The Use of Postoperative Bracing Following ACL Reconstruction

How often do you use an immobilizer after ACL reconstruction?  The January 2009  issue of American Journal of Sports Medicine is out and there a few interesting articles I wanted to feature.  The first of which discusses the use of knee bracing and immobilization postoperatively following ACL reconstruction using a hamstring tendon graft

The Use of Postoperative Bracing Following ACL Reconstruction

DSC01582In this study, 82 patients were randomized into two groups: 1) a group of patients that wore an unhinged knee immobilizer and 2) a control group that did not use a brace.  At 2 week postoperatively, the authors report that there were no differences between groups for pain, medications consumed, complications, and range of motion.

The authors conclude that an unhinged postoperative knee brace is not recommended following ACL reconstruction for the purpose of pain control.  That is the exact phrasing that was used.  The last part of the sentence is significant, “for the purpose of pain control.”  The paper is centered around pain control more than any other variable, it is even in the title of the paper.

 

Methodological Issues

There are a couple of methodological flaws that I found that are likely significant in the presentation of the results

  • Compliance for brace use was extremely low and only documented by subjective reports.  Only 86% of subjects in the immobilizer reported wearing their brace from day 7-13 and by day 14 only 26% of subjects reported wearing their brace as instructed.  Since this is only self-reported, you can assume that these numbers are best-case scenario as I wouldn’t be surprised if a few subjects were not completely honest.  Regardless, taking these numbers into consideration, you can argue that the brace group consisted of only 11 patients and the non-brace group had 73 subjects.  Not sure that this low of compliance can lead to a good comparison.
  • All of the patients were on pain medication consisting of either Percocet or Tylenol with codeine and naproxen.  As previously mentioned, pain scales were of primary importance to the authors in the discussion section of the paper.  However, it appears that pain was controlled with pharmaceuticals and likely has no correlation to brace use.

 

Clinical Implications

I am not sure that based on the results of this study, my choice to use a brace or not following ACL reconstruction will be influenced.  Clinically, I have always used a postoperative knee brace following ACL reconstruction, though have always used a drop-lock hinged knee brace.  This allows the patient to have the knee free to move throughout the day, however can lock the brace into full knee extension during ambulation.DSC00996

While I feel that this is helpful for stability and protection of the knee postoperatively, these are not the reasons why I use a brace.  For me, it is for a much more simplistic reason:

The quadriceps are susceptible to reflexive inhibition due to the pain and effusion associated with surgery. 

Ambulating without full volitional control of the quadriceps encourages improper gait and makes the limb susceptible to “giving-way episodes” and potential harm.

The brace is utilized for the first 7-21 days depending on the patient and their ability to restore volitional control of the quad.  Many factors will affect the duration of the brace use, including patient selection, age, and previous activity level.  For example, an athlete that has an acute ACL reconstruction will likely restore their volitional control sooner than an older, sedentary patient.  The key is to assess and individualize.

Another interesting fact that I took from this paper really has nothing to do with the topic of the study, but nevertheless was interesting to me.  Look at the progression of reported pain on a VAS over the course of two weeks:

1 hour postoperatively20.0-20.8
Day 0 PM29.3-30.8
Day 1 AM28.7-34.1
Day 1 PM41.9-45.5
Day 2 AM35.1-40.8
Day 2 PM32.6-35.2
Day 727.5-29.3
Day 1412.9-14.1

Pain appears to peak at 36 hours after surgery and remain high day 1 and day 2 postoperatively before gradually decreasing to a fairly tolerable level by week 14.  This is important information for clinicians and patients.  When I see a patient immediately postoperatively, I commonly tell them that the first few days are the worst and that it is not uncommon to feel worse days 2 or day 3.  This helps assure them that they have not reinjured themselves when pain worsens.

This is also helpful regarding pain’s role in the inhibition of the quadriceps.  Based on these numbers, it wouldn’t surprise me if a patient was having difficulty with volitional control of the quadriceps 1 week after surgery despite appropriate rehabilitation.  If you were using a brace for this reason, as I suggest above, it looks like day 7 may be too early to discharge the brace and that 2 weeks may be more appropriate for many patients.

Food for thought either way I guess.  How common do you use brace immediately after ACL reconstruction?  What is the duration?  What is your reasoning?  Would love to hear what other centers are doing.

L. A. Hiemstra, S. M. Heard, T. M. Sasyniuk, G. L. Buchko, J. G. Reed, B. J. Monteleone (2008). Knee Immobilization for Pain Control After a Hamstring Tendon Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial The American Journal of Sports Medicine, 37 (1), 56-64 DOI: 10.1177/0363546508322896

16 replies
  1. wrw7772000
    wrw7772000 says:

    Mike-

    Excellent post. The findings regarding pain scale are probably the most significant part of this paper.

    The pain ratings from day 7 to day 14 seem to represent the most significant drop percentage wise so that a 14 day rule of thumb makes a lot of sense. Could you do it earlier? Maybe but based upon the numbers presented, it would almost make more sense to wait and then if all is well at day 14 – the brace can be eliminated – if not, recheck t/o with the target at day 21.

    The numbers, for this instance, seem to provide pretty sound evidence for waiting until at least day 14 before the brace is removed.

    Nice job and good analysis.

    Bill White, ATC

  2. Mik Reinold
    Mik Reinold says:

    Bill, I wish they had more information on the pain scale between days 7 and 14, maybe it settles down around day 10? Not sure based on this study but agree with you completely, thanks Bill.

