Article

Generation II knee bracing for severe osteoarthritis of the knee

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Abstract

To investigate the clinical efficacy of the Generation II (G II) knee brace, a newly developed knee orthosis, on patients experiencing severe medial compartment osteoarthritis (OA) of the knee. Case series. A national medical and pharmaceutical hospital in Japan. Twenty primary OA subjects (excluding those with secondary OA), all older than 55 years of age and experiencing only knee joint problems, were selected according to their ability to walk more than 500 meters independent of support. These patients had arthritis in both knees and no less than one half of normal joint space remaining as revealed by roentgenogram studies. The more severely affected side was selected for bracing. For 12 months, each patient wore a G II knee brace on the affected knee on a daily basis, removing it only at night. To evaluate the effects of G II OA brace alone, additional use of new oral drugs or any other treatment was prohibited from 1 month before application of the G II OA brace and throughout the trial period. Clinical efficacy was evaluated using the Japan Orthopaedic Association's knee scoring system. X-ray evaluation was performed with patients standing on one leg. A dynamometer was used to evaluate isokinetic quadriceps muscle strength. The center of gravity was measured using an X-Y recording. Clinical evaluation was performed every 2 months thereafter. Final evaluation was at 12 months. Nineteen of the 20 patients answered that they experienced significant pain relief. Knee pain scores on walking increased from 18.0 to 21.5 and on ascending and descending stairs increased from 12.8 to 15.8. The femorotibial angle decreased in 12 of the patients, and the mean angle decreased from 185.1 degrees before application to 183.7 degrees with the brace on at the final observation period. In addition, isokinetic quadriceps muscle strength increased from an average of 36.8 Nm to 42.8 Nm for all patients. In 17 patients, quadriceps muscle strength increased, while it decreased in 2 and remained the same in 1. Finally, lateral movement of the center of gravity decreased compared with before G II application in all patients. G II bracing is a beneficial treatment for severe medial OA of the knee.

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... • l'angle fémorotibial [9][10][11][12][13] ; ...
... Les résultats pour l'angle fémorotibial sont contradictoires. Trois études de niveau 4 du score Anaes ont montré une effet valgisant des orthèses articulées sur le compartiment fémorotibial interne [10,12,13]. Une étude de niveau 2 [11] et une étude de niveau 4 [9] n'ont pas retrouvé cet effet. ...
... Parmi les études positives, une a été réalisée en condition statique : les radiographies antéropostérieures en appui monopodal avec et sans contention valgisante après 12 mois d'utilisation ont été comparées chez 20 patients [13]. Cette étude retrouvait une diminution en varus de 1,4 • . ...
Article
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Objectif Développer des recommandations de pratique clinique sur l’utilisation des orthèses de contention (de repos, souples non adhésives et articulées) dans la gonarthrose. Méthodes La méthodologie de la Société française de médecine physique et de réadaptation (Sofmer), qui associe une revue systématique de la littérature, un recueil des pratiques professionnelles et une validation par un panel d’experts multidisciplinaires, a été utilisée. Résultats Il existe peu d’études de niveau de preuve élevé sur les orthèses de contention dans la gonarthrose. L’efficacité des orthèses de repos n’a pas été démontrée. Les orthèses souples non adhésives ou genouillères élastiques diminuent la douleur dans la gonarthrose et leur utilisation s’accompagne d’une amélioration subjective. Ces actions ne semblent pas dépendre d’un effet thermique local. L’efficacité des orthèses souples n’est pas démontrée dans l’incapacité liée à la gonarthrose. Les orthèses articulées valgisantes diminuent la douleur et réduisent l’incapacité fonctionnelle dans la gonarthrose fémorotibiale interne à court et à moyen termes. Leur efficacité paraît supérieure à celle des orthèses souples, elles améliorent la qualité de vie, la proprioception du genou, la force du quadriceps, la symétrie du pas et, enfin, diminuent la charge compressive dans le compartiment fémorotibial interne. Cependant, l’efficacité des orthèses valgisantes est inconstante, il peut en résulter un inconfort et des effets indésirables. Des thrombophlébites des membres inférieurs secondaires à l’utilisation de telles contentions ont été rapportées. Les orthèses, quelles qu’elles soient, sont peu souvent prescrites en pratique clinique dans l’arthrose des membres inférieurs. Conclusion Seules des recommandations de faible niveau de preuve existent sur l’efficacité des orthèses (de repos, souples non adhésives et articulées de décharge) dans la gonarthrose. Celles-ci restent peu prescrites dans la pratique clinique française. Des essais randomisés sur l’utilisation des orthèses dans la gonarthrose restent nécessaires.
... This has spurred research efforts to reduce pain, preserve joints, delay replacement, and where possible restore joint function. High loads across the medial compartment of the OA knee in particular have been linked to both disease severity 1,2 and progression, 3 and so reduction of the loads at the knee is the basis for a number of potentially successful OA treatments, such as wedge insoles, braces, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] and high tibial osteotomy. [24][25][26][27] A novel approach to reduce loads across the medial knee compartment is offered by the KineSpring system (Moximed, Hayward, CA, USA), which has been in clinical use for unicompartmental knee OA patients since mid-2008. ...
... Availability limited the number of specimens included, and during the study the sample size was further challenged by soft-tissue structure deficits in two of the specimens. In spite of this, the number of right-and left-leg specimens were equal, and they came from an equal number of male and female donors (five of each), spanning a range of ages (53-98 years old) and body mass index values (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). ...
Article
Full-text available
The KineSpring implant system has been shown to provide load reductions at the medial compartment of the knee, and has demonstrated clinical success in reducing pain and increasing function in patients with medial knee osteoarthritis. These results depend on the ability of the KineSpring to rotate, lengthen, and shorten to accommodate knee motions, and in response to knee position and loading. The present study was undertaken to determine length changes of the implanted KineSpring in response to a range of knee positions, external knee loads, and placements by different orthopedic surgeons. KineSpring system components were implanted in ten cadaver leg specimens by ten orthopedic surgeons, and absorber-length changes were measured under combined loading and in different positions of the knee. Spring compression consistent with knee-load reduction, and device lengthening and shortening to accommodate knee loads and motions were seen. These confirm the functionality of the KineSpring when implanted medially to the knee.
... Eleven studies (of 30) reported effects on lower limb varus alignment 31,33,36,40,44,46,49,51,53,56,59 . Five studies used the knee adduction angle calculated from three-dimensional gait analysis 46,51,53,56,59 . ...
... One study used fluoroscopic gait analysis and reported a decrease in varus alignment (2.2 ) in 80% of patients (n ¼ 12/15) 36 . Five studies used the hipekneeeankle or femorotibial angle (FTA) measured on standing AP radiographs 31,33,40,44,49 . Non-significant decreases 31,40,49 and significant improvements in lower limb alignment (1.4 ) 33 were reported. ...
Article
To review and synthesize the biomechanical effects of valgus knee bracing for patients with medial knee osteoarthritis.Methods Electronic databases were searched from their inception to May 2014. Two reviewers independently determined study eligibility, rated study quality and extracted data. Where possible, data were combined into meta-analyses and pooled estimates with 95% confidence intervals (CI) for standardized mean differences (SMD) were calculated.ResultsThirty studies were included with 478 subjects tested while using a valgus knee brace. Various biomechanical methods suggested valgus braces can decrease direct measures of medial knee compressive force, indirect measures representing the mediolateral distribution of load across the knee, quadriceps/hamstring and quadriceps/gastrocnemius co-contraction ratios, and increase medial joint space during gait. Meta-analysis from 17 studies suggested a statistically significant decrease in the external knee adduction moment during walking, with a moderate-to-high effect size (SMD=0.61; 95%CI: 0.39, 0.83; p<0.001). Meta-regression identified a near-significant association for the knee adduction moment effect size and duration of brace use only (β, -0.01; 95% CI: -0.03, 0.0001; p=0.06); with longer durations of brace use associated with smaller treatment effects. Minor complications were commonly reported during brace use and included slipping, discomfort and poor fit, blisters and skin irritation.Conclusions Systematic review and meta-analysis suggests valgus knee braces can alter knee joint loads through a combination of mechanisms, with moderate-to-high effect sizes in biomechanical outcomes.
