Brace or no brace after anterior cruciate ligament reconstruction (ACLR).

Brace or no brace

According to a systematic review based on six clinical practice guidelines (CPGs), four of the guidelines did not support the routine use of postoperative functional knee brace after anterior cruciate ligament reconstructions (ACLR). One guideline recommended postoperative knee brace according to patient’s preferences or associated ligament injuries and the last guideline did not provide any recommendations (1). There is a general belief that the use of brace does not affect clinical outcomes after ACLR (2), does not offer any advantages such improving limb symmetry (4), as well as being ineffective for physical function and laxity (5) and does not confer additional benefits (6). However, in a survey of 46 American Orthopedic surgeons, only 17% of the surgeons did not use a postoperative brace and 83% of surgeons use postoperative bracing, with most (55%) bracing for 3 to 6 weeks postoperatively.

Why is the brace still commonly used if it is not recommended. The primary purposes of knee bracing are protecting the graft or preventing subsequent injury to the meniscus repairs or load to cartilage. To achieve this, knee braces are commonly used to limit the knee range of motion. However, concerns of long term use of knee braces are muscle atrophy and arthrogenic muscle inhibition (AMI).

The use of brace and post surgical restriction is often based on the surgeon’s preferences. Always have the dialogue with your surgeon about the use of braces and if the brace is based on old protocols or if there is surgical reasoning behind. Based on the current literature it is not recommended to use braces for isolated ACLR. However, it can often be more relevant when ACLR have additional meniscus repairs or cartilage intervention. The brace restriction will then be based on the surgeon’s decision. Often the brace is used to keep the leg in full extension during sleep the first weeks after surgery, then gradually open to knee flexion for 90 DEG at 4 to 6 weeks. It is commonly recommended to remove the brace during the post-operative exercises.

Reference 

1. Andrade R, Pereira R, van Cingel R, Staal JB, Espregueira-Mendes J. How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II). Br J Sports Med. 2020;54(9):512-519. doi:10.1136/bjsports-2018-100310
2. Yapıcı F, Gür V, Sarı İF, Köksal A, Yurten H, Üçpunar H, Çamurcu Y. Prescription of knee braces after anterior cruciate ligament reconstruction: Fact or fiction? Turk J Phys Med Rehabil. 2022 Aug 25;68(3):355-363. doi: 10.5606/tftrd.2022.8906. PMID: 36475105; PMCID: PMC9706800.
3. Lin TJ. Editorial Commentary: There Is No Standard for or Standardization of Postoperative Rehabilitation Protocols After Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2023;39(3):590-591. doi:10.1016/j.arthro.2022.10.001
4. Glattke KE, Tummala SV, Chhabra A. Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review. J Bone Joint Surg Am. 2022;104(8):739-754. doi:10.2106/JBJS.21.00688
5. Culvenor AG, Girdwood MA, Juhl CB, et al. Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. Br J Sports Med. 2022;56(24):1445-1453. doi:10.1136/bjsports-2022-105495
6. Nelson C, Rajan L, Day J, Hinton R, Bodendorfer BM. Postoperative Rehabilitation of Anterior Cruciate Ligament Reconstruction: A Systematic Review. Sports Med Arthrosc Rev. 2021;29(2):63-80. doi:10.1097/JSA.0000000000000314