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The published, peer-reviewed scientific literature reveals few clinical studies to support improvement in subjective responses, such as increased stability, decreased pain, improved performance or increased patient confidence, with use of the functional brace. In addition, most authors report that lower extremity muscle strengthening, flexibility, and improvement and refinement of athletic techniques are more important than functional bracing when treating ligamentous knee injuries (Paluska and McKeag, 2000; Risberg, et al., 1999). The effectiveness of and the need for bracing post-ACL reconstruction is controversial. Due to the inconsistent literature reports, further studies are required to support improved outcomes and efficacy for the use of functional knee braces for this purpose.
Rehabilitative Knee Braces
Rehabilitative knee braces are intended to control the knee flexion-extension angle during the initial healing period after cruciate ligament or meniscal fracture management or reconstructive surgery. Rehabilitative braces are typically used short term for the early postoperative period to protect the fracture site or surgical repair while range-of-motion, weightbearing and muscle activity are initiated. This type of brace generally consists of foam liners, rigid bars with hinges, and nonelastic straps that hold the brace in place, and they are frequently purchased off the shelf. They are designed to allow controlled joint motion and are commonly used for 6-12 weeks post acute injury or surgery. They allow adjustment for swelling and are easy to remove for examinations and therefore may be preferred over splinting or casting postoperatively. They are preferred over full knee immobilization, because they allow motion and loading and have been shown to decrease muscle atrophy, maintain cartilage health and decrease the chance of knee stiffness (France and Paulos, 1994). A review of the literature indicates that there is little clinical data supporting the use of rehabilitative braces, although they appear to be well accepted clinically and avoid the risks to the knee associated with cast immobilization. Rehabilitative knee braces include, but are not limited to, the DonJoy IROM (dj Orthopedics, Inc., Vista, CA) and the Bledsoe Post Operative Knee Brace (Bledsoe Brace Systems, Grande Prairie, TX).
Unloading/ Offloading Knee Braces
Unloading braces are recommended for the treatment of pain and disability that may result from moderate to severe osteoarthritis of the knee. These devices externally apply a three-point bending force, with one force applied at the center of the knee and two opposing forces proximal and distal to the knee joint, to reduce joint reactive forces in the involved compartment (Cole and Harner, 1999). Osteoarthritis of the knee is associated with an overload of a focal area of cartilage. This focal overload leads to failure of the load-bearing capacity of the affected cartilage and subchondral bone. Unloading braces include the GII Unloader® (Ossur North America, Aliso Viejo, CA), and the Townsend Premier Reliever (Townsend Design, Bakersfield, CA).
The Kellgren-Lawrence scale describes the severity of articular cartilage changes associated with osteoarthritis. The scale emphasizes patellofemoral joint space narrowing and the presence of osteophytes as determined by radiographs:
Grade 0 No osteophytes
Grade 1 Doubtful osteophytes
Grade 2 Minimal osteophytes, possible narrowing, cysts and sclerosis
Grade 3 Moderate or definite osteophytes with moderate joint space narrowing
Grade 4 Severe with large osteophytes and definite joint space narrowing
Grade 3 or 4 on the above grading scale is considered moderate to severe osteoarthritis.
Unicompartmental osteoarthritis of the knee is defined as a condition characterized by degenerative articular cartilage in the medial or lateral aspect of the tibiofemoral joint, which may be associated with meniscal disruption, ligamentous instability and malalignment (Iorio and Healy, 2003). Nonoperative treatment for unicompartmental degenerative arthritis of the knee generally involves the reduction of pain through modalities such as oral and injectable medications, weight loss, exercise, physical therapy, canes, crutches, braces and orthoses. Forces applied through bracing can shift pressure from the degenerative compartment to the less worn compartment. Bracing may also improve proprioception in unstable knees. In most cases, unicompartmental osteoarthritis and varus and valgus deformities can be treated by unloading braces, although joint disease that is present in both medial and lateral