Functional anterior cruciate ligament braces may have a role in select patient groups although there is presently limited evidence supporting or refuting their routine use: A scoping review of clinical practice guidelines and an updated bracing classification.

PURPOSE: The purpose of this study was to perform a scoping review of clinical practice guidelines (CPGs) concerning the use of functional anterior cruciate ligament (ACL) braces and to clarify the nomenclature for bracing relevant to ACL injury treatment in order to support prescribing clinicians. METHODS: A PubMed search for CPGs for the use of braces following ACL injury or reconstruction was performed. CPGs on the treatment of ACL injuries with sufficient attention to postoperative braces were included in this scoping review. The references used for supporting the specific CPG recommendations were reviewed. Specific indications for brace use including brace type, period of use following surgery and activities requiring brace use were collected. RESULTS: Six CPGs were identified and included this this review. Three randomised trials provided the evidence for recommendations on functional brace use following ACL reconstruction in the six CPGs. Functional ACL braces were the primary focus of the three randomised trials, although extension braces (postoperative knee immobilisers) were also discussed. A novel dynamic ACL brace category has been described, although included CPGs did not provide guidance on this brace type. CONCLUSIONS: Guidance on the use of functional ACL braces following ACL reconstruction is provided in six CPGs supported by three randomised trials. However, the brace protocols and patient compliance in the randomised trials render these CPGs inadequate for providing guidance on the use of functional ACL braces in the general and high-risk patient populations when returning to sport after ACL reconstruction. Functional ACL braces are commonly utilised during the course of ACL injury treatment although there is presently limited evidence supporting or refuting the routine use of these braces. Future studies are, therefore, necessary in order to provide guidance on the use of functional and dynamic ACL braces in high-risk patient populations. LEVEL OF EVIDENCE: Level II.

Revitalizing quality of life: a case report on the beneficial impact of comprehensive rehabilitation therapy in treating upper-limb lymphedema following breast cancer surgery.

Objective: To underscore the paramount significance of incorporating comprehensive rehabilitation therapy as a crucial aspect of managing lymphedema caused by breast cancer surgery, and to illuminate our first-hand experience and insights gained in utilizing this approach. Methods: We present a case report of a breast cancer survivor who had been suffering from persistent left upper-limb edema for over 15 years, who was effectively treated with a combination of conventional rehabilitation (seven-step decongestion therapy) and a comprehensive rehabilitation program (seven-step decongestion therapy, along with core and respiratory function training, as well as functional brace wearing). The efficacy of the rehabilitation therapy was evaluated through a comprehensive assessment. Results: Although the patient underwent the conventional rehabilitation program for one month, only limited improvement was observed. However, after an additional month of comprehensive rehabilitation treatment, the patient exhibited significant improvement in both lymphedema and the overall function of the left upper limb. The patient's progress was quantified by measuring the reduction in arm circumference, which demonstrated a notable decrease. Furthermore, improvements in joint range of motion were observed, with forward flexion of the shoulder enhancing by 10°, forward flexion improving by 15°, and elbow flexion increasing by 10°. In addition, manual muscular strength tests revealed an increase in strength from Grade 4 to Grade 5. The patient's quality of life was also significantly improved, as evidenced by the increase in the Activities of Daily Living score from 95 to 100 points, the increase in the the Functional Assessment of Cancer Therapy: Breast score from 53 to 79 points, and the decrease in the Kessler Psychological Distress Scale score from 24 to 17 points. Conclusion: While seven-step decongestion therapy has been shown to be effective in reducing upper-limb lymphedema caused by breast cancer surgery, it has limitations in treating more chronic cases of the condition. However, when combined with core and respiratory function training and functional brace wearing, seven-step decongestion therapy has been shown to be even more effective in reducing lymphedema and improving limb function, ultimately leading to significant improvements in quality of life.

Effect of a functional brace in combination with physical therapy for early correction of cubitus varus in young children.

BACKGROUND: This study aimed to assess the clinical and radiologic outcomes of a functional brace in combination with physical therapy (FBPT) for early correction of cubitus varus in young children. METHODS: Eighteen consecutive patients with cubitus varus secondary to supracondylar fractures were enrolled between July 2017 and March 2019. We used the FBPT technique to correct varus and sagittal plane deformity for early cubitus varus in young children. The clinical evaluation included measurement of varus angulation, sagittal plane, and range of motion at three, six, and twelve months post-intervention. The clinical and radiographic results were assessed according to the Bellemore criteria. RESULTS: Pre-treatment humerus-elbow-wrist (HEW) angle measured on the affected side (varus deformity) ranged between -38° and -12° (average, -23.2°) while the post-treatment HEW angle ranged between -10° and + 15° (average, 8.8°). Compared with the unaffected side, no statistically significant difference was found in the affected side post-intervention (P > 0.05). According to the Bellemore criteria, we got excellent results in fourteen patients (77.8%), good results in three patients (16.7%), and poor result in one patient (5.5%). All patients and their parents (except one patient with residual varus deformities) were satisfied with the functional and cosmetic outcomes. CONCLUSIONS: The FBPT is effective for the treatment of cubitus varus in children, especially for young children within 6 months of the injury.

