System (Computerized Functional Testing
Corp [CFTC], Chicago, Ill). The equipment included a two-camera video-based optoelectronic
digitizer for measuring motion and a multicomponent force plate (Bertec, Columbus, Ohio)
for measuring ground reaction force, camouflaged under a 10-m walkway. Measurements were
obtained by a micro-computer based acquisition system and remotely processed at the CFTC
laboratory using techniques described previously.6-9
The testing protocol involved
placing passive reflective markers at the superolateral most aspect of the iliac wing, the
lateral most aspect of the greater trochanter, the lateral most aspect of the joint line
of the knee, the lateral malleolus, and the lateral head of the fifth metatarsal of the
left and then the right side of the body. Each side was marked and tested separate from
the other. Limb movement and mechanical moments were calculated by computer software based
on information from the three-dimensional position of these markers.
Subjects completed two tests:
a pre-brace gait analysis and a post-brace gait analysis (minimum of 4 weeks after brace
wear). At the post-brace test, the patient was tested both with and without the brace.
Each subject was asked to walk at normal, fast, and slow walking speeds along a 10-m
walkway. Data were collected during the middle stride of several strides with the
measurements starting just before the foot reached the force plate and continued after the
foot left the force plate to obtain a complete cycle of stance and swing phase. To control
for the effect of walking speed on other gait variables, measurements were obtained over a
range of walking speeds to select and compare tests of similar walking speeds.
For purposes of analysis and
comparison, measurements taken at the speed closest to 1 m/sec were used.7,10,11
Five subjects were tested both immediately after fitting the brace and after 6 weeks of
wear to determine if brace wear led to any learned alterations in gait. Data from these
six subjects demonstrated no apparent learned alterations in gait. Therefore, only four
other subjects underwent gait analyses immediately after being fitted with the brace.
Printed data were generated in
graphic form to correlate events with the gait cycle. Kinematic data in the sagittal plane
and kinetic data in the sagittal, coronal, and transverse planes of the hip, knee, and
ankle were available for evaluation. Peak values during stance phase were identified and
recorded for each patient.11
The statistical means and
standard deviations for all nine patients were calculated, and peak values with and
without bracing were compared using a paired, two-tailed Student’s t-test. The
gait analyses of 11 unbraced control subjects with no knee injury who were matched for
walking speed were used as a control group. An unpaired, two-tailed Student’s t-test
was used to compare patient values to control subjects. All moments were expressed as
external moments and normalized to body weight and height (hence the use of units of %
body weight (BW) X height (Ht) to allow comparison between subjects of different sizes.
Statistical Analysis. The
statistical analysis means and standards for all patients were calculated, and values with
and without bracing were compared using a paired, two-tailed Student’s t-test.
The level of significance was P<.05.
RESULTS
Brace Wear. At the first
follow-up, the mean (± standard deviation) number of hours patients spent wearing the
brace was 6.9±4.6 hours (range: 1 to 14 hours) and the mean number of days of brace wear
was 5.2±2.1 days (range: 1 to 7 days). At the second follow-up, the mean number of hours
of brace wear was 7.7±3.6 hours (range: 0 to 12 hours) and the mean number of days of
brace wear was 5.1±2.1 days (range: 0 to 7 days). Between the two follow-up evaluations,
6 patients increased the hours of brace wear per day, 6 decreased, and 1 remained the
same.
Articular Cartilage and
Radiographic Evaluation. Abnormal articular cartilage lesions were found in the medial
tibiofemoral compartment in 14 of the 18 patients during arthroscopy performed a mean of
22 months prior to the initiation of brace wear. Grade IIA lesions were found in four
patients, grade IIB lesions were found in three of the patients, and grade IIIA lesions
(subchondral bone exposure) were found in 7 patients. The lateral tibiofemoral compartment
had a normal appearance in all but 6 patients who had small (<15 mm in diameter) grade
IIA lesions. Abnormal articular cartilage lesions were found in the patellofemoral
compartment in 13 patients. These included grade IIA lesions in 8 patients, grade IIB
lesions in 2 patients, and grade IIIA lesions in 3 patients.
Moderate to severe loss of
medial tibiofemoral joint space was found in 7 of the 18 patients a mean of 8 months prior
to brace wear. Eleven patients had no or only a mild loss of medial tibiofemoral joint
space on radiographs.
