ArticlePDF AvailableLiterature Review

An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis from the Last 10 Years: A Literature Review

Authors:

Abstract

Background The incidence of osteoarthritis is increasing and it is one of the most common causes of chronic conditions. Total knee replacement is the mainstay of treatment for end-stage knee osteoarthritis; however, with long waiting lists and high levels of dissatisfaction, a treatment like knee braces could potentially delay surgery. Unicompartmental knee osteoarthritis is associated with misalignment of the knee, and unloader bracing has been recommended by various guidelines to correct this misalignment. The aim of this report was to provide an update of evidence from the past 10 years on knee braces. Methods MEDLINE/EMBASE search was performed from the past 10 years. Results We reviewed the evidence from 14 published articles. Almost all articles supported knee brace use and showed it to decrease pain, improve function, and improve the quality of life of patients. One study in 2017 followed patients for long term and found knee bracing to be more cost effective than total knee replacement, and could replace the need for surgery. Several minor complications were reported with bracing, like soft tissue irritation, which could be due to poor fitting. A management strategy for this could be regular follow-up at a nurse-led clinic. Conclusions Unloader braces are an economical and effective treatment for unicompartmental knee osteoarthritis. They can significantly improve a patient's quality of life and potentially delay the need for surgery. Patients should be managed with a multidisciplinary approach with conservative management and knee bracing, before surgery is considered.
An Update on Unloading Knee Braces in the Treatment
of Unicompartmental Knee Osteoarthritis from the
Last 10 Years: A Literature Review
Dylan A. Mistry1Amit Chandratreya, MB, MS, DNB, MCh, FRCS2PaulY.F.Lee,MBBCh,MFSEM,MSc,
PhD, FEBOT, FRCS3,4
1South Wales Orthopaedic Research Network, Cardiff University,
Welshbone, Cardiff, Edwalton, Nottingham, United Kingdom
2South Wales Orthopaedic Research Network, Abertawe Bro
Morgannwg University Health Board, Wales Hospital, Welshbone,
Bridgend, United Kingdom
3Department of Trauma and Orthopaedic, LEO Institute, Grantham
and District Hospital, United Lincolnshire Hospitals NHS Trust,
Grantham, United Kingdom
4School of Sport and Exercise Science, Universit y of Lincoln, Lincoln,
Lincolnshire, United Kingdom
Surg J 2018;4:e110e118.
Address for correspondence Dylan A. Mistry, Cardiff University,
Park Place, Cardiff, CF10 3AT, United Kingdom
(e-mail: MistryDA@cardiff.ac.uk).
Osteoarthritis is a common condition with 18% of people over
45 years old seeking treatment for osteoarthritis of the knee
joint,1and 12% have symptoms associated with osteoarthritis
aged 25 to 75 years.2Varus or valgusmalalignment is a cause of
the pathophysiology, specically for unicompartmental knee
osteoarthritis. A varus alignment increases the mechanical
load and risk of medial compartmental osteoarthritis,whereas
a valgus alignment affects the lateral compartment.2
Keywords
knee osteoarthritis
braces
walking
knee arthroplasty
varus
valgus
Abstract Background The incidence of osteoarthritisis increasing and itis one of the most common
causes of chronic conditions. Total knee replacement is the mainstay of treatment for end-
stage kneeosteoarthritis; however,with long waiting lists andhigh levels of dissatisfaction, a
treatment like knee braces could potentially delay surgery. Unicompartmental knee
osteoarthritis is associated with misalignment of the knee, and unloader bracing has
been recommended by various guidelines to correct this misalignment. The aim of this
report was to provide an update of evidence from the past 10 years on knee braces.
Methods MEDLINE/EMBASE search was performed from the past 10 years.
Results We reviewed the evidence from 14 published articles. Almost all articles
supported knee brace use and showed it to decrease pain, improve function, and
improve the quality of life of patients. One study in 2017 followed patients for long
term and found knee bracing to be more cost effective than total knee replacement,
and could replace the need for surgery. Several minor complications were reported
with bracing, like soft tissue irritation, which could be due to poor tting. A manage-
ment strategy for this could be regular follow-up at a nurse-led clinic.
