ROSE MUSCULOSKELETAL RESEARCH LABORATORY

AN IN VIVO ANALYSIS OF THE EFFECTIVENESS OF THE OSTEOARTHRITIC KNEE BRACE DURING HEEL STRIKE OF GAIT

Richard D. Komistek, PhD^1,2
Douglas A. Dennis, MD^1,2
Eric J. Northcut¹
Adam Wood¹

¹Rose Musculoskeletal Research Laboratory
2425 S. Colorado Blvd., Suite 280
Denver, CO 80222

²Colorado School of Mines
Division of Engineering
Golden, CO 80401

Presently, there are multiple nonoperative techniques a surgeon can use to alleviate the pain of an osteoarthritic joint: medication, physical therapy, and off-loading knee bracing. The objective of this study was to analyze subjects under in vivo, dynamic, weight-bearing conditions using fluoroscopy to determine if off-loading knee braces actually separate the femoral condyle from the tibial plateau, thus avoiding a bone-on-bone condition. While fluoroscopy has proven to be a valuable tool for determining in vivo kinematics, previous studies utilizing fluoroscopic techniques have concentrated on knee kinematics in total knee arthroplasty.^27,28

D = Dm (brace) - Dm (no brace),

and the actual amount of change in varus/valgus was determined from the equation:

q = q_s (brace) - q_s (no brace).

Figure 1. Subject performing normal gait on a treadmill a) without a brace and b) with a brace.

Figure 2. Schematic of the digitized points on the femur and the tibia.

Figure 3. Fluoroscopy of a randomly selected subject at heel strike a) without a brace and b) with a brace.

Figure 4. Fluoroscopy of a randomly selected subject at heel strike a) without a brace and b) with a brace.

Figure 5. Fluoroscopy of a randomly selected subject at heel strike a) without a brace and b) with a brace.

The osteoarthritic knee joint is very painful and often debilitating. Numerous treatments for the osteoarthritic knee that can be prescribed for the patient, of which, the most prescribed surgical treatment is the tibial osteotomy.^24,29-33 In a perspective study Odenbring, et al. (1989),analyzed thirty-two knees having a tibial osteotomy in thirty-two patients. The subjects were randomized with either a cylinder fill plaster cast (17 knees) or hinge cast brace (15 knees) after being treated for medial gonarthrosis at six weeks, three months, and one year after surgery they reported that the range of motion was better in the cast brace group. There was no difference in the other critical results at three months and one year after surgery nor in the changes of the osseous correction along the final medial line. All patients in the cast brace group were satisfied with their early motion. They concluded that there was a positive experience with the patients in the cast brace group which leads them to conclude that early knee mobilization can be initiated without harm after tibial osteotomy using a staple as an internal fixation and a brace as an external support. Kriegshauser and Bryan, (1985) and Hackel et al (1987) have reported good results with early motion after high tibial osteotomy for gonarthrosis. After this operation they compared early knee mobilization using a hinge cast brace as an external support and a control group with the plaster cast mobilization. The results of these two studies were very similar to those obtained by Odenbring et al (1989). Myrnerts (1980), conducted a study that concluded 78 tibial osteotomies for medial gonarthrosis. The knees were gently mobilized for ten days followed by six weeks in a cylindrical plaster cast. After twelve months follow-up knee flexion was either unchanged or was reduced more than 5 degrees in one-third of the patients respectively. The results from this study cannot lead to a definite conclusion on whether the subjects benefited from being immobilized in a plaster cast. Tjornstrand et al (1981), found that knee flexion exceeded ninety degrees in 50 of the 52 preoperative knees, and 47 of the 52 subjects one year after tibial osteotomy. In two studies by Hackel et al (1984, 1987), they reported that 39 subjects had successful healing of osteotomies in the first study and 132 successful osteotomies in his second study. In a study by Heine³⁴ (1926), he concluded that osteoarthritis occurred most commonly in the knee joint. More than 90% of osteoarthritis occurred in patients 60 years of age and older. This study correlated well with the roentgenologic assessment of the Kellegan and Lawrence³⁵ (1958). They discovered that more than 80% of the subjects 55 years of age and older, experienced osteoarthritis to some degree. In this study, Kellegan and Lawrence concluded that subjects in older populations are at much higher risk of surgical and anesthetic procedures for osteoarthritis.^36-39 Goldberg (1977) reported that the operative risk to osteoarthritic patients was related to their decline in general medical condition. In particular, these subjects experienced cardiovascular and respiratory ailments. Specifically, in Japan for example, cardiovascular disease is 3.5 times higher in persons older than 55.⁴⁰ Therefore, Goldberg (1977) reported that it is important to avoid surgery whenever possible and to choose an alternative procedure that would most benefit osteoarthritic patients. He concluded that it is most effective to use a wedge insole orthosis whenever possible for osteoarthritic patients. However, other studies have shown that this treatment modality has been shown to be effective only in early stage osteoarthritis, whereas subjects who suffered severely from osteoarthritis were not affected by this treatment.^41-42 Because high tibial osteotomy surgery is very expensive and is shown to be a risk to elderly patients, and because wedge insole orthosis modality has shown to be non-effective in patients who severely suffer from osteoarthritis, it is important to develop a more effective therapy . Our study concentrates on the effectiveness of an osteoarthritic knee brace for patients who have been diagnosed with osteoarthritis. The results for this study fifteen subjects were prescribed a Bledsoe Thruster knee brace by their orthopedic surgeon. We found that the brace was very easy for the subjects to use, they were able to very quickly learn how to attach the brace. Pain levels during treadmill gait were assessed for each subject with and without an attached osteoarthritic brace. Subjects were instructed to qualitatively express levels of pain relief and comfort while wearing the brace. Twelve of the fifteen subjects informed us that, while wearing the brace, the brace was providing some pain relief. However, the subjects who exhibited minimal benefits were rated as below average candidates because of poor brace fixation due to obesity. These three subjects still felt pain when they walked with the brace. When the videos were downloaded to the computer workstation and subsequently digitized it was quite noticeable that the twelve subjects who no longer felt knee pain while wearing a knee brace had significant separation of the medial condyle from the tibial plateau. Impact loads generated due to heel strike during gait represent a worse case scenario in effectiveness in functional knee bracing. Twelve of the fifteen subjects (80%) entered in this study experienced significant medial compartmental separation while wearing a knee brace, therefore, it can be concluded that the Bledsoe Thruster brace is a beneficial form of treatment for the osteoarthritic patient.

