Question: Is functional bracing more effective than nonbracing after
anterior cruciate ligament (ACL) reconstruction in patients with a high level
of physical activity?
Design: Randomized (allocation not concealed), unblinded, controlled
trial with a mean 29-month follow-up.
Setting: 3 United States military academies.
Patients: 100 cadets and midshipmen with ACL injury, no previous
knee injury to the affected knee, no significant chondral injury, no grade-III
posterior cruciate or collateral ligament injuries, no serious meniscal
injury, surgical reconstruction within 8 weeks of injury, and available for
follow-up for =2 years.
Intervention: Patients were allocated to wear (n = 47) or not wear a
brace (n = 48). The braced group wore a DonJoy IROM brace (dj Orthopaedics,
Vista, California) locked in extension for 3 weeks after surgery (removed 2 to
3 times daily for physical therapy) and adjusted to allow for increasing range
of motion during the 3 to 6 weeks after surgery. At 6 weeks, patients wore an
off-the-shelf functional knee brace daily for 6 months and for rigorous
activities for =1 year. Patients in the nonbrace group wore a knee
immobilizer for 3 weeks after surgery (removed for physical therapy).
Postoperative rehabilitation for all patients included range-of-motion
exercises, cycling on a stationary bicycle, pool exercises, strengthening
exercises, and functional training.
Main outcome measures: Measures of stability, function, and strength
of the affected knee (range of motion, prone heel height difference,
isokinetic testing, single-legged hop for distance, Lysholm score, KT-1000
arthrometer testing, International Knee Documentation Committee score, Lachman
test, pivot shift test, and knee radiographs). The study was powered to detect
a 20% difference in Lysholm score.
Main results: Patients who were braced and those who were not braced
did not differ for any outcomes
(Table). Knee radiographs were
normal in both groups of patients. One patient in the nonbraced group could
not return to the same level of sport activity. Two braced and 3 nonbraced
patients had re-injury to the affected knee.
Conclusion: In patients with a high level of physical activity, the
outcomes with regard to stability, function, and strength were not
significantly different between patients who did or did not wear a brace after
anterior cruciate ligament reconstruction.
McDevitt and colleagues presented a well-done randomized trial of brace use
following ACL reconstruction with the central third patellar tendon in cadets
and midshipmen from the United States Army, Navy, and Air Force academies. The
nonbraced group wore a knee immobilizer for 3 weeks (except for 2 to 3 times
each day during physical therapy), while the braced group wore the brace for
an additional 3 weeks, with the brace adjusted to allow range of motion,
followed by a functional brace. The investigators elected to use a knee
immobilizer for the first 3 weeks in the group that was not treated with a
functional brace because they believed that an immobilizer would prevent loss
of knee extension.
It is worth noting that these patients were extremely active and were
required to participate in sports and military activities, including
aggressive jumping, cutting, and pivoting. While many of the patients in the
braced group preferred to use the brace because it made them feel more
confident and gave them a sense of security, others believed that it
negatively affected sports performance, and 8 of 38 questionnaire respondents
(21%) stopped using the brace before the end of the follow-up period.
As always with prospective ACL research, sample size sufficient to detect a
difference in complication or re-injury rates is difficult to achieve.
However, the levels of function and knee stability following ACL
reconstruction in a very active population were found to be similar with and
without the use of a functional brace. This finding is consistent with
previous research and should be considered when caring for patients after ACL
reconstruction.