Functional bracing in distal radius fractures: a cadaveric pilot study.

Background: Extra-articular distal radius fractures are often treated by circular casting. A functional brace, however, may equally support the fracture zone but allows early mobilization of the radiocarpal joint. Since the amount of fracture movement for different types of fixation is currently unknown, a study was initiated to investigate the degree of bone displacement in extra-articular distal radius fractures fixated by regular circular casting, functional bracing, or no-fixation. Methods: In four cadaveric arms, an extra-articular distal radius fracture was simulated and immobilized by the three ways of fixation. After creating an extra-articular distal radius fracture, the fracture was reduced anatomically and the cadaveric arm was strapped in a test frame. Hereafter, flexion, extension and deviation of the hand were then induced by a static moment of force of one newton meter. Subsequently CT scans of the wrist were performed and bone displacement was quantified. Results: Immobilization of an extra-articular distal radius fracture by functional bracing provides comparable fixation compared to circular casting and no fixation, and shows significantly less extension-rotation displacement of the distal bone segment for the wrist in flexion and palmodorsal translation and extension-rotation for the wrist in extension. Conclusion: Functional bracing of extra articular distal radius fractures in cadaveric arms provides significant less extension-rotation displacement in flexion and palmodorsal translation and extension-rotation in extension compared to circular casting and no fixation.

Initial management of humeral shaft fractures with functional splints versus coaptation splints.

PURPOSE: Humerus shaft fractures are commonly acutely immobilized with coaptation splints (CS), which can be difficult to apply and poorly tolerated by the patient. Functional splints (FS), which work on the same principle as functional braces, are an alternative to CS. The purpose of this study was to directly compare CS and FS in terms of application and fracture reduction. METHODS: A retrospective review identified humeral shaft fractures managed nonoperatively with initial immobilization in a FS (n = 19) versus a CS (n = 15). In addition, 13 residents completed a blinded survey on splint application. RESULTS: The FS and CS groups did not differ in initial fracture angulation and translation on anteroposterior (AP) and lateral radiographs. Post-splint application, there was no clinically relevant difference in fracture angulation/translation between groups, and this persisted at the subsequent follow-up visit. All residents reported that the FS was easier to apply and took less time. CONCLUSION: This study results demonstrated the FS results in similar reductions in humeral shaft fractures as CS. A survey of residents found that the FS was easier to apply, took less time, and was better tolerated by patients. Subsequently, we prefer the FS over the CS for the acute management of humeral shaft fractures.

Evaluation of Clinical and Radiological Results of Humeral Diaphyseal Fractures with Treated Sarmiento Brace.

Aim In our study, we aimed to evaluate the duration and rate of the union of adult humerus diaphysis fractures treated with a functional brace. Methods Forty-six adult patients admitted to our hospital with humeral diaphyseal fracture between January 2010 and April 2014 and treated with a functional brace were evaluated retrospectively. The demographic data, fracture type, level of fracture, and presence of bone union of the patients were evaluated from clinic records. The Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire score of the patients was registered for patients and analyzed, and its correlation with parameters such as patient age and fracture bone union time was evaluated. Results It was observed that of the patients with the mean age of 45.5 years, six (13.6%) had non-union and five had delayed bone union (10.86%). Three (6.5%) patients had radial nerve injury, and all recovered without sequelae. Out of the patients with the bone union, 12 (30%) had an angulation above give degrees, and 3 (7.5%) had radiological shortness. The mean Quick-DASH score was 6.7, and there was no statistically significant correlation with parameters such as fracture type, level, angulation, radiological shortness and radial nerve involvement (p>0.05). Conclusions A functional brace is a good treatment choice with low complication rates and has satisfactory bone union rates in humerus diaphyseal fractures.

Humeral shaft fracture: a randomized controlled trial of nonoperative versus operative management (plate fixation).