Previous biomechanical studies have documented excessive loads occurring in knees diagnosed with degenerative unicompartmental osteoarthritis. Pain management has made it necessary to release or offload the diseased femoral condyle. These high loads across the knee joint, if not treated effectively, could lead to total failure in the knee requiring total knee arthroplasty. As stated earlier, osteoarthritic knee braces have been developed to lessen loads in the degenerative compartment while subsequently reducing knee pain. This present study demonstrated that articular separation of a degenerated knee compartment was achieved with the Bledsoe Thruster knee brace with subsequent subjective relief of knee pain. Although these knee braces seem to be very effective devices for pain management, they may be limited in their effectiveness to offload and relieve pain in heavier patients.

1. Beynnon BD, Johnson RJ, Fleming, BC, Peura GD, Renstrom PA, Nicholas CE, Pope, and Pope MH: The effect of functional knee bracing on the anterior cruciate ligament in the weightbearing and nonweightbearing knee. Am J of Sports Med 25(3): 353-359, 1997.

2. Bagger J, Ravn J, Lavard P, et al: Effect of functional bracing, quadriceps and hamstrings on anterior tibial translation in anterior cruciate ligament insufficiency. A preliminary report. J Rehabil Res Dev 29:9-12, 1992.

3. Beck C, Drez D, Young J, et al: Instrumented testing of functional knee braces. Am J of Sports Med 14: 253-256, 1986.

4. Beynnon, BD, Popr MH, Wertheimer CM, et al: The effect of functional knee-braces on strain on the anterior cruciate ligament in vivo. J Bone Joint Surg 74A: 1298-1312, 1992.

5. Branch TP, Hunter R, Donath M: Dynamic EMG analysis of anterior cruciate deficient legs with and without bracing during cutting. Am J Sports Med 17:35-41, 1989.

6. Cawley PW, France EP, Paulos LE: The current state of functional knee bracing research. A review of the literature. Am J Sports Med 19: 226-233, 1991.

7. Colville MR, Lee CL, Ciullo JV: The Lenox Hill brace. An evaluation of effectiveness in treating knee instability. Am J Sports Med 14: 257-261, 1986.

8. Cook FF, Tibone JE, Redfern FC: A dynamic analysis of a functional brace for anterior cruciate ligament insufficiency. Am J Sports Med 17: 519-524, 1989.

9. Jonsson H, Karrholm J: Brace effects on the unstable knee in 21 cases: A roentgen stereophotogrammetric comparison of three designs. Acta Orthop Scand 61: 313-318, 1990.

10.Martin RC, Steadman JR: Quantitative analysis of anterior tibial translation using the MVP brace. Am J Knee Surg 5: 129-134, 1992.

11.Mishra DK, Daniel DM, Stone ML: The use of functional knee braces in the control of pathologic anterior knee laxity. Clin Orhtop 241: 213-220, 1989.

12.Pettrone FA, Rood C: A comparative study of brace effectiveness in the anterior cruciate ligament-deficient knee. Am J Knee Surg 5: 117-122, 1992.

13.Rink PC, Scott RA, Lupo RL, et al: A comparative study of functional bracing in the anterior cruciate deficient knee. Orthop Rev 18: 719-727, 1989.

14.Romash MM, Henningsen HJ, Claybaugh J: Knee braces - comparative functional testing. Orthop Trans 13: 501, 1989.

15.Wojtys EM, Luobert PV, Samson SY, et al: Use of a knee brace for control of tibial translation and rotation. A comparison in cadavera of available models. J Bone Joint Surg 72A: 1323-1329, 1990.