In combining the arthroscopic
and radiographic data, 15 of the 18 patients exhibited a significant loss of medial
tibiofemoral joint space or articular cartilage lesions in the medial tibiofemoral
compartment. Two knees with mild medial compartment narrowing on radiographs had both had
medial meniscectomies more than 10 years prior to our evaluation. One other patient who
had normal radiographs wore the brace for lateral and posterolateral ligamentous
deficiency.
Pain Analysis. Before
receiving the brace, 17 of the 18 patients stated their pain was localized to the medial
tibiofemoral compartment and 1 patient had diffuse pain. At the first follow-up, 16
patients had medial joint pain, 1 had lateral joint pain, and 1 had diffuse pain. At the
second follow-up, 8 of the 13 patients had medial joint pain and 5 had diffuse pain.
Before receiving the brace, 10
patients were using medications for pain relief. At the first follow-up evaluation, 11
patients were using medications, and at the second follow-up, 6 patients were using pain
medications. The majority of medications were non-steroidal anti-inflammatory medications
and over-the-counter pain agents.
Statistically significant
differences for the Cincinnati Knee Rating pain scores were found between the pre-brace
evaluation and both follow-up evaluations (Fig. 2). The pre-brace mean value of 2.3±1.8
points improved to 4.0±2.2 points at the first follow-up (P=.001) and to 4.2±2.2 points
at the second follow-up (P=.0008). Before wearing the brace, 14 patients (78%) had
moderate to severe pain with daily activities. At the first follow-up, only 7 patients
(39%) continued to have such pain, and at the second follow-up, 4 of 13 patients (31%)
continued to be so affected. Compared with the pre-brace evaluation, the pain score
improved in 10 patients at the first follow-up evaluation and in 9 patients at the second
follow-up evaluation. There was no significant difference in the pain scores between the
two follow-up evaluations.
 |
| Fig2 : Results of the Cincinnati Knee Rating System pain scale before
brace wear and following 9 weeks and 1 week of brace wear. The percent of patients who had
pain with daily activities was significantly reduced at both follow-up evaluations
(P<.001) compared with the pre-brace evaluation. |
Statistically significant
differences were found between the pre-brace evaluation and both follow-up evaluations for
the pain analogue scale (1 being no pain and 10 being worst pain). The pre-brace mean
value of 7.3±2.3 points decreased significantly to 4.4±2.1 points (P=.0001) at the first
follow-up, and to 4.8±2.1 points (P=.0001) at the second follow-up. Again, compared with
the pre-brace evaluation, this pain score decreased in 17 patients at the first follow-up
evaluation and in 13 patients at the second follow-up evaluation. There was no significant
difference in the mean values between the two follow-up evaluations.
Statistically significant
improvements were found for the analysis of minutes patients could walk without
experiencing pain for both follow-up evaluations compared with the pre-brace evaluation
(P<.01 for all comparisons) (Fig. 3). The use of medication had a significant effect on
this variable only at the second follow-up evaluation (P<.05). There was no significant
difference in this variable between the two follow-up evaluations.
 |
| Fig 3: The mean minutes patients could walk before experiencing knee pain
is shown before brace wear and after 9 weeks and 1 year of brace wear. The effect of
medication intake on minutes of pain-free walking also is shown. The improvements
found for both follow-up evaluations were significant (P<.01) compared with the
pre-brace evaluation. The use of medication had a significant effect on this variable only
at the second follow-up evaluation (P<.05). |
Patients reported a decrease
in the intensity of pain during mall shopping for both 30- and 60-minute evaluations (0
being no pain and 5 being excruciating pain). For 30 minutes, the pre-brace pain intensity
mean of 3.7±1.5 points decreased significantly to 1.9±1.5 points (P=.001) at the first
and to 2.2±1.7 points (P=.001) at the second follow-up evaluations. For 60 minutes of
mall shopping, the pre-brace pain intensity mean of 4.1±1.4 points significantly
decreased to 2.5±1.9 points at the first and to 2.7±1.9 points at the second follow-up
evaluations. There was no significant difference in these scores between the two follow-up
evaluations for either the 30- or 60- minute evaluation.