... improve function. Although several studies have investigated the effectiveness of unloading brace treatment for knee OA [6][7][8][9][10][11][12] , the recently published Cochrane review that included 13 studies (4 investigating unloading knee braces) concluded that there is still very limited evidence for the benefits of bracing, mainly because of bias questioning the results from most studies 13 . In addition, the reported beneficial effect of unloading knee braces varies depending on whether they are compared to controls without brace, with neutral knee braces, with knee sleeves or with insoles 14 . ...
... Results showed that combination of the REBEL RELIEVER unloading knee brace with usual care was superior to usual care alone in terms of improvement of last 24h-pain, pain on motion, functional disability, disease evolution assessed by both the patient and the investigator, and clinical response rate after a 6-week treatment period. These results are consistent with previous published data suggesting that treatment with unloader braces improves pain and physical function 6,7,10,[17][18][19] . ...
Article
Full-text available
Evidence is still inconclusive for the benefits of bracing in patients with knee osteoarthritis. To assess the effect of REBEL RELIEVER unloading knee brace in conservative treatment of knee osteoarthritis, a randomized controlled trial was conducted in 67 patients with symptomatic medial knee osteoarthritis, who randomly received 6-week treatment with either REBEL RELIVER unloading knee brace + usual care (Brace group, N = 32) or usual care alone (Control group, N = 35). Primary outcome was the global last 24h-pain relief (100-mm visual analogic scale [VAS]) at 6 weeks. Secondary endpoints included pain on motion (100-mm VAS), function (Lequesne index), safety and observance. At 6 weeks, mean [SD] last 24h-pain decreased significantly more in Brace group versus Control group (-41.35 [3.37] vs -15.37 [3.23], difference -25.98, 95% CI -41.64 to -10.33, P < 0.0001). Higher mean [SD] pain on motion decrease (-51.91 [3.49] vs -19.91 [3.34], difference -32.01, 95% CI -48.21 to -15.80, P < 0.0001) and better improvement of Lequesne index score (-5.8 [0.5] vs -2.3 [0.5], difference -3.5, 95% CI -5.0 to -2.0, P < 0.0001) were observed in Brace group. Safety and observance to the brace were excellent. The additive clinical benefit of wearing REBEL RELIEVER unloading knee brace was demonstrated in knee osteoarthritis patients.
... If a brace is large, and inconvenient, it probably would not be used, even if technically it is sound [12,23,57]. In addition, braces with relatively poor cosmetics may also be rejected, and skin irritation may also lead to non-use [12,47,58,59]. With these factors in mind, four pneumatic braces noted in this study have been made of lightweight materials such as neoprene [12,31,33,35]. ...
... Further to these observations, we recommend that basic factors related to convenience, comfort and usability of the braces should be high priorities, without necessarily changing their specific mechanisms of usage [12,28,31,60]. In addition, one of the main challenges for brace designers is achieving a close fit throughout the gait cycle that does not require any consistent adjustment during usage [12,59]. ...
Article
Full-text available
Osteoarthritis of the knee is a debilitating condition affecting increasing numbers of individuals each year. One option for treatment is orthotic knee braces, but a little independent reviews have taken place to date on their relative outcomes for users. This study therefore evaluates the efficacy of different types of knee orthoses (braces) with regard to key aspects of use, including gait parameters, mobility and levels of comfort and compliance in subjects presenting with osteoarthritis (OA) of the knee. The collated data is presented with relevant supporting literature and appropriate descriptions in relation to each knee orthosis type that was identified, within appropriate subsections with advantages and disadvantages appropriately allocated. An analysis of each brace as presented by the corresponding article is then described further in terms of the design and structure, user outcomes and assessment summaries. According to the study carried out in this paper, it is presented and proved that applying the use of knee braces can reduce the knee adduction moment (KAM), but the amount of reduction afforded varies between designs. All of the studies reported significant pain reduction and functional improvement with the use of a knee brace, although their effect on the knee joint range of motion vary. Knee braces long-term use depends upon high levels of comfort and patient compliance, and further studies need to be conducted on larger numbers of subjects over greater time periods to reflect the long-term outcomes accurately.
... Another common method for unloading the knee joint is through knee bracing. Most knee OA braces attempt to restore function and reduce pain in patients with unicompartmental OA of the TF joint [23][24][25][26][27]. Unicompartmental TFOA typically results from malalignment of the tibia and femur in the frontal plane, turning a portion of the ground reaction force into an adduction moment acting about the joint [28,29]. ...
... Other unloading braces are typically focused on providing unicompartmental offloading of the TF joint [23][24][25][26][27][32][33][34] without addressing PF compartment loading. An important limitation of unicompartment offloaders is that as the offloading benefit is realized by one side of the TF joint, the opposite TF compartment experiences an increase in loading. ...
Article
Knee osteoarthritis (OA) is a significant problem in the aging population, causing pain, impaired mobility, and decreased quality of life. Conservative treatment methods are necessary to reduce rapidly increasing rates of knee joint surgery. Recommended strategies include weight loss and knee bracing to unload knee joint forces. Although weight loss can be beneficial for joint unloading, knee OA patients often find it difficult to lose weight or exercise due to knee pain, and not all patients are overweight. Uni-compartment offloader braces can redistribute joint forces away from one tibiofemoral (TF) compartment, however, <5% of patients have uni-compartmental TFOA, while isolated patellofemoral or multi-compartmental OA are much more common. By absorbing body weight and assisting the knee extension moment using a spring-loaded hinge, sufficiently powerful knee-extension-assist (KEA) braces could be useful for unloading the whole knee. This paper describes the design of a spring-loaded tri-compartment unloader (TCU) knee brace intended to provide unloading in all three knee compartments while weight-bearing, measures and compares the force output of the TCU against the only published and commercially available KEA brace, and calculates the static unloading capacity of each device. The TCU and KEA braces delivered maximum assistive moments equivalent to reducing body weight by 45 and 6 lbs, respectively. The paper concludes that sufficiently powerful spring-loaded knee braces show promise in a new class of multi-compartment unloader knee orthoses, capable of providing a clinically meaningful unloading effect across all three knee compartments.
... Our results are within the range of their findings. Matsuno et al. measured the changes in adduction moments before and after wearing the knee brace, but not have quantified the contact pressures and contact area on the articular cartilage [14]. Pollo et al. calculated the reduction of loads on the medial compartment during normal walking using the mathematical model, but have not measured the incremental loads on the lateral cartilage [1]. ...
Conference Paper
Full-text available
Knee osteoarthritis that prevalently occurs at the medial compartment is a progressive chronic disorder affecting the articular cartilage of the knee joint, and lead to loss of joint functionality. Valgus braces have been used as a treatment procedure to unload the medial compartment for patients with medial osteoarthritis. Valgus braces through the application of counteracting external valgus moment shift the load from medial compartment towards the lateral compartment. Previous biomechanical studies focused only on the changes in varus moments before and after wearing the brace. The objective of this study was to investigate the influence of opposing external valgus moment applied by knee braces on the lateral tibial cartilage contact conditions using a 3D finite element model of the knee joint. Finite element simulations were performed on the knee joint model without and with the application of opposing valgus moment to mimic the unbraced and braced conditions. Lateral tibial cartilage contact pressures and contact area, and tibial rotation (varus-valgus and internal-external) were estimated for the complete walking gait cycle. The opposing valgus moment increased the maximum contact pressure and contact area on the lateral tibial cartilage compared to the normal gait moment. A peak contact pressure of 8.2 MPa and maximum cartilage loaded area of 28% (loaded cartilage nodes) on the lateral cartilage with the application of external valgus moment were induced at 50% of the gait cycle. The results show that the use of opposing valgus moment may significantly increase the maximum contact pressures and contact area on the lateral tibial cartilage and increases the risk of articular cartilage damage on the lateral compartment.
... Our results are within the range of their findings. Matsuno et al. measured the changes in adduction moments before and after wearing the knee brace, but not have quantified the contact pressures and contact area on the articular cartilage [14]. Pollo et al. calculated the reduction of loads on the medial compartment during normal walking using the mathematical model, but have not measured the incremental loads on the lateral cartilage [1]. ...