Conclusions Unloader braces are an economical and effective treatment for uni-
compartmental knee osteoarthritis. They can signicantly improve a patientsquality
of life and potentially delay the need for surgery. Patients should be managed with a
multidisciplinary approach with conservative management and knee bracing, before
surgery is considered.
received
December 10, 2017
accepted after revision
May 16, 2018
DOI https://doi.org/
10.1055/s-0038-1661382.
ISSN 2378-5128.
Copyright © 2018 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
Review Article
THIEME
e110
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
The NationalInstitute forClinical Excellence (NICE) state, in
their 2014 guidelines, that treatment for osteoarthritis should
take a holistic approach.3This should include, at its simplest,
patient education and nonpharmacological treatment like
exercise, weight loss, aids, and devices such as knee braces,
insoles, and walking sticks.3Surgical treatments are cost-
effective treatments for osteoarthritis and include total knee
replacement, unicompartmental knee arthroplasty, and high
tibial osteotomy.4,5 However, waiting lists can be up to
8months,
6and there is evidence to suggest that these treat-
ments are not suitable for younger patients suffering from
knee osteoarthritis.7This is because younger patients tend to
have more active lifestyles which increases the risk of any
surgical arthroplasty loosening or wearing out.7This com-
bined with their longer life expectancy means that they are
much more likely to require a revision,7especially considering
revision rates after 5 years are 6% and 12% after 10 years.8
Younger patient age groups are more likely to respond better
and have improved knee function after total knee replace-
ment; however, a major concern is that they are much more
likely to be left dissatised with the outcome, especially
considering one-fth of all patients have been reported to
be unhappy with their knee after having surgery.9
NICE guidelines recommend the use of knee braces for the
treatment of osteoarthritis, as part of the nonpharmacological
management.3Osteoarthritis Research Society International
have produced guidelines which include biomechanical inter-
ventions to treat patients with mild to moderate varus/valgus
instability to improve stability and reduce pain.10Knee bracing
is also incorporated in the European League Against Rheuma-
tism recommendations in 2003, as part of the nonpharmaco-
logical management of osteoarthritis.11
Knee Bracing
There are different types of knee braces, which can be used to
treat knee problems. Depending on the pathology and diag-
nosis, different types of mechanical support are required. For
unicompartmental knee osteoarthritis, unloading type knee
braces are more appropriate to unload the affected compart-
ment and realign the knee joint. Studies into knee braces date
back into the 20th century. Although the studies of Lindenfeld
et al,12 in 1997, and Kirkley et al,13 in 1999, are small, they
found that valgus knee braces were able to reduce pain and
improve function. Also, Katsuragawa et al14 demonstrated that
valgus bracing in patients with medial compartmental osteoar-
thritis can alter mechanical alignment and increase bone
mineral density in the lateral side of the femur and tibia.14
This suggests there has been an unloading effect from the
medial compartment because of the knee brace, and the bone
strengthened on the lateral side as it received more load.14
Out of all the unloading type knee braces, the Unloader
One® brace (Ossur) has the most published evidence. It has a
3-point leverage system which is able to unload the affected
compartment and is recommended for mild to severe uni-
compartmental osteoarthritis.15 The studies by Lindenfeld
et al,12 Kirkley et al13 and Katsuragawa et al14 showed that
there is some evidence to support unloader knee braces
published over 10 years ago. However, in the past 10 years
peoples lifestyles have changed and the prevalence of
osteoarthritis has increased. This along with the fact that
surgical techniques have improved and, as a result, expecta-
tions have changed, mean an up-to-date review on the past
10 years is required.
The aim of this report was to review previous evidence for
unloader knee braces and provide an update on new evi-
dence that has been published in the past 10 years to collate
our knowledge on this potential treatment for unicompart-
mental knee osteoarthritis.