16.Acierno SP, D'Ambrosia, Colomonow M, Baratta RV, D-Ambrosia RD: Electromyography and biomechanics of dynamic knee brace for anterior cruciate ligament deficiency. Orthopedics 18:12, 1995.

17.Feller, J, Bartlett J, Chapman S, Delahunt M: Use of an extension-assisting brace following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 5(1): 6-9, 1997.

18.Harilainen A, Sandelin J, Vanhanen I, Kivinen A: Knee brace after bone-tendon-bone anterior cruciate ligament reconstruction. Randomized, prospective study with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 5(1): 10-13, 1997.

19.DeVita P, Torry M, Glover KL, Sperone DL: A functional knee brace alters joint torque and power patterns during walking and running. J Biomech 29(5): 583-588, 1996.

20.Alexander AH: In search of the perfect ACL brace. Am J Orthop 24(4): 328-336, 1995.

21.Decoster LC, Vailas JC, Swartz WG, Functional ACL bracing. A survey of current opinion and practice. Am J Orthop 24(11): 838-843, 1995.

22.Helfet, AJ, Manley, MT, Vaughan: The helicoid knee brace: A lightweight but effective support for the damaged knee. Injury 15: 189-192, 1983.

23.Veldhuizen JW, Verstappen FTJ, Koene FMM, Greep JM: Effects of cast-bracing of the knee on physical performance in healthy subjects. Int J Sports Med 15: 520-524, 1994.

24.Odenbring S, Lindstrand A, Egund N: Early knee mobilization after osteotomy for gonarthrosis. Acta Scand 60(6): 699-702, 1989.

25.Matsuna H, Kadowaki, KM, Tsuji H: Generation II lnee bracing for severe medial compartmental osteoarthritis of the knee. Arch Phys Med Rehabil 78: 745-749, 1997.

26.Jawad ASMm goodwill CJ: TVS brace in patients with rheumatoid arthritis or osteoarthritis of the knee. Brit J Rheum 25:4: 416-416, 19__.

27.Dennis DA Komistek RD, Hoff WA, Gabriel SM: In vivo knee kinematics derived using an inverse perspective technique. Clin Orthop, 331:107-117,1996.

28.Steihl JB Dennis DA, Komistek RD, Keblish PA: In vivo kinematic analysis of a mobile bearing total knee prosthesis. Clin Orthop, 345: 60-66, 1997.

29.Myrnerts R. High tibial osteotomy with overcorrection of varus malalignment in medial gonarthrosis. Acta Orthop Scand 51: 557-560, 1980.

30.Tjornstrand B, Egund N, Hagstedt B, Lindstrand A: Tibial osteotomy in medial gonarthrosis. The importance of over-correction of varus deformity. Arch Orthop Trauma Surg 99(2): 83-89, 1981.

31.Kriegshauser LA, Bryan RS: Early motion with cast brace after modified Coventry high tibial osteotomy. Clin Orhtop 195: 168-172, 1985.

32.Hackel H, Schnidlmaisser H: Die Verwendung einer modifitzierten Stufenklammer zur gipsfreien Fixation bei der Coventry Osteotomie. Orthop Prax 20(11): 889-893, 1984.

33.Hackel H, Schnidlmaisser H: Die Kremser Klammer zur Stabilizierung der Coventry Osteotomie. Erfahrungen aus 132 Fallen. Orthop Prax 23(1): 68-72, 1987.

34.Heine J: Uber die arthritis deformans. Virchows Archiv 260: 521-663, 1926.

Kellegan JH, Lawrence JS: Osteoarthritis and disc degeneration in an urban population. Ann Rheum Dis 17: 388-397, 1958.

35.Goldberg VM: Surgery in osteoarthritis: general conditions. In: Moakowitz RW, Howell DS, Goldberg VM, Mankin HJ, editors, Osteoarthritis; diagnosis and medical/surgical management. 2nd ed. Philadelphia: Saunders, 535-543, 1992.

36.Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Jrogstad D, Murray B, et al: Multifactorial index of cardiac risk in noncardiac surgical procedure. N Engl J Med 297: 845-850, 1977.

37.Cohen MM, Duncan PG, Tate RB: Does anesthesia contribute to operative mortality? JAMA 260: 2859-2863, 1988.

38.Tiret L, Desmonth JM, Hatton F, Vourch G: Complication associated with anesthesia: a postoperative survey in France. Can Anaesth Soc J 33: 336-344, 1986.

39.Murakami M, Ohta K, Imabori K, editors. Handbook of gerontology. Vol 2. Tokyo; Johokaihatsu Res, 1984 In Japanese.

40.Sasaki T, Yasuda K: Clinical evaluation of the treatment of osteoarthritic knees using a newly designed wedged insole. Clin Orthop 221: 181-187, 1987.

41.Yasuda K, Sasaki T: The mechanics of treatment of the osteoarthritic knee with a wedged insole. Clin Orthop 215: 162-172, 1987.