... Initially, there is a tendency towards a varus deformity, followed by an increase in the adduction moment in the knee during gait as well as a reduced joint space in the medial compartment. [2][3][4] The conservative treatment of medial osteoarthritis of the knee involves several techniques; physiotherapy has an important role using several resources, among them valgus orthoses, because minimization of loading on the medial compartment is the ultimate strategic biomechanical goal of treatment, for patients with medial compartment knee OA. [5][6][7] The benefits of using orthosis are a consensus in the literature; however, valgus orthoses are made of rigid material that promotes correction of gait moment, 6,8 but are of difficult adaptation to the individual, as they promote areas of pressure and, eventually, cutaneous lesions. Custom-made orthoses would have the beneficial effect of providing a better fitting and increasing adherence, reducing therefore lesions in this subjects. ...
... Blood biochemistry analyses were performed before the study and after 8 weeks of each intervention. The patients' knee symptoms were evaluated at 0, 2, 4, 6, and 8 weeks according to the following criteria: the Japanese Knee Osteoarthritis Measure (JKOM) [13], the knee pain visual analog scale (VAS) included in JKOM, and the knee scoring system of the Japanese Orthopedic Association (JOA) [14]. JKOM consists of 25 questions divided into 4 subcategories-pain and stiffness, condition in daily life, general activities, and health conditions-for patient self-assessment, and is based on the World Health Organization's International Classification of Functioning, Disability, and Health. ...
Article
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Background We previously developed a surface-controlled water-dispersible form of curcumin and named it Theracurmin® (Theracurmin; Theravalues, Tokyo, Japan). The area under the blood concentration–time curve of Theracurmin in humans was 27-fold higher than that of curcumin powder. We determined the clinical effects of orally administered Theracurmin in patients with knee osteoarthritis during 8 weeks of treatment. Methods Fifty patients with knee osteoarthritis of Kellgren–Lawrence grade II or III and who were aged more than 40 years were enrolled in this randomized, double-blind, placebo-controlled, prospective clinical study. Placebo or Theracurmin containing 180 mg/day of curcumin was administered orally every day for 8 weeks. To monitor adverse events, blood biochemistry analyses were performed before and after 8 weeks of each intervention. The patients’ knee symptoms were evaluated at 0, 2, 4, 6, and 8 weeks by the Japanese Knee Osteoarthritis Measure, the knee pain visual analog scale (VAS), the knee scoring system of the Japanese Orthopedic Association, and the need for nonsteroidal anti-inflammatory drugs. Results At 8 weeks after treatment initiation, knee pain VAS scores were significantly lower in the Theracurmin group than in the placebo group, except in the patients with initial VAS scores of 0.15 or less. Theracurmin lowered the celecoxib dependence significantly more than placebo. No major side effects were observed with Theracurmin treatment. Conclusion Theracurmin shows modest potential for the treatment of human knee osteoarthritis.
... The treatment using wedge insoles has been shown to be effective only in early-stage osteoarthritis . Knee bracing for osteoarthritis has gained popularity due to its ability to provide patients with pain relief while being relatively easy to use (Matsuno, et al., 1997, Self, et al., 2000. ...
Article
Full-text available
In this study, as a fundamental approach to realize orthotic device for patients with osteoarthritis of the knee considering screw home movement, bending and extension movements of lower thigh of able-bodied persons are analyzed and inherent screw home movement is examined. The analyzed extension movement of lower thigh with screw home movement is mathematically modeled and the structure of an orthotic device is proposed based on the model. It is confirmed by the simulation based on FEM analysis that the force acting on the leg when using the proposed orthotic device is helpful to realize normal screw home movement and valgus rotation, which is expected to be useful for patients with osteoarthritis of the knee.
... Heaviness and inappropriate appearance is one of the major problems of brace [34,35]. ...
Article
The knee unloader brace can change loading on knee which may be effective in reducing symptoms and progression of disease in people with knee osteoarthritis. The purpose of this study was to evaluate the effect of a new knee brace during walking in a patient with medial compartment knee osteoarthritis. Two brace types were used: new brace and conventional brace. A pneumatic cuff of novel brace was fitted in the bottom of the medical slipper that were connected to the cuff section of the knee through the tube. After the knee brace is deployed, its force can vary in different stages of the gait. During the heel strike, the weight of the cuff is compressed on the floor, causing the air to flow inside it and entering the volume of air into the knee pad. The results of using this pneumatic knee brace compared with conventional knee braces on a patient showed that in both cases, the open and closed palatal pump, the adduction moment and ROM was decreased in the stance phase. But the three-point knee pressure, however, was less effective in reducing the adduction moment but also reduced the knee ROM. Using novel brace can eliminate the patient’s need for painful and costly surgery to reduce the symptoms of osteoarthritis.
... Bastonlar, koltuk değnekleri, yürüme cihazları, özel diz breysleri, tabanlıklar ve ayakkabı modifikasyonları ağrıyı ve ekleme binen yükü azaltmada, hastanın mobilizasyonunu arttırmada faydalıdır. Yardımcı cihazların bir uzman tarafından reçete-lenmesi ve kontrol edilerek gerektiğinde hastaya yönelik değişikliklerin yapılması, uygun olmayan cihaz kullanımına bağlı olarak oluşabilecek komplikasyonları önleyecek ve rehabilitasyonun başarısını yükseltecektir (7,18,24). ...
... Valgus knee braces have also been shown to significantly reduce knee pain in the short term (0-12 months). 69,73,109,120,129,149 In a randomized controlled trial of 117 patients with medial knee OA, valgus bracing resulted in better knee function and walking distance compared with no brace in patients with varus malalignment. 19 However, many patients in that study did not adhere to the brace treatment, mainly because of skin irritation and poor fit. ...
Article
Synopsis: Altered knee joint biomechanics and excessive joint loading have long been considered as important contributors to the development and progression of knee osteoarthritis. Therefore, a better understanding of how various treatment options influence the loading environment of the knee joint could have practical implications for devising more effective physical therapy management strategies. The aim of this clinical commentary was to review the pertinent biomechanical evidence supporting the use of treatment options intended to provide protection against excessive joint loading while offering symptomatic relief and functional improvements for better long-term management of patients with knee osteoarthritis. The biomechanical and clinical evidence regarding the effectiveness of knee joint offloading strategies, including contralateral cane use, laterally wedged shoe insoles, variable-stiffness shoes, valgus knee bracing, and gait-modification strategies, within the context of effective disease management is discussed. In addition, the potential role of therapeutic exercise and neuromuscular training to improve the mechanical environment of the knee joint is considered. Management strategies for treatment of joint instability and patellofemoral compartment disease are also mentioned. Based on the evidence presented as part of this clinical commentary, it is argued that special considerations for the role of knee joint biomechanics and excessive joint loading are necessary in designing effective short- and long-term management strategies for treatment of patients with knee osteoarthritis. Level of evidence: Therapy, level 5.
... Although there is little empirical evidence to support the implementation of joint protection and energy conservation strategies advocated for knee osteoarthritis, 140 appliances (e.g., canes, 140,[191][192][193] unloader braces, and neoprene sleeves or splints) might help protect the joint from excessive stresses, 58,63,140,194,195 particularly in the presence of muscle weakness, leg malalignment, and instability. Likewise, orthotic devices that facilitate or improve function by fostering the favorable application of biomechanical forces and, hence, the magnitude of joint stresses falling on the medial or lateral compartments may be benefi-cial, 40,74,186,187,[196][197][198][199][200][201][202][203][204] as may well-cushioned footwear. ...
Article
Full-text available
This article reviews some nonoperative and nonpharmacologic management strategies for alleviating the symptoms of the common joint disease, osteoarthritis. This chronic condition results in considerable disability, particularly in later life, and can have a profound effect on earning potential and the quality of life. There is no known cure for osteoarthritis, and the condition is usually progressive despite available operative and pharmacological interventions. Thus, other intervention forms, especially those that might prevent further disability and that can be carried out cost-effectively, practically, and with no side effects, are immensely important in the management of the disease. This target article attempts to synthesize an integrated plan of management for people with osteoarthritis by incorporating nonpharmacological and nonoperative treatment strategies that appear most beneficial in alleviating the pain and disability of hip and knee osteoarthritis. This article focuses on interventions that view osteoarthritis as an emergent mechanically driven joint disorder and, to minimize their disability and improve their quality of life, emphasizes the importance of including individuals with osteoarthritis as participants in their personal management programs.