PURPOSE: This randomized controlled trial was conducted to investigate the outcomes of humeral shaft-fracture management with the functional Sarmiento brace (nonoperative) versus open reduction internal fixation (ORIF). METHODS: Sixty humeral shaft-fracture patients with a minimum age of 18 years were randomly assigned into two groups: operative treatment with open reduction-internal fixation (ORIF) or functional brace (Sarmiento). A similar postoperative rehabilitation program was applied for all subjects for the next 12 months. The outcomes of each method were measured in terms of nonunion rate, union time, "quick" Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire scores, and rate of complications, such as malunion, infection, and radial nerve injury. RESULTS: The two groups had similar baseline characteristics, including age, sex, smoking status, and type and mechanism of fracture. The mean union time was about 4.8 weeks shorter in the ORIF group (13.9 weeks in operative group versus 18.7 weeks in nonoperative group), indicating a definite significant superiority (p=0.001) of ORIF management to functional Sarmiento bracing. However, a comparison of quick DASH scores revealed a borderline-significant difference between the groups (p=0.065). Additionally, we found that treatment of humeral shaft fractures using functional bracing was associated with slightly higher risk of nonunion; however this was not significant (p=0.492). CONCLUSION: According to the present findings, there is remarkable superiority of ORIF over functional Sarmiento bracing in the management of patients with humeral shaft fracture.

Closed treatment of humeral shaft fractures by functional bracing using polyvinyl chloride versus plaster-of-paris cast: A randomized clinical trial

INTRODUCTION@#This study compared Polyvinyl Chloride (PVC) made vs Plaster of Paris (POP) made functional braces in the closed treatment of fractures of the humeral shaft. Outcomes examined were the rate of fracture union, radiographic alignment, DASH scores and the range of motion of the shoulder and elbow@*METHODS@#This was a parallel randomized clinical trial conducted at the Corazon Locsin-Montelibano Memorial Regional Hospital from July 2016 to July 2017. All eligible patients were included and randomly allocated into PVC and POP treatment groups. All patients were followed-up on the 3rd, 6th, 10th, and 14th week for clinical and radiographic evaluation.@*RESULTS@#There were 31 patients, 14 and 17 in the PVC and POP groups, respectively. The median rate of union in the PVC and POP groups were 10.50 and 10.00 weeks, respectively. The median varus and valgus angulation in the PVC and POP groups were 15.75° and 16.5°, respectively. The median anterior and posterior alignment in the PVC group was 1.7° and POP group was 9.6°. The median DASH score of the PVC and POP groups were 7.1 and 12.5, respectively. The median range of motion in the elbow was 135° for both groups. The median range of motion in the shoulder in the PVC group was 150° and POP group was 140°.@*CONCLUSION@#There was a high rate of union of humeral shaft fractures with acceptable functional outcome with the use of the PVC made functional brace compared to the traditional POP made functional brace.

Dynamically tensioned ACL functional knee braces reduce ACL and meniscal strain.

PURPOSE: The effectiveness of ACL functional knee braces to reduce meniscal and ACL strain after ACL injury or reconstruction is not well understood. A new dynamic knee tensioning brace system has been designed to apply an active stabilizing force to the knee. The ability of this system to reduce tissue strains is unknown. The purpose of this study was to test the ability of the dynamically tensioned brace to reduce strain in both the ACL and meniscus during rehabilitation activities. METHODS: A combined in vivo/in silico/in vitro method was used to study three activities: gait, double leg squat, and single leg squat. Muscle forces and kinematics for each activity were derived through in vivo motion capture and applied to seven cadaveric knee specimens fitted with custom braces. Medial meniscal strain and ACL strain were measured in ACL intact, deficient and reconstructed conditions. RESULTS: The brace lowered peak and average meniscal strain in ACL deficient knees (P < 0.05) by an average of 1.7%. The brace was also found to lower meniscal strain in reconstructed knees (1.1%) and lower ACL strain in ACL intact (1.3%) and reconstructed knees (1.4%) (P < 0.05). CONCLUSIONS: This study supports the use of a brace equipped with a dynamic tensioning system to lower meniscal strain in ACL-deficient knees. Its use may help decrease the risk of subsequent meniscal tears in chronic ACL deficiency or delayed reconstruction. In ACL-intact and reconstructed knees, the brace may be beneficial in injury prophylaxis or in protecting the ACL graft following reconstruction. These results will aid clinicians make informed recommendations for functional brace use in patients with unstable knees. LEVEL OF EVIDENCE: II.

Functional Brace in ACL Surgery: Force Quantification in an In Vivo Study.