When asked if the brace
provided any pain relief, 7 patients had significant, 10 patients had some, and 1 patient
had no pain relief at the first follow-up evaluation. At the second follow-up evaluation,
3 patients had significant, 8 patients had some, and 2 patients had no pain relief with
brace wear.
Functional Limitations.
Statistically significant improvements were found for limitations with walking on the
Cincinnati Knee Rating scale at both follow-up evaluations (P=.01 for both comparisons)
(Fig. 4). Before wearing the brace, 8 (44%) patients could not walk more than three blocks
and 4 (22%) could not walk more than one block. At the first follow-up evaluation, only 5
(28%) patients continued to be so affected, and at the second follow-up, 3 (23%) of 13
patients had these limitations. Walking scores improved in 12 patients between the
pre-brace and first follow-up evaluations, and theses scores improved in 9 patients
between the pre-brace and second follow-up evaluations.
 |
| Fig4 : Functional limitations experienced by patients with normal
walking, as rated on the Cincinnati Knee Rating scale, before brace wear and after 9 weeks
and 1 year of brace wear. Significant improvements were found at both follow-up
evaluations (P=.01). |
There were no significant
improvements in stair climbing or squatting scores at either follow-up evaluation.
Additionally, no significant improvements were found in the 3 sports functions assessed
(running, jumping, and twisting) at either follow-up evaluation. Only 2 patients were able
to perform the 3 sports functions with no or only mild limitations. The remaining patients
did not even attempt these activities.
Sports and Occupational
Rating. Before the original knee injury, all 18 patients were participating in sports
activities (Table 1) with no symptoms or knee limitations. Prior to receiving the brace,
only 4 patients continued to participate, and three of these patients had symptoms and had
been advised to give up their athletic activities. At both follow-up evaluations, 6
patients were participating in swimming or bicycling activities.
Before receiving the brace,
nine patients were working (five with symptoms) and eight were on full disability due to
their knee condition (Table 2). Seven of the eight patients on disability received
workers’ compensation. At the first follow-up evaluation, no change was found in the
occupational rating; however, three patients who had symptoms while working before wearing
the brace reported their symptoms had decreased and no longer affected their work
activities. At the second follow-up evaluation, one patient who had been on disability
(not on workers’ compensation) had been able to return to work without significant
symptoms. Seven other patients who were evaluated were working; three had symptoms with
their occupations. None of the workers’ compensation patients who were disabled
before wearing the brace returned to work during the follow-up evaluation period.
Patient Perception of
Overall Knee Condition. During the pre-brace evaluation, the mean patient perception
score (1 being poor and 10 being normal) was 3.4±1.4 points, with 14 (78%) patients
rating their knee condition as poor or fair and 4 (22%) patients rating it as good. At the
first follow-up evaluation, the mean score had improved significantly to 5.4±2.1 points
(P=.001) with 6 (33%) as good, 5 (28%) as very good, and 1 (6%) as normal. At the second
follow-up evaluation, the mean score of 4.7±2.0 remained significantly improved compared
with the pre-brace evaluation (P=.01). Six (46%) patients rated their knee condition as
poor or fair, 5 (38%) as good, 1 (8%) as very good, and 1 (8%) as normal.
Sixteen of the 18 patients
provided a higher score on the perception scale at the first follow-up evaluation compared
with the pre-brace evaluation. Nine of the 13 patients evaluated at the second follow-up
provided a higher score on the scale compared with that given during the pre-brace
evaluation.
Gait Analysis Evaluation.
After brace application, the mean value for the adduction moment did not change. Mean
adduction moment without the brace measured 3.5±0.8% BW X Ht versus 3.5±0.8% BW X Ht
when wearing the brace. There was no observed decrease in the adduction moment of the
involved knee when wearing the brace, and there was no readily apparent gait adaptations
following brace application.
Peak force during stance and
gait velocity were not altered with brace wear (P<.05). There were no differences
between the adduction moment at the hip, the flexion or extension moment at the knee, or
the inversion-aversion moments at the ankle with brace wear (P<.05), nor were there
significant differences in foot progression angle in the unbraced versus the braced
condition. In addition, when multiple regression analysis was used to examine the
relationship between the alteration in adduction moment with brace wear and the alteration
in each of the aforementioned parameters separately and in combination, no significant
correlations were found.