Article
Brace treatment has been selected for knee osteoarthritis (OA) patient as a conservative treatment. However, it is difficult to evaluate the effects of braces on the three-dimensional (3D) motion of the knee joint and thus there was no clear criterion for physician to choose a brace for each patient. Previously, we developed a 2D/3D registration technique using bi-plane fluoroscopic images and 3D computed tomography image to provide the 3D motion information of the knee joint and conversion procedure of 3D motion information to angular and displacement parameters which are clinically used. These parameters represent relative posture angles and relative positions from the femur to the tibia or to the patella, respectively. In this study, we applied this technique to assess and compare effect of two kinds of braces on the femorotibial and patellofemoral joints Data were collected from ten knee OA patients and analyzed. Effect of braces for 3D relative motion between femur and tibia, or femur and patella with knee OA could be assessed through the use of highly accurate 2D/3D registration technique. Effects for displacement parameters on the both joints were very small. As for the angular parameters on femorotibial joint, both braces reduced the abduction. Two angular parameters of patellofemoral joint, abduction and internal were influenced by the both braces.
Article
Hintergrund Valgisierende Orthesen stellen eine kostengünstige Alternative in der Behandlung der medialen Gonarthrose dar. Sie helfen zum einen in der präoperativen Diagnostik als Entscheidungshilfe, ob ein Patient aller Voraussicht nach von einer valgisierenden Osteotomie des Tibiakopfes profitiert. Darüber hinaus ist ein direkter klinischer Nutzen in Form einer Schmerzlinderung und Besserung der Kniegelenkfunktion in einigen Arbeiten gezeigt worden. Diskussion Die genauen Wirkungsmechanismen werden kontrovers diskutiert. Es wird eine Verringerung der mechanischen Last im medialen Kompartiment des Kniegelenks durch Verringerung des Varus, sowie eine Reduktion des gesteigerten Muskeltonus angenommen. Schlussfolgerung Ein langfristiger Nutzen der entlastenden Kniegelenkorthesen ist jedoch umstritten, da zum einen der degenerative Gelenkverschleiß fortschreitet, zum anderen aufgrund des oft fehlenden Tragekomforts der Orthesen die Bereitschaft zum Tragen der Orthese mit der Zeit abnimmt.
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The most common cause of disability in the United States is knee osteoarthritis (OA). This disease affects more than 27 million Americans commonly older than -40 years (Centers for Disease Control and Prevention [CDC], 2012). Osteoarthritis develops gradually over a period of years and results in the gradual deterioration of the hyaline cartilage that covers the articulating surfaces of the knee joint. In most people, the disease is idiopathic but can also be hereditary or the result of trauma, which causes pain, stiffness, limited range of motion, and localized swelling in the knee (Brandt and Slemenda. Osteoarthritis epidemiology, pathology and pathogenesis. In: Primer on the Rheumatic Diseases. 10th Ed. Atlanta, GA: Arthritis Foundation; 1993, p 18408). Knee OA cannot be cured, but there are interventions available to help manage the symptoms. An unloading knee orthosis is one course of action. The principle of the unloader knee brace is to create a varus or a valgus moment at the knee, creating additional space in the joint space, thus relieving pain caused by bone-on-bone contact and improving function within the knee for activities of daily living (ADLs) (Kirkley et al. J Bone Joint Surg 1999;81[4]:539-547. Sharma et al. JAMA 2001;286[2]:188-195). After extensive research, 42 custom and off-the-shelf OA knee braces are currently available within the United States for patients with varus and valgus gonarthrosis secondary to OA. Upon further examination, it was noted that only 15 of the 42 have evidence-based information to support their effectiveness in relieving symptoms common within the knee for an individual with a diagnosis of OA. The 15 braces are SofTec OA brace (Bauerfeind), Thruster 2/Dynamic Unloading Osteoarthritis (DUO) (Bledsoe), Legacy Thruster OA (Bledsoe), Fusion OA (Breg), Defiance OA (Donjoy), OA Adjuster (Donjoy), OA Nano (Donjoy), OAsys (Ossur), Unloader ADJ (Ossur), Unloader Express (Ossur), Unloader One (Ossur), Unloader Select (Ossur), Unloader Spirit (Ossur), Genu Arthro-Model 28K29/21 (Ottobock), and Bionicare Knee System (VQ OrthoCare). The purpose of this article was twofold. The first was to examine the pros and cons indicated within the evidence-based articles for each of the 15 OA knee braces currently on the market, and the second was to provide an updated picture for each of the 15 braces, as well as the manufacturer, description, indication(s), features, warranty, and approximate price list.
Article
INTRODUCTION: The aim of this work was to collect literature data to assess the knee orthosis use with controlled clinical trials.METHOD: The international literature relating to the years 1980-2000 was carried out with the Medline data bank.RESULTS: Five hundred and twelve articles were collected and 35 were retained, 32 related to clinical studies and three related to toxicity. The evaluations were performed with either functional tests or clinical studies. The open-non controlled clinical trials are far higher than prospective comparative clinical trials that were developed only during last years. Main criteria of judgement are articular stability, functional pain and clinical index. Most of studies focused the anterior cruciate ligament lesions, patellar pains and osteoarthritis.DISCUSSION: This review of the literature may help to determine the interest and the limits of orthosis use as well as side effect occurrence. Both these clinical and experimental data point out the methodological difficulties facing the investigatory clinician in knee orthosis evaluation.CONCLUSION: Many studies contributed to the clinical evaluation of the knee orthosis. This work highlights various clinical indications for the same orthosis and variable results for the same indication. These methodological difficulties may not prevent a further evaluation of these devices to improve their use in current practice.
Article
Purpose: Unicompartmental knee osteoarthritis (OA) is often treated with the prescription of an unloading knee brace to decrease pain and stiffness. Braces have been shown to improve the quality of life by applying an external moment to offset increased compressive tibiofemoral contact loads, but evidence regarding mechanical efficacy at the joint is controversial. Thus, the purpose of this study was to review the current state of unloading braces on knee mechanics, clinical impact, and long-term disease progression. Methods: A literature search was performed through the PubMed MEDLINE database for the search terms "osteoarthritis," "knee," "brace," and derivatives of the keyword "unload." Articles published since January 1, 1980 were reviewed for their relevance. Evidence for the effectiveness of unloading braces for disease management both biomechanically and clinically was considered. Results: While significant research has been done to show improvement in OA symptoms with the use of an unloading brace, current literature suggests a debate regarding the effectiveness of these braces for biomechanical change. Clinical findings reveal overall improvements in parameters such as pain, instability, and quality of life. Conclusion: Although clinical evidence supports brace use to improve pain and functional ability, current biomechanical evidence suggests that unloading of the affected knee compartment does not significantly hinder disease progression. LEVEL OF EVIDENCE: III.
Article
Study design: Secondary analysis of a randomized controlled trial. Background: The use of external supports has been questioned because they may lead to weakness in the surrounding muscles. To our knowledge, there is no investigation into the effect of knee supports or braces on quadriceps muscle strength and quadriceps inhibition in individuals with patellofemoral joint (PFJ) osteoarthritis (OA). Objectives: To investigate the effects of a flexible knee support on quadriceps maximum voluntary contraction (MVC) and arthrogenous muscle inhibition (AMI) in patients with PFJ OA. Methods: The study included 108 participants who had at least 3 months of patellofemoral pain and a Kellgren-Lawrence score of 2 or 3 for PFJ OA. The participants were randomized to a group that wore a flexible knee support (brace) or a group that did not wear a support (no brace) in a 6-week randomized controlled trial, followed by an open-label trial, in which all participants wore the brace for a total of 12 weeks. Quadriceps MVC, measured isometrically, and quadriceps AMI, measured by twitch interpolation, were assessed at the 6-week and 12-week time points. Results: After 6 weeks, MVC did not differ between the brace and no-brace groups (9.09 Nm; 95% confidence interval [CI]: -4.89, 23.07; P = .20). Arthrogenous muscle inhibition significantly decreased in the brace group (-8.62%; 95% CI: -13.90%, -3.33%; P = .002). After 12 weeks, in all of the participants who wore a flexible knee support, MVC increased by 7.98 Nm (95% CI: 2.52, 13.45; P = .004) and AMI decreased (-8.42%; 95% CI: -11.48%, -5.36%; P<.001). Although statistically significant, these results have doubtful clinical significance. Conclusion: A patellofemoral flexible knee support in participants with PFJ OA does not have an adverse effect on quadriceps MVC or AMI. Using a knee support should not be discouraged because of concerns about deleterious effects on quadriceps strength and inhibition. Level of evidence: Therapy, level 1b.