Methods
A MEDLINE and EMBASE search was performed using
search terms including knee, bracing, osteoarthritis, uni-
compartment
, unloader, valgus, and varus. The search was
limited to the English language and the past 10 years. Papers
had to be original research published in peer-reviewed jour-
nals. Their focus had to be on the unloader knee brace and
specically for their treatment in unicompartmental knee
osteoarthritis. Articles had to compare unloader braces to a
control or other treatment, or look at a cohort that was using
unloaderknee braces.One of the main outcomes had to be pain,
function, quality of life, knee adduction moments, biomecha-
nics, and gait analysis. The papers were narrowed down based
on their titles, abstracts, andthen after readingthe whole paper
by D.M.and P.L.The references and relatedarticles of the papers
found were screened for suitable articles. We did not include
papers which looked at misalignment after other orthopedic/
surgical procedures such as anterior cruciate ligament (ACL)
reconstruction.
Results
The search produced 112 papers, which were narrowed
down to 22 based on their titles. Overall, 14 articles were
looked at, including 2 papers from 2017. Each paper is
presented below and the summary of the evidence is pre-
sented in Table 1.
Previous Clinical Studies
In 2006, Brouwer et al16 conducted a randomized controlled
trial (RCT) involving 117 patients and reviewed them at 3, 6,
and 12 months. Half of the patients were given just con-
servative management, and the other half knee bracing and
conservative management; and they found improvements in
knee function and pain in the group using the brace.16 This
study is limited by the fact that patie nts were not followed up
for long term and compliance issues (some patients did not
continue to use the brace for more than 3 months).16 It did
see better results in the patients who had varus alignment
and in patients un der 60 years of age, and therefore they state
unloader braces could potentially be used to avoid or delay
surgery in the younger patient.16
Gaasbeek et al17 in 2007 looked at 15 patients with medial
osteoarthritis. The braces were worn for 7 days a week for
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al. e111
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Table 1 Summary of evidence
Study Type of
study
Model Method Results Conclusion
Brouwer et al
(2006)16 In vitro Multicent er
randomized
controlled trial
Patient s with unicompar tmental oste oarthritis we re
split into t wo groupsconser vative treatment alon e
or conser vative plu s brace treatment. Th ey were
then asse ssed for pain sever ity, knee function score,
walking distance, and qualit y of life. Multilin ear
regression models we re used
117 patients were used and followed up at 12 mo. Brace
treatment group outp erformed the conservative group in
all outcomes. Those who responde d better were varus
patients, severe osteoarthritis patients, secondary
osteoar thritis patients, and <60 y
Some benecial effec ts seen due to knee brace
treatment. Some patients did not comply with
the brace in th e long term
Gaasbeek et al
(2007)17 In vitro Prospective
cohort study
Patients with media l knee oste oarthritis were
identied and were give n a valgus knee brac e for
6 wk. At which point ga it analysis and pain and
function we re assess ed
There were improvements in pai n and function af ter 6 wk
and gait an alysis sh owed a reduction in varus mo ment
about the knee and th is effec t was in creased in patients
with greate r deformit y
This study identied certain effects knee braces
have in a patients gait. These may have cl inical
relevance in the future
Ramsey et al
(2007)18 In vitro Prospective
cohort study
Patients were recruited based on a criteria, which
included them havin g medial knee osteoar thritis.
Gait analysis was performed without a brace, wi th a
brace in neutral alignment and with the brace in
4° valgus. Pain, inst abilit y, and function were
assessed using questionnair es
16 patients were rec ruited. Scores for pain, function, and
instability were worst without a brace, but best with the
brace in neu tral alig nment. Cocontractions of paired
muscles we re reduced with the kn ee braced, more so with
the brace in neutral align ment
Neutral alignment kn ee braces perform just as
well as valgus align ed knee braces in th e
treatment of medial knee osteoarthritis. Thi s is
in regard to reducing pain, disability and
cocontrac tion
FantiniPaganietal
(2010)19 In vitro Prospective
cohort study
Healthy pat ients wi th varus alignment were
recruited. Gait analysis of pa tients were measured
with and without a val gus knee brace, in neutral,
4° valgus, and 8° valgus
During walking, th ere was a signicant reduction in knee
adductio n moments and adduction angular impulse with
the brace in 4° va lgus and 8° valgus. Ho wever, more
signican t differences were only fo und when the bra ce was
in 8° valgus wh en running
Knee braces were effective at reducing knee
adductio n moment s during walking and
running, wh ich should aid slowi ng the
progress ion of osteoarthritis
Schmalz et al
(2010)20 In vitro Prospective
cohort study
Patients were recruited if they had med ial knee
osteoarthritis. After the subjects had worn the brace
for 4 wk, gait an alysis an d valgus moments of the
knee were assessed
There was a reduction in the valgus moment to 10% of it
without th e brace, which may explain the pain relief
experien ced by patie nts. There was a reduction in gait
asymmetr y when patients we re using the brace
Bracing reduced valgus moment s around the
knee which unloads the medial compartment.