DISCUSSION
Of the 18 patients who
completed the short-term evaluation and brace wear in this study, 15 benefited with either
a reduction in pain symptoms, an increase in walking tolerance, or both. Of the 13
patients who continued to wear the brace for an average of 1 year, 10 had an improvement
in pain or function compared with their pre-brace evaluation. While use of this brace did
not provide the dramatic improvements in symptoms, function, and patient satisfaction that
are obtained after osteotomy,1 it did help the majority of patients in this
study.
The mean age of the patients
selected for brace wear was 41 years. Osteoarthritis in patients younger than 50 years
presents a difficult problem: total knee arthroplasty is not recommended due to increased
activity levels, a longer expected life span, and the projected need for multiple future
revisions. Arthroscopic debridement may provide temporary relief, but in cases of
significant articular cartilage loss, this is generally a temporary measure at best.12
If the goal of a
valgus-producing brace is to buy a period of time for patients who cannot undergo or wish
to avoid osteotomy or knee arthroplasty, then the brace tested in this investigation
appears to be a reasonable alternative for pain relief and improved function. We
acknowledge the variability in the success rate of osteotomy, its high risks of
complications, and the potential difficulty of eventual revision to total knee
arthroplasty.2,6,10,12 However, in our experience, osteotomy has provided more
symptom relief for longer periods of time, more patient satisfaction, and more improvement
in function in younger active individuals with symptomatic medial compartment arthrosis
and varus malalignment than any commercially available brace that we are aware of.
Several criteria were used to
assess pain during this investigation. Some of the most dramatic improvements were found
in the minutes of walking patients could tolerate before the onset of pain symptoms.
Wearing the brace allowed patients to more than double their walking time without pain,
from 51 to 138 minutes without medication following 9 weeks of brace wear and to 107
minutes after 1 year of brace wear.
Before the investigation, 14
patients had pain with daily activities. After 9 weeks of brace wear, only 7 patients
continued to have pain with daily activities and after 1 year, 4 of the 13 patients
continued to be so affected. Seventeen of the 18 patients felt some alleviation of pain
symptoms after 9 weeks of wear, and 11 of 13 continued to feel this improvement after 1
year of wear.
The brace had little impact on
returning patients to sports activities; only a few patients attempted any type of
athletics, and these were typically light swimming or bicycling activities only. These
individuals were advised to avoid high-impact strenuous activities involving turning,
twisting, cutting, or jumping motions due to the amount of joint arthrosis and the varus
malalignment present. Additionally, the brace had little effect on returning patients who
were disabled back to work. However, seven of the eight individuals on full disability
were supported by workers’ compensation, which may have had an additional effect on
the motivation to return to work.
The patients tended to use the
brace a mean of 7 hours each day, 5 days each week. This was a high use level, and we
advised some of these patients to be careful of overusing the knee due to the underlying
arthrosis. The physician and physical therapist are important components of successful
brace use and the achievement of a high patient satisfaction level. The clinical team must
educate the patient concerning the proper use of the brace and be ready to help with any
brace problems when necessary. It is important to educate the patient concerning the
issues of slipping, pinching, skin irritation, and wearing the brace under high
temperature conditions.
Most patients wore the brace
during high-activity periods of the day. Eight patients were able to use the brace alone
to alleviate their pain symptoms, while the remaining 10 patients continued to use some
level of nonsteroidal anti-inflammatory medication in addition to the brace. The
combination of these two treatment modalities provided significant pain relief and
functional improvement.
We have used valgus-loading
braces for indications other than pain relief of medial compartment gonarthrosis and found
these braces to be useful in protecting the knee from varus thrusting motions after
lateral and posterolateral ligament reconstructions. These braces may function as an
additional restraint that adds stability to the knee joint.2,13,14 One patient,
a 23-year-old woman, was totally disabled when she presented to our center 4 years
following an industrial accident and a failed lateral reconstruction. She could walk only
5 minutes prior to the onset of pain symptoms that she described as excruciating. After 9
weeks of brace wear, she could walk for 1 ½ hours before the onset of pain. The brace was
used successfully in conjunction with an intensive gait retraining program15 to
prepare this patient for the lateral and posterolateral reconstruction. This clinical
situation offers indication for brace wear in select patients with lateral and
posterolateral ligament insufficiency, and varus recurvatum and thrust during walking
activities.
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