Article
INTRODUCTION: The aim of this work was to proceed to a literature review to determine the physiological justifications underlying knee orthosis use in medical practice.METHOD: An analysis of the international literature relating to the years 1980-2000 was carried out with the Medline data bank. We added extra articles focusing on the validity of the protocols used in the different evaluations.RESULTS: Five hundred and twelve articles were selected and 46 articles of experimental validation were retained. The experimental protocols are divided into in vitro studies and clinical studies carried out in both healthy subject and patients. Only the in vitro experimental data allowed to reach strain values simulating traumatisms of the articular structures. They allowed to define the interest and limits of the orthosis according to articular physiology. Measurements carried out in vivo were effective to characterize the parameters of stability and proprioception and to disriminate between the orthosis. These studies correspond to experimental situations with related constraints that remain far below lesional constraints, focusing on their clinical validity.CONCLUSION: This work point out many studies focusing on the physiological characterization of the knee orthosis. This evaluation of the orthosis through a single methodology remains difficult and justifies confrontation with clinical trials data.
Article
Conclusion Des résultats encourageants ont été récemment observés dans le traitement des arthroses sur laxité, permettant d’améliorer le confort de vie de ces patients. Il est toujours difficile de décider du traitement idéal.
Article
Regular exercise and weight reduction are not only important for maintaining general health, they are also strongly recommended conservative modalities for managing knee osteoarthritis (OA). The objective of this paper is to discuss the mechanics of knee joint loading and to review the most recent literature with respect to the functionality and efficacy of unloader braces for managing knee OA, specifically from the perspective of the middle-aged athlete. Evidence suggests valgus braces for medial compartment knee OA significantly reduce knee adduction angle measures and improve measures relating to medial knee joint loading, as well as gait symmetry and speed. Benefits were demonstrated during walking and during more demanding functional measures such as running and negotiating stairs. No studies have investigated the efficacy of bracing for relatively young athletic OA patients and, thus, the role of bracing for this population during sports remains unclear.
Article
The effect of knee OA on kinetic and kinematic parameters during walking and standing is still controversial. Stability and energy consumption have not been well investigated in patients with OA. This research investigated the parameters distinguishing between the healthy subjects and patients with OA performance. It also examined the differences in stability and energy consumption between patients with OA and healthy subjects. Fifteen patients with OA and fifteen healthy subjects were recruited into this study. Kinematic and kinetic assessments were performed using Qualysis motion analysis and a force plate Kistler, respectively. Stability of the subjects during walking was determined using COP. Energy consumption was calculated using the Physiological Index. Independent t test was used to determine the differences between gait, stability, and energy consumption healthy participants and patients with knee OA. The excursion of the knee, hip and pelvis in sagittal plane, excursion of the knee joint in the mediolateral plane were significantly higher (all p < 0.05) in patients with OA of the knee compared with their healthy counterparts. In addition, energy consumption was significantly higher in patients with OA (p = 0.009) than in healthy participants. However, margin of stability was significantly lower (p = 0.05) in patients with OA of the knee than in healthy subjects. These findings suggest that gait parameters and energy consumption assessments may be important in patients with OA of the knee. Therefore, clinicians are to be aware of these findings by developing appropriate gait rehabilitation for patients with OA of the knee.
Article
Medial knee osteoarthritis (OA) is a common disorder often associated with pathologic joint loading. Insoles, braces, and high tibial osteotomy are OA treatments aimed at reducing medial joint loads, but their use and effectiveness are limited. The KineSpring System implant also intends to reduce knee loads in OA patients while overcoming those limitations. The current study was undertaken to test the implant's effect on loads at the knee. Six cadaver knees with Outerbridge Grade I-II medial OA were subjected to simulated gait using a kinematic test system. Knees were tested with and without the medial knee implant while thin film sensors measured medial and lateral femorotibial contact pressures. Significant medial compartment load reductions (134 +/- 53 N [P =.002]) were found throughout the stance phase of gait in the treated knee. Significant total joint load decreases (91 +/- 40 N [P =.002]) were also observed without substantial changes in lateral compartment loads. These significant reductions of medial and total intra-articular loads are also within clinically effective ranges of other unloading systems. This suggests that the KineSpring System could be a viable treatment for medial knee OA.
Article
Unicompartmental arthritis of the knee is a degenerative condition characterized by abnormal articular cartilage in the medial or lateral part of the tibiofemoral joint, which may be associated with meniscal disruption, ligamentous instability, and limb malalignment. Nonoperative treatments for unicompartmental degenerative arthritis of the knee include oral and injectable medications, weight loss, exercise, physical therapy, canes, crutches, braces, and orthoses. Arthroscopy for unicompartmental arthritis of the knee can provide a clinical benefit in terms of reduced pain and improved function for patients with mechanical symptoms, mild degenerative disease, and minimal or no malalignment. Meniscal tears, loose bodies, osteophytic spurs, or chondral flaps can cause mechanical symptoms, which can be treated successfully with arthroscopy. Proximal tibial valgus osteotomy and distal femoral varus osteotomy for treatment of unicompartmental arthritis of the knee can realign a deformed limb, reduce pain, and improve function for active, high-demand patients with a projected life expectancy of twenty years or more. As a patient's life expectancy and expectations for activity decrease as a result of age and disease, unicompartmental and total knee arthroplasty provide predictably successful surgical options for the treatment of unicompartmental arthritis of the knee.
Article
Background: A medial meniscal tear is a common knee injury, especially following an anterior cruciate ligament injury. Decreasing the compressive force on the medial meniscus during dynamic activities using an unloader knee brace could reduce meniscal strain, effectively reducing injury risk and/or severity. Objectives: To investigate the efficacy of two unloader knee braces on medial meniscus strain during dynamic activities in intact & deficient anterior cruciate ligament states. Study design: Combined in vivo/in vitro study. Methods: In vivo knee kinematics and muscle force profiles from a healthy individual performing single/doubleleg squats and walking motions were simulated on 10 cadaveric specimens using a dynamic knee simulator system. Simulations were performed on knees in unbraced and braced scenarios, with and without the anterior cruciate ligament. Anterior and posterior medial meniscal strains were measured. Results: Two different braces each showed a significant reduction in the posteromedial meniscal strain ( p ⩽ 0.01) in an intact anterior cruciate ligament state. Neither brace mirrored this result for the anteromedial strain ( p > 0.05). In the deficient anterior cruciate ligament state, the braces had no significant effect on strain ( p > 0.05). Conclusion: Two unloader knee braces effectively reduced strain in the medial meniscus with an intact anterior cruciate ligament during dynamic activities. Neither brace made a significant reduction in strain for anterior cruciate ligament-deficient knees. Clinical relevance Unloader knee braces could be used to reduce the medial meniscus strain following meniscal surgery and during rehabilitation in patients with an isolated medial meniscus injury. However, these braces cannot be recommended for this purpose in patients with an anterior cruciate ligament deficiency.
Article
Full-text available
IndoKnee is an unpowered knee assisting device designed and patented by Newndra Innovations. In this paper, we report a clinical study to characterize the reduction in load on the major muscles of the knee from the use of this device. Thirty healthy subjects without any history of knee problems underwent this trial. The protocol consists of three sets of events which are a) without IndoKnee (WOD), b) with IndoKnee at a minimum level of support (WDmin) and c) with IndoKnee at a maximum level of support (WDmax). Each set consists of five sitting and five standing activities. Surface electromyography was recorded from six major knee flexion/extension muscles, which are Bicep Femoris (BF), Semitendinosus (ST), Semimembranosus (SM), Rectus Femoris (RF), Vastus Medialis (VM) and Vastus Lateralis (VL). Paired t-tests were performed on our comparison between WOD vs WDmin and WOD vs WDmax to establish a significant difference in the EMG peak amplitudes during sitting and standing activities. The average reduction in all the six muscles for sitting activity is about 15% for both level of support and the standing activity, it is about 15% at a minimum level of support and 20% at a maximum level of support. In our investigation, IndoKnee did effectively reduce the required muscular effort for the knee flexion/extension. Thus, IndoKnee may prove to be an effective device in reducing knee pain, supporting osteoarthritis patients and faster rehabilitation from knee injuries.
