Post-operative Bracing for ACL Reconstruction

Worn in the early postoperative period (0-6
 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.1
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
 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
› 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.4
Wright et al.5
› Review of level 1 and 2 studies identified 54
appropriate randomized controlled trials of ACL
 11 included use of rehabilitative postop.
› 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
› Only one study6 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-poststraps and Velcro straps.2
 Intended to limit anterior tibial translation
and rotation at the knee joint.7
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 pain1, ROM1,3,
strength3, functional tests3,7, joint stability7,8,
graft stability1, re-injury rates1,8, kinesthetic
awareness8, or knee scores3 compared to
patients who did not use a functional
brace during rehabilitation and return to
play after ACL reconstruction.
Rate of use by orthopedic surgeons9
› Do you recommend functional braces for full
return to activity?
17.6% (35)
37.2% (74)
45.2% (90)
2.9% (1)
31.4% (11)
65.7% (23)
1.2% (1)
88.2% (75)
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: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
› Wright1 performed a review of Level I evidence to
determine if there was appropriate evidence to
support the use of functional braces after ACL
 12 randomized controlled trials found between
years 1966-2005
 All 12 had potential biases- 10 selection, 2
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
› 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 bracefree.
› 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. 2nd 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;30:8115.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):15815.doi:10.1177/0363546506289883
a. Use of Knee Braces in Comprehensive Knee Rehabilitation & Knee Pain Management. Availableat
d. Rishiraj et al. Functional knee bracing and athletic performance. Journal of Foot and Ankle
Research.2011, Available at www.lowerextremity

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