BACKGROUND: A need exists for a functional anterior cruciate ligament (ACL) brace that dynamically supports the knee joint to match the angle-dependent forces of a native ACL, especially in the early postoperative period. PURPOSE/HYPOTHESIS: The purpose of this study was to quantify the posteriorly directed external forces applied to the anterior proximal tibia by both a static and a dynamic force ACL brace. The proximal strap forces applied by the static force brace were hypothesized to remain relatively constant regardless of knee flexion angle compared with those of the dynamic force brace. STUDY DESIGN: Controlled laboratory study. METHODS: Seven healthy adult males (mean age, 27.4 ± 3.4 years; mean height, 1.8 ± 0.1 m; mean body mass, 84.1 ± 11.3 kg) were fitted with both a static and a dynamic force ACL brace. Participants completed 3 functional activities: unloaded extension, sit-to-stand, and stair ascent. Kinematic data were collected using traditional motion-capture techniques while posteriorly directed forces applied to the anterior aspect of both the proximal and distal tibia were simultaneously collected using a customized pressure-mapping technique. RESULTS: The mean posteriorly directed forces applied to the proximal tibia at 30° of flexion by the dynamic force brace during unloaded extension (80.2 N), sit-to-stand (57.5 N), and stair ascent (56.3 N) activities were significantly larger, regardless of force setting, than those applied by the static force brace (10.1 N, 9.5 N, and 11.9 N, respectively; P < .001). CONCLUSION: The dynamic force ACL brace, compared with the static force brace, applied significantly larger posteriorly directed forces to the anterior proximal tibia in extension, where the ACL is known to experience larger in vivo forces. Further studies are required to determine whether the physiological behavior of the brace will reduce anterior knee laxity and improve long-term patient outcomes. CLINICAL RELEVANCE: ACL braces that dynamically restrain the proximal tibia in a manner similar to physiological ACL function may improve pre- and postoperative treatment.

Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation.

PURPOSE: Counteracting posterior translation of the tibia with an anterior force on the posterior proximal tibia has been demonstrated clinically to improve posterior knee laxity following posterior cruciate ligament (PCL) injury. This study quantified forces applied to the posterior proximal tibia by two knee braces designed for treatment of PCL injuries. METHODS: The forces applied by two knee braces to the posterior proximal tibia and in vivo three-dimensional knee kinematics of six adult, male, healthy volunteer subjects (mean ± standard deviation: height, 182.5 ± 5.2 cm; body mass, 83.2 ± 9.3 kg; body mass index, 24.9 ± 1.5 kg/m(2); age, 25.8 ± 2.9 years) were measured using a custom pressure mapping technique and traditional surface marker motion capture techniques, while subjects performed three functional activities. The activities included seated unloaded knee flexion, squatting, and stair descent in a new generation dynamic force (DF) PCL brace and a static force (SF) PCL brace. RESULTS: During unloaded flexion at the lowest force level setting, the force applied by the DF brace increased as a function of flexion angle (slope = 0.7 N/°; p < 0.001) compared to the SF brace effect. Force applied by the SF brace did not significantly change as a function of flexion angle (slope = 0.0 N/°; n.s.). By 45° of flexion, the average force applied by the DF brace (48.1 N) was significantly larger (p < 0.001) than the average force applied by the SF brace (25.0 N). The difference in force continued to increase as flexion angle increased. During stair descent, average force (mean ± standard deviation) at toe off was significantly higher (p = 0.013) for the DF brace (78.7 ± 21.6 N) than the SF brace (37.3 ± 7.2 N). Similar trends were observed for squatting and for the higher force level settings. CONCLUSIONS: The DF brace applied forces to the posterior proximal tibia that dynamically increased with increased flexion angle. Additionally, the DF brace applied significantly larger forces at higher flexion angles compared to the SF brace where the PCL is known to experience larger in situ forces. Clinical studies are necessary to determine whether the loading characteristics of the DF brace, which more closely replicated the in situ loading profile of the native PCL, results in long-term improved posterior knee laxity following PCL injury. LEVEL OF EVIDENCE: II.

Functional testing to determine readiness to discontinue brace use, one year after acl reconstruction.