Chapter
Injuries to various structures of the knee joint, including the ligaments, menisci, and patellofemoral components, compose a significant portion of sports-related injuries seen by health care providers and compromise a patient's knee joint function and stability. Knee orthoses have been used in each step of the sport performance process, such as injury minimization, ligament rehabilitation after reconstruction, and treatment of functional instability of the knee joint. The knee joint allows for flexion and extension with some degree of translation and axial rotation. Shear forces act upon the knee during gait and in weight-bearing tasks. Proper functioning of knee braces must take into account these biomechanical factors. Both prefabricated (“off-the-shelf”) and custom-made knee brace designs have proven effective, and each has benefits with cost, fit, weight, and material components. More recently, braces have been manufactured with composite lightweight materials, such as carbon fiber and aluminum. Athletes have used knee orthoses both to prevent medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injury and to protect ACL-deficient knees or an ACL-reconstructed graft while returning to full activity. Knee braces have become an important component in functional rehabilitation programs for treatment of MCL sprains. Acute grade I and II posterior cruciate ligament (PCL) tears have been shown to heal with bracing, protected weight bearing, and quadriceps muscle rehabilitation. Braces are now used in osteoarthritis to enhance function and reduce pain.
Conference Paper
Knee orthoses are designed to reestablish the normal kinematics of the knee joint. However, the data on the effectiveness of them on modifying the internal joint kinematics are scarce. The aim of this study was to develop a method to allow accurate comparison of the knee contact kinematics in osteoarthritic (OA) subjects with and without wearing a valgus knee orthosis using imaging techniques. Biplane x-ray images of a subject (68 yrs., female, 1.70 m, 89 kg, left knee) was recorded during a weight-bearing squat at five positions. The same squat trial was repeated while wearing the orthosis. The 3D models of the knee were reconstructed from the biplane x-rays and the joint kinematics as well as the tibiofemoral contact point locations and bone-to-bone distance were compared at each posture. This could be seen as a proof of concept for the use of contact point locations as a parameter for evaluating the effectiveness of knee orthoses.Clinical Relevance- Joint kinematics derived from the skin markers suffer from low accuracy. The real impact of the knee orthoses on the skeleton takes vigorous techniques, which allows detecting the subtle kinematics changes directly at the joint level.
Article
Knee osteoarthritis (OA) is common among older adults and associated with impaired knee strength. OBJECTIVE: Describe isokinetic testing procedures and clinimetric findings associated with the testing of knee strength in the presence of knee OA. METHODS: Relevant articles were identified by an electronic search of PubMed using the search string 'isokinet∗ AND knee osteoarthritis.' RESULTS: One-hundred and twenty-nine relevant articles were found. The articles support the validity and reliability of isokinetic strength testing for patients with knee OA. The responsiveness to various therapeutic interventions has been reported. CONCLUSIONS: Isokinetic dynamometry is a valid and reliable measure of muscle strength in knee OA.
Article
Full-text available
Purpose: To compare the effect of unloading knee brace with physical therapy (PT) in Asian patients with osteoarthritis (OA) of the knee. Method: This is a non-random, two-group comparative study. Patients with medial compartment knee OA (n = 41) were assigned to either the brace group (n = 20) or PT group (n = 21). Patients in the brace group were fitted with an unloading knee brace for three months and the PT group received a 60-min session of physiotherapy over the affected knee, three times a week, for three months. The primary outcome measures were the pain visual analogue scale (VAS) and the Western Ontario McMaster University Osteoarthritis Index (WOMAC); the second outcome measures were the 36-item Short-Form Health Survey (SF-36) and patient's satisfaction. The patients were evaluated at baseline, and at one month and three months. Results: Group comparison showed no significant difference regarding pain VAS, WOMAC, SF-36, and patient's satisfaction, except stiffness in WOMAC (P = .006) and social functioning in SF-36 (P = .007). Time and group interaction revealed significant differences only in general health (P = .007) and mental health (P = .006) of SF-36. Within-group comparison found that pain VAS and WOMAC decreased significantly at one months and three months in both groups. Conclusion: The effect of brace fitting in patients with knee OA was similar to that of physical therapy. A Western-made unloading knee brace is acceptable in some Asian people with knee OA. Clinical trial registration number: NCT02712710.
Article
Aim: The aim of this study was to evaluate the effect (6 weeks) of the use of a knee brace and a lateral wedge insole, both in isolation and combined, on the knee adduction moment (KAM), pain levels, kinematics (velocity, stride length, cadence), knee ROM, function, and satisfaction in patients with knee osteoarthritis (OA). Methods: Twenty-one patients with medial compartment knee OA were participated in this study. A relatively light three-point valgus knee brace (VB) and full length custom-made lateral wedge insole with arch support were prepared for each subject. Patients divided into three groups at random. Results: The use of a custom fit valgus brace with lateral edge insole concurrently can reduce a greater peak KAM than use in isolation (30%). In addition, the use of both interventions can improve walking velocity, cadence, and reduce levels of pain in patients with medial compartment OA. Conclusion: All parameters except stride length and KAM in comparison with first day of wearing interventions improved significantly in the combined, concurrent usage group. The use of a lateral wedge insole and a valgus knee brace in combination can improve the kinetic and kinematic parameters in patients with medial compartment knee OA.
Article
Background: Evidence that knee braces used for the treatment of osteoarthritis mediate pain relief and improve function by unloading the joint (increasing the joint separation) remains inconclusive. Alternatively, valgus-producing braces may mediate pain relief by mechanically stabilizing the joint and reducing muscle cocontractions and joint compression. In this study, therefore, we sought to examine the degree to which so-called unloader braces control knee instability and influence muscle cocontractions during gait. Methods: Sixteen subjects with radiographic evidence of knee malalignment and medial compartment osteoarthritis were recruited and fitted with a custom Generation II Unloader brace. Gait analysis was performed without use of the brace and with the brace in neutral alignment and in 4 degrees of valgus alignment. A two-week washout period separated the brace conditions. Muscle cocontraction indices were derived for agonist and antagonist muscle pairings. Pain, instability, and functional status were obtained with use of self-reported questionnaires, and the results were compared. Results: The scores for pain, function, and stability were worst when the knee was unsupported (the baseline and washout conditions). At baseline, nine of the sixteen patients reported knee instability and five of the nine complained that it affected their activities of daily living. Poor knee stability was found to be correlated with low ratings for the activities of daily living, quality of life, and global knee function and with increased pain and symptoms. Knee function and stability scored best with the brace in the neutral setting compared with the brace in the valgus setting. The cocontraction of the vastus lateralis-lateral hamstrings was significantly reduced from baseline in both the neutral (p = 0.014) and valgus conditions (p = 0.023), and the cocontraction of the vastus medialis-medial hamstrings was significantly reduced with the valgus setting (p = 0.068), as a result of bracing. Patients with greater varus alignment had greater decreases in vastus lateralis-lateral hamstring muscle cocontraction. Conclusions: When knees with medial compartment osteoarthritis are braced, neutral alignment performs as well as or better than valgus alignment in reducing pain, disability, muscle cocontraction, and knee adduction excursions. Pain relief may result from diminished muscle cocontractions rather than from so-called medial compartment unloading.
Article
Résumé La prise en charge non médicamenteuse devient une part non négligeable du traitement de la gonarthrose. Un de ces traitements consiste à réduire la contrainte physique appliquée au compartiment de l’articulation par le port d’orthèses du genou ou du pied. Le but de cette mise au point est de rapporter les différents types d’orthèses – genou et pied – à notre disposition dans la gonarthrose fémoro-tibiale – médiale ou latérale – et fémoro-patellaire. Nous rapporterons ensuite quelques études et méta-analyses sur le port d’orthèses dans les gonarthroses. Un nouveau type d’orthèse associant la distraction (écartement) et rotation latérale sera abordé.
Chapter
This chapter concerns the effects of lower limb deformities on gait (► Fig. 21-1), including compensatory mechanisms that attempt to minimize gait deviations and the consequences of failure of these mechanisms. Pathologically abnormal gait can arise from a variety of musculoskeletal and neurological conditions, but the basic causes are few: deformity, pain, muscle weakness, and altered neuromuscular control. This text addresses deformity causes of pathologically abnormal gait. Pain and muscle weakness are discussed to a lesser extent in this chapter, and neuromuscular control effects are discussed in Chap. 22.
