Members of the American Orthopaedic Society for Sports Medicine, AOSSM, revealed only 13 percent of respondents never braced their ACL reconstructed patients.
The orthopaedic community has recognized – with increasing clarity, throughout the past decade – that peer reviewed evidence does not support empiric post-operative functional bracing after ACL reconstruction surgery. In addition, mounting pressure to control costs associated with surgical and post-operative care makes the additional expense of empiric bracing a less appealing treatment strategy.
So, in the face of clinical evidence and economic reality, why do patients leave the operating room with a knee immobilizer after ACL reconstruction and then get fitted for a functional ACL brace at six weeks post op? This is a question many surgeons should ask themselves, as a 2003 survey of members of the American Orthopaedic Society for Sports Medicine, AOSSM, revealed only 13 percent of respondents never braced their ACL reconstructed patients.
Bracing of ACL injuries and reconstructions is habit for many surgeons and should be investigated from several angles as the clinical question is not completely straightforward. These decisions include prophylactic bracing for high risk activities, functional bracing of the ACL deficient knee, immediate post-operative bracing, and ultimately functional bracing during rehabilitation and return to sport. Each is a specialized area of physician and patient concern and one answer may not fit all patients or situations. This review attempts to assess data surrounding empiric knee bracing for ACL injury and reconstruction to determine if any benefit for the patient is realized with the continuation of this practice.
Prophylactic Knee Bracing has been advocated to reduce injuries during activities at high risk for knee ligamentous injury. The primary designs of prophylactic braces include hinged single or dual uprights with the primary goal of limiting valgus stress to prevent the characteristic sequence of injury to the MCL, ACL, and PCL. Clinical studies have supported the use of prophylactic bracing, including a 1990 study of 1,396 West Point cadet intramural tackle football players where the rate of injury in the unbraced group was more than double that of the braced group (3.4 vs. 1.5 injuries/1000 exposures).
A similar study of 987 Big Ten varsity football players stratified by position and playing condition showed a trend towards decreased MCL injuries with prophylactic bracing at all positions during practice and among linemen, linebackers, and tight ends in games. These data are balanced by studies that demonstrate a significant decrease in athletic performance with the use of braces, including measures such as energy consumption, muscular fatigue as well as speed and agility.
In a position statement written in 1997 and retired in 2008 by The American Academy of Orthopaedic Surgeons, prophylactic braces were not endorsed for routine use. In the role of team physician, the recommendation for brace wear may depend on the player’s position, the level of competition, and the preferences of the player, however empiric bracing is not indicated for prophylaxis in an otherwise healthy population.
Excerpt from ACL bracing update, Team physician’s corner, American Orthopaedic Society for Sports Medicine, AOSSM
ACL bracing update, Brendan D. Masini MD MAJ MC. Brett D. Owens, MD LTC MC. Sports Medicine Update, American Orthopaedic Society for Sports Medicine, AOSSM November/December 2011
Updating Recommendations for Rehabilitation After ACL Reconstruction, John A. Grant PhD MD. Clinical Journal of Sport Medicine 2013;23(6):501-502.