BACKGROUND: While the use of functional knee braces for return to sports or high level physical activity after ACL reconstruction (ACLR) is controversial, brace use is still prevalent.(1,2,3,4,5) All active patients in the practice are braced after ACLR and must pass a battery of sports tests before they return to play in their brace. Criteria include a 90% score on 4 one-legged hop tests(9) burst superimposition strength test,(10) Knee Outcome Survey Activities of Daily Living Scale,(8) and a global rating of knee function. PURPOSE: The purpose of this study was to describe the use of criterion-based guidelines to determine if athletes who had undergone an ACLR function better with or without their functional brace, one year after surgery. STUDY DESIGN: Cross-Sectional Study. METHODS: Sixty-four patients post ACLR performed 4 one-legged hop tests,(9) burst superimposition strength test,(10) and completed the Knee Outcome Survey Activities of Daily Living Scale,(8) and a global rating of knee function one year after surgery with and without their brace. RESULTS: Participants included 35 men and 29 women with a mean age of 25 years. The Mean Knee Outcome Survey Activities of Daily Living score was 98%, and the global rating was 97%. Of the subjects, one patient failed hop testing by at least one criterion with and without the brace. Three additional patients failed the test while braced but passed un-braced, and one patient passed with the brace, but failed without the brace. Subjects performed significantly better un-braced than braced in all hop tests: single leg hop braced = 101%; un-braced = 107% (p<0.001); cross-over hop braced = 100%; un-braced = 105% (p<0.001); triple hop braced = 99%; un-braced = 101% (p=0.003); timed hop braced = 98%; un-braced = 103% (p = 0.004). CONCLUSIONS: Sixty-two of 64 patients continued to score above return to play criteria one year after ACLR. All but two subjects in the cohort performed better un-braced than braced. Based on the criterion set for this testing session, 62/64 individuals performed well enough to discontinue use of their brace. LEVEL OF EVIDENCE: 2b.

Arthrometric evaluation of stabilizing effect of knee functional bracing at different flexion angles.

Previous in-vivo investigations on the stabilizing efficacy of knee bracing for ACL reconstructed patients have been often limited to 20-30 degrees of knee flexion. In this study, the effectiveness of a uniaxial hinged functional brace to improve the knee stability was assessed at 30, 60 and 90 degrees of knee flexion. Arthrometry tests were conducted on 15 healthy subjects before and following wearing the brace and the tibial displacements were measured at up to 150 N anterior forces. Results indicated that functional bracing has a significant stabilizing effect throughout the range of knee flexion examined (p < 0.05). The rate of effectiveness, however, was not consistent across the flexion range, e.g., 50% at 30 degrees and only 4% at 90 degrees. It was suggested that accurate sizing and fitting as well as attention to correct hinge placement relative to the femoral condyles can limit brace migration and improve its effectiveness in mid and deep knee flexion. With using adaptive limb fittings, through flexible pads, and a polycentric joint a more significant improvement of the overall brace performance and efficacy might be obtained. Key pointsFunctional bracing improves the knee joint stability mostly in extension posture.Unlike the non-braced condition, the least knee joint stability appears in mid and deep flexion angles when using a hinged brace.Accurate sizing and fitting and attention to correct hinge placement relative to the femoral condyles can limit brace migration and improve its effectiveness in mid and deep knee flexion.The overall brace performance and efficacy might be improved significantly using adaptive limb fittings through flexible pads and/or polycentric joints.

Functional Knee Braces for Control of Hyperextension

The functional knee hrace has been used to provide or to assist knee stahility in the anterior cruciate ligament (ACL) deficient knee, Nowadays, it is more indicated in the postoperative care of ACL injury to protect the reconstructed or repaired ligament, but eontroversies still exist regarding the effectiveness and the selection of an appropriate model. For successful application, it must restrict the knee motion within the range of certain arc, especially hyperextension, during weight bearing together with convenience and comfort.. The six commercial functional knee braces, which were introduced in Korea, were ehecked to detect the angle discrepancy between angle of brace and knee joint motion. The purpose of this study was to guide correct application of the functional knee brace in preventing hyperextension of the knee joint. Each brace was grouped into small, medium and large by size, and fixed with the arc of motion 30 to 90. The brace was applied to 3 healthy volunteers whose size was just fit mth the brace size small, rnedium and large, respectively. True lateral X-ray of the knee joint was taken in active flexion and extension state under the fluoroscopic control and measured the lateral intershaft angle of femur and tibia. Average angle discrepancy between the brace and the intershaft ang]e of femur and tibia in active extension was 22 and 3 in acTive flexion. In active extension at 30, angle discrepancy of Denzo brace was the large:st recording 26, that of Sentry hrace was the smallest recording 17. In active flexion at 90', angle discrcyancy of Sentry hrace was the largest recording 13, that of ACL brace (custom made modified Sentry brace) was the smallest recording 2. There was no statistically significant difference of the angle discrepancy among each size of brace. This study suggests that, at least 20 of angle discrepancy must be considered in appling the knee brace for prevention of hyperextension of the knee joint and careful selection of the brace, which may be affected by the design of hrace and the soft tissue compliance, is mandatory.