Chapter
The treatment of the young ACL deficient patients with an osteoarthritic knee has been a great dilemma for orthopaedic surgeons. The treatment options in the past have been limited and the literature gave us little direction. Patients were granted analgesics, anti-inflammatories, physical therapy and were braced until they were old enough for total knee replacement. However in the last eight years surprisingly good results have been reported in these patients with anterior cruciate reconstruction, high tibial osteotomies, meniscal allografts and combined procedures.
Chapter
The goals of physical therapy and rehabilitation in the treatment of osteoarthritis (OA) are prevention, relief of pain, restoration or maintenance of movement, offsetting function loss and physical impairment reduction.
Chapter
Primary osteoarthritis is the most common disorder affecting the musculoskeletal system. Prevalence nears ubiquity over the age of 65 and therefore it has been considered a degenerative disease of the elderly1 Prevalence rates however, approximate 200–250/1000 population in patients 40 to 60 years of age. Many of these patients still desire an active athletic lifestyle.2 In patients with ligament or meniscal injury, as well as those patients with acute chondral injury, the curve representing the onset of secondary arthritis over time slopes upward earlier and steeper. Acute chondral injury has been reported by one study to occur in at least 5% of all arthroscopies performed on patients younger than 40, and it has been estimated that 900,000 Americans suffer acute articular cartilage injuries each year.3 Replacement of joint surfaces in younger, more active patients is fraught with danger and therefore many of these patients need more effective palliative treatments. Recent years have seen advances in the nonsurgical management options for painful arthritis and articular surface loss.
Article
Unicompartmental knee osteoarthritis (UKOA) is a complex issue that is estimated to affect roughly 28% of patients with knee OA, and can result in severe cartilage degeneration, meniscus deficiency, and concomitant varus or valgus malalignment. This malalignment results in abnormally high joint reaction forces in the affected compartment, which can elicit pain, cause dysfunction, and exacerbate joint degradation. For more than two decades, the use of knee unloader braces has been advocated as a cost-effective option for symptomatic management of UKOA. During bipedal ambulation with a normal lower extremity mechanical axis, ground reaction forces create a knee adduction moment (KAM) such that the medial compartment of the knee experiences approximately 60% of joint loading and the lateral compartment experiences approximately 40% of joint loading. UKOA disrupts the mechanical axis, altering KAM and joint loading and causing pain, dysfunction, and disease progression. In theory, knee unloader braces were designed to mitigate the symptoms of UKOA by normalizing KAM via shifts in the lever arms about the knee. However, studies vary, and suggest that push-mechanism knee unloaders do not consistently provide significant biomechanical benefits for medial or lateral UKOA. Current evidence suggests that pull-mechanism unloaders may be more effective, though contrasting data have also been reported, such that further validation is necessary. The purpose of our study was to synthesize current best evidence for use of knee unloader braces for management of UKOA to suggest evidence-based best practices as well as gaps in knowledge to target for future studies. Unloader bracing for patients with UKOA appears to be a cost-effective treatment option for patients with medial UKOA who have insurance coverage. Pull-mechanism unloader bracing should be considered in conjunction with other nonoperative management therapies for those who are willing to adhere to consistent brace use for weight-bearing activities.
Article
Lateral-wedged insoles have been shown to help clinically alleviate pain associated with medial compartment osteoarthritis, This study analyzed the effects of lateral-wedged insoles on the gait and medial knee compartment load of 17 healthy subjects. Three-dimensional gait analysis was performed for each subject with and without wearing a 5 degrees lateral-wedged insole, Subjects walked at a constant velocity for both conditions. A motion analysis system and force plate were used to calculate temporal and spatial parameters, joint angles, moments, and powers. An analytical model was developed to estimate medial compartment loads at the knee for each subject during both conditions. Results were compared with a Student's paired t test, There were no significant differences in temporal and spatial parameters, joint angles at the hip, knee, and ankle, or kinetics at the hip and ankle. However, the external varus moment and estimated medial compartment load at the knee were reduced significantly with the addition of the lateral-wedged insole, These results suggest that the pain relief and improvement in function reported by patients with osteoarthritis while using lateral-wedged insoles may be achieved by a reduction in external varus moment and medial compartment load.
Conference Paper
Background: Patients with osteoarthritis (OA) may experience severe pain, progressive loss of movement function, and disability. Many pain-relieving medications are not effective, and are not able to improve the existing pathology. Objectives: This review summarizes (1) the pathology, mechanisms of pain production, and conservative management of OA with respect to pain; and (2) explains the role of nitric oxide (NO) in pain reduction and production, especially as related to OA. Discussion: NO is produced in biologic cello by a family of enzymes referred to as the nitric oxide synthases (NOSs). The beneficial or harmful effects of different is.6forms, constitutive NOS (cNOS) and inducible NOS (iNOS), respectively, suggest dual effects of NO in biologic structures. The harmful effects of NO are most often reported in the literature. We suggest that (1) NO via the beneficial cNOS pathway is decreased in joint structures exposed to chronic load-induced stresses and biochemical change-induced stresses, (2) monochromatic infrared light energy at an 890nm wavelength, applied at the skin surface, is absorbed into blood vessels and stimulates production of NO in joints by the beneficial cNOS pathway, (3) NO from the cNOS pathway may help decrease the detrimental effects of NO induced by iNOS and produced in OA pathology, and (4) NO-based intervention may produce substantial pain relief without undesirable side effects by increasing circulation, decreasing nerve irritation, and decreasing inflammation in joints. Key Messages: (1) The roles of NO in nociception are dual and complex. (2) NO via cNOS, produced transiently in small amounts, can bring dramatic relief to people with painful OA.
Article
Medial knee osteoarthritis (OA) is a common disorder often associated with pathologic joint loading. Insoles, braces, and high tibial osteotomy are OA treatments aimed at reducing medial joint loads, but their use and effectiveness are limited. The KineSpring System implant also intends to reduce knee loads in OA patients while overcoming those limitations. The present study was undertaken to test the implant's effect on loads at the knee. Six cadaver knees with Outerbridge Grade I-II medial OA were subjected to simulated gait using a kinematic test system. Knees were tested with and without the medial knee implant while thin film sensors measured medial and lateral femoro-tibial contact pressures. Significant medial compartment load reductions (134 ± 53 N (P = .002)) were found throughout the stance phase of gait in the treated knee. Significant total joint load decreases ((91 ± 40 N) (P = .002)) were also observed without substantial changes in lateral compartment loads. These significant reductions of medial and total intra-articular loads are also within clinically effective ranges of other unloading systems. This suggests that the KineSpring System could be a viable treatment for medial knee OA.
Article
An anesthesia follow-up program (100 000 anesthetics) and vital statistics data were used to assess the role of anesthesia in operative deaths. Four factor groups (patient, surgical, anesthesia, and "other") were assessed by logistic regression analysis to ascertain which variables were predictive of seven-day mortality. Advanced age, male gender, physical status, major surgery, emergency procedure, procedures performed in 1975 to 1979, intraoperative complications, narcotic techniques, and having one or two anesthetic drugs administered were associated with increased mortality, whereas duration of anesthesia, experience of the anesthesiologist, and inhalation techniques were not. Receiver-operator characteristic curves showed no increment in prediction of operative mortality greater than that for patient plus surgical factors when "other" or anesthetic factors were added. Patient and surgical risk factors were much more important in predicting seven-day mortality than the anesthesia factors we studied. (JAMA 1988;260:2859-2863)
Article
An orthosis may offer the only relief possible for patients suffering gross damage of the knee because of certain forms of arthritis. An orthosis is indicated when the knee requires support either for relief of pain or to give stability for preserva­ tion of function. These conditions may occur when a surgical approach is not appropriate, and when physiotherapy alone is not sufficient. Because clinicians at the Canadian Arthritis and Rheumatism Society in Vancouver, Canada, wanted to be able to identify cases that might benefit from use of an orthosis, and then to be able to provide them with an appropriate ortho­ sis, a knee clinic was established which included the authors as the Engineering Component. We were struck by the gross nature of the disabilities from which the patients were suffering, and found it difficult to sift out just what was perti­ nent in order to identify what was needed. The average age of the patients was about 70. They often had gnarled hands and feet. Sometimes, other joints were affected. The difficulties pre­ sented often had been present for a long time. Some cases had seemed to fall apart rapidly, often presenting insurmountable problems for those providing therapeutic assistance. The problems seemed to be in such a mixed-up array, as our untrained eyes saw them, that we were forced to isolate some specific malfunction as a point of entry into the problem of orthosis design. It was decided that mediolateral knee instabil­ ity would be the most likely malfunction to tackle for development of an orthotic solution.