  3. amy castillo
    amy castillo says:

    I typically see a variety. Some of our physicians don’t refer until 1 or (yikes) 2 weeks post op! But no matter the course, I find that over 90% are out of the brace by week 2. Those that aren’t have issues. These are usually my persistently swollen knees.
    However, I was excited at first when I saw the title. I was thinking you were going to discuss functional bracing for return to play or agility rehab. Some of our physicians insist on this and I know the group out in Deleware advocates a brace.

    It seems I have the patient get fitted, pay out of pocket 200-300$, and then the kid hates it and stops using it. I have observed altered running patterns and slower speeds. I am not familiar, has any study proven it prevents re-injury?

  4. Mike Reinold
    Mike Reinold says:

    agree with your comments regarding the functional braces, will have to post on this one in the future too…

  5. Brian O'Neil, PT
    Brian O'Neil, PT says:

    Mike, I was also excited about this week’s topic because of the volume of ACL patients I see. Most of my docs have switched to a smaller medial/lateral stab brace for their post-op ACLs, which I hate because it keeps the knee in a few degrees of flexion. I try to get them out of it as quickly as possible(by 3 weeks post op), but I still prefer the old Bledsoe braces that we could lock in full extension. It also brings to mind significant regional differences in post-op ACL protocol. When working in Boston patients always started PT post-op day 2 or 3. In the Hartford region most are begun 14 days post op and I have even seen some 1 month post-op. Long term(6-9mos)they come out fine, but of course they are tight when beginning PT. When are most beginning rehab and is anyone alse out there seeing these smaller bracing options?

  6. Trevor Winnegge
    Trevor Winnegge says:

    I agree with others in that a functional bracing post would be great! our doc doesn’t believe in them, yet some people swear by them. I myself am not a believer.

    Regarding this post, our doc uses a drop lock hinged bledsoe brace. His patients all attend at least 1 pre-operative PT session for hep. He tells them up front, when you can perform 30 slr with no quad lag, it is ok to d/c the brace. By the time I see them-at 7 days post op-some of them have self d/c the brace and are doing fine. Others are afraid to walk without it but can perform the 30 slr without difficulty so I d/c brace. I have only had a few people unable to go without the brace, but by day 14 they have all been out of it. Not sure if someone has done a study on role of pre-hab strengthening on post op functional recovery. Might be a good study.

  7. Mike Reinold
    Mike Reinold says:

    wow, keeping the patient in a little flexion is not good! i would bet these are not B-PT-B grafts? the majority of my rehab is done in the first 4 weeks, can’t imagine a patient just doing some quad sets and heel slides at home all that time! Each doc is different, some conservative by nature and others have less goals for their patients than we do (i.e. we want to get them to tennis, doc just happy if they walk).

    Trevor, that is a good way to progress the patient, i like that with the SLR. I dont think it is the best indicator of quad inhibition but at least it is something!

  8. Brian O'Neil, PT
    Brian O'Neil, PT says:

    No, all our guys have switched over to HS autografts. Is anyone still seeing B-pt-B grafts?… yes, you can imagine having that slight flexion they have a mild flexion contracture by the time I see them. more work for me… I have also used the ability to SLR as an indicator to DC the brace, but I have gotten away from that recently since a healthy knee never reaches full extension during normal gait.

  9. Mike Reinold
    Mike Reinold says:

    I would definitely still use a B-PT-B if it were my ACL. Nothing like bony fixation. Hamstrings work good too but my preference is still patellar tendons, but patient dependent. Sedentary person likely better suited for hamstring with less postop problems but athletes that have good rehab should be fine with PT.

  10. Dave Nolan
    Dave Nolan says:

    I too use SLR and assess the presence of lag along with quality of overall quad firing when determining the appropriate time to D/C brace. I am curious as to what criteria, if any, others have as part of their thought process. My concerns with prolonged brace use are limited extension due to flexion contracture or scar tisse as well as altered gait pattern with hip hike etc.

  11. Trevor Winnegge
    Trevor Winnegge says:

    Dave,
    I agree with you. not only do you see hip hike with prolonged brace use, but i especially used to see circumduction. especially ascending stairs. prolonged brace use promotes bad habits!!!!!

  12. mike reinold
    mike reinold says:

    hi dave, i agree with trevor. my biggest factor when d/c’ing the brace is just their ability to do a nice, solid quad set. once they get that voluntary control i am happy.

  13. generic cialis
    generic cialis says:

    i am going to have ACL reconstruction very soon…..would anyone know how long will it take for me to walk properly after the surgery without crutches?

  14. Anonymous
    Anonymous says:

    Hi Mike-

    What are your thoughts on ACL bracing for return to play in terms of risk of re-injury?

    Thanks!

  15. Scott
    Scott says:

    Hi all, I had the BTB ACL graft.
    Waking pain was horrific.
    After 4 days, pain pretty much gone.
    I had other repairs done & knee cleaned up by an earlier sugery(6 weeks before ACL reco).
    At 7 days now, still on crutches and being careful of the graft.
    The moving around amongst home based PT and RICE, has been the best thing.
    I have full ext, 90 deg bend can bare reasonable weight, not full.
    To use a brace? No way… Why weaken the leg muscles more… Wake them up… Just be cautious post-op…..
    Everywhere I read says 50/50 brace & no brace, brace make no proven benefits to the ACL recovery! I haven’t used one after the first day…no need.

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