Article
A double crossover study was designed and carried out on 39 patients to test the efficacy of valgus bracing using a GII brace in patients with medial gonarthrosis. Two brace designs were studied-one with a medial and one with a lateral hinge. The double crossover technique involved evaluating each patient under conditions of no brace, brace in neutral, and brace in valgus, each for a period of 6 weeks. Pain and function were recorded by subjects on diary forms daily and at the end of each week. Standing posterior-anterior radiographs were done on all patients under conditions of weight bearing, nonweight bearing, without brace, and with brace in valgus. Statistical analysis using repeated measures analysis of variance showed statistically significant pain relief compared to baseline with both a lateral hinge in valgus (p = 0.02) and a medial hinge in valgus (p < 0.0001). No significant change in function was found and no significant radiographic evidence of change in femoral-tibial angle or joint space alteration was demonstrated. Seventy-four percent of patients purchased their brace at the end of the study. Follow-up at an average 20 months after the study showed 58% of the patients with a lateral hinge and 93% of the patients with a medial hinge were still using their braces as the principal form of therapy. Valgus bracing using a GII brace, especially with a medial hinge, can be a useful treatment modality for reducing pain in the patient with medial gonarthrosis to replace or delay surgery. (C) Lippincott-Raven Publishers.
Article
A prospective survey of complications associated with anaesthesia was carried out in France from 1978 to 1982 in a representative sample of 198,103 anaesthetics performed in 460 public and private institutions chosen at random in the country as a whole. There were 268 major complications associated with anaesthesia occurring during or within 24 hours of anaesthesia (one per 739 anaesthetics), among which 67 were followed by death within 24 hours and 16 by coma persistent after the 24th hour. The incidence of death and coma was one per 2387 anaesthetics. The incidence of death and coma totally attributable to anaesthesia was one per 7924 anaesthetics. Fifty-eight per cent of complications occurred during anaesthesia while 42 per cent were observed during the recovery period. Mortality was lower following complications during anaesthesia than for those during the recovery period. Half of the deaths and cases of coma totally attributable to anaesthesia were due to postanaesthetic respiratory depression. The rate of complications appeared to be dependent upon several risk factors: the patient's age, thenumber of associated diseases, the preoperative status, whether the operation was an emergency and the duration of procedure.
Article
To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, we identified nine independent significant correlates of life-threatening and fatal cardiac complications: preoperative third heart sound or jugular venous distention; myocardial infarction in the preceding six months; more than five premature ventricular contractions per minute documented at any time before operation; rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram; age over 70 years; intraperitoneal, intrathoracic or aortic operation; emergency operation; important valvular aortic stenosis; and poor general medical condition. Patients could be separated into four classes of significantly different risk. Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk. If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.
Article
One hundred thirty-nine cemented and 132 cementless Miller-Galante total knee prostheses were followed between three and six years (average, 43-44 months). The fixation technique was based on patient age, bone quality, and ability to delay full-weight bearing. Clinical follow-up studies were possible on 116 cemented knees. Fifteen knees were lost because of death before the three-year follow-up study, and eight knees required component removal. One hundred twenty-three cementless knees were available for clinical follow-up studies; there were three deaths, and six failures required component removal. No cemented failure was due to fixation, and three cementless failures were due to lack of tibial ingrowth in two and pain of undetermined etiology in one. Preoperative knee scores were slightly significant with cemented knees averaging 48 points and cementless knees averaging 52 points. A similar significant difference was maintained at the final follow-up study. No significant differences were noted for pain, limp, or support scores. Average range of motion was similar in the two groups. Radiolucent lines about the femoral component were rare. Cementless tibial radiolucencies were partial in up to 20% of examined zones, and complete tibial tray radiolucency was seen in only three patients. No correlation between radiolucency and knee scores was seen.
Article
For the purpose of investigating the clinical efficacy of a newly designed wedged insole, 149 patients with medial osteoarthritis of the knee were followed from one year to five years and five months. A rating system for pain, walking ability, and both were used for evaluation of the clinical results. Comparing two groups consisting of 107 patients with early radiographic stages (Stage I or II), 67 patients (Group I) treated with both a wedged insole and anodyne (Indomethacin 600 mg/day) showed a significantly greater improvement than 40 patients (Group II) treated with anodyne alone. Analyzing the therapeutic efficacy of the wedged insole according to the radiographic stage, the prescription of a wedged insole was significantly more effective for patients with mild osteoarthritis (Stages I, II, and III), and ineffective for those with advanced osteoarthritis (Stage IV). The wedged insole, designed on the basis of an established hypothesis, represents an excellent means of conservative treatment for early medial osteoarthritis of the knee.
Article
The mechanism of the static effects of the wedged insole for the medial osteoarthritic knee was studied in ten women. They stood with one leg on the wedged sole board, and the change of the position of the line through the center of gravity, the femorotibial angle, the tibiocalcaneal angle, and the spatial position of the whole lower limb were investigated using load transducers and roentgenograms. When the subjects stood on the wedged sole board, the line through the center of gravity and femorotibial angle did not change. The change in the spatial positions of the lower limb (p less than 0.02), i.e., the mechanical axis of the lower limb near an upright position, and the change of the calcaneus to valgus direction in the subtalar joint (p less than 0.01) were observed. These changes were considered from two-dimensional analysis to reduce the excessive loading on the medial joint surface and the excessive tensile force of the lateral side. The wedged insole thus proved effective for the conservative treatment of the medial compartment osteoarthritic knee.
Activation and coordination patterns of the three parts of the quadriceps femoris muscle (rectus femoris, vastus medialis and vastus lateralis) and one of their antagonists (semimembranosus) in the knee extension movement were investigated under both maximal and submaximal conditions. Five male subjects performed both leg horizontal extension on a special electromechanical dynamometer with four constant linear velocities ranging from .12 m x s-1 to .69 m x s-1 in the three test postures; sitting (105°), recumbent (125°) and supine (165°). The subjects were able to exert highest leg extension forces and then also the highest mechanical power value in the recumbent posture at all measured speeds. Because the combined agonist IEMG-activity was the same in all test postures, the more efficient force and power production in the recumbent posture was thought to be due to the improved mechanical advantage of some of the agonist muscles and their interactions with the antagonist function. The sitting test posture demonstrated activation patterns, which were slightly different from those in the recumbent and supine postures. Sitting posture caused rectus femoris to reach its peak activation at higher knee angles than in the other postures. This is likely to be due to the shortened starting length of the rectus femoris according to force-length - principle in the sitting posture. This working length principle seems to apply also to the activation of the semimembranosus whose activation was highest in the sitting posture as compared to other test positions. The vasti muscles, functioning only around the knee joint, demonstrated a plateau type activation in the slowest contraction speed of the sitting posture. This was thought to imply that the vasti muscles have an additional stabilizing function in the slow speed to serve for the chain type activation of the leg extensor muscles.
Article
Electrical activity of ‘postural’ muscles (sacrospinales, hamstrings, gastrocnemii, quadriceps femoris) in normal subjects during different positions and movements of the body varies in different individuals. The sacrospinales become active whenever slight displacements of the center of gravity occur. The sacrospinalis of both sides participate in lateral flexion and extension, and rotation of the vertebral column. In leaning forward, these muscles (except the quadriceps) are working essentially under isometric conditions and their electrical activity is prominent. Stretch, then, appears to be a major factor for the activation of these muscles. In flexion of the trunk, the sacrospinales cease to function at a ‘critical point,’ however, further trunk flexion occurring mainly at the hip joints continues to be accompanied by the activity present in the hamstrings. In more complex movements, such as sitting and standing, the same basic mechanisms related to stretch and displacement of the center of gravity appear to hold true.
Osteoarthrosis and disc degeneration in an urban population
  • Kellegan
Cemented and ingrowth fixation of the Miller-Galante prosthesis
  • Rosenberg
Multifactorial index of cardiac risk in noncardiac surgical procedure
  • Goldman
Surgery in osteoarthritis: general conditions
  • Goldberg