This leads to reducti on in pain and increase in
function
van Raaij et al
(2010)21 In vitro Randomized
controlled trial
Patients with mild medial symptomatic kn ee
osteoarthritis were recruited and randomized into a
lateral we dge foot in sole group or a val gus brac e
group. They were assessed at 6 mo on pa in severity
and function
There wer e no differences in the improve ments in pain and
severit y after 6 mo in either treatment grou p. The ins ole
group had bet ter compliance
Lateral w edge foot in soles may be an alternative
to valgus bracing to treat medial knee
osteoar thritis
Briggs et al
(2012)22 In vitro Prospective
cohort study
Patients were recruited who had been diagnosed
with unicompartmental knee osteoarthritis.
Patients were instructed to complete the SF -12,
WOMAC, and Tegner acti vity questionnaires, at
enrolment, 3 wk, 6 wk, and 6 mo. They also com-
pleted an expectation quest ionnaire at enrol ment
39 patients were found, all were prescribed an un loader
brace. There was a signicant improvement in qua lity of
life, pain, st iffness, and function. Important expectations
of these p atients included return to re creational sports,
improving abilit y to walk, and pain relief
Unloader braces can be ef fective treatment s to
increase function of t he knee by reducing pai n.
This leads to an increase in overall health.
Patientsexpectations can be met using the
brace
Wilson et al
(2011)23 In vitro Retrospective
study
30 patient s with unicompar tmental knee osteoar-
thritis were treated with knee braces and followe d
up at an average of 2.7 y and then again at 11.2 y
24 out of the 30 patients were availa ble to contac t. Five
patient s died but they sp oke to the family relative s of these
patients. At 2.7 y, 41% were stil l using the brace, 35%
stopped usi ng it, and 24% had undergone ar throplasty. At
the second fol low-up, 59% had undergone arthro plasty
and none of the patients were using the brace
They found t he unloader to be ef fective in the
short te rm but for the long term, most patients
preferred to un dergo ar throplasty surgery
Larsen et al
(2013)24 Clinical Prospective
cohort study
Patients were recruited with va rying degrees of
knee osteoarthritis and were tested on walking and
sit-to- stand activitie s after 2 mo of treatment with a
knee brace. Pain was also assessed
There were no differences in the improvement of pain
between t he different grades o fos teoarthritis .Sit -to-stand
activities were pe rforme d better at 1 mo in mod erate
osteoar thritis and at 2 mo by milder osteoa rthritis grades
This study provides data which may help rene
the optimum use of knee braces
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al.e112
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Table 1 (Continued)
Study Type of
study
Model Method Results Conclusion
Niazi et al
(2013)25 Clinical Prospective
cohort study
Patients with symptomatic med ial osteoarthr itis
were identied and were treated with the unloader
brace for 6 mo before being asse ssed for pain, knee
function , walking distance, and alignment on X-r ay.
They were also assessed at baseline
80 patients were enrolled. Af ter 6 mo, there were
statistically signicant changes in pain an d walking
distance by using the unloader brace compared with
baseline scor es
Unloader braces were ef fective at manag ing pain
relief and im proving function in knee
osteoar thritis
Iqbal (2014)26 Clinical Randomized
controlled trial
Patients with symptomatic med ial knee os teoar-
thritis were enrolled. Half were given a knee brace;
the other half were given a later al wedge foot in sole.
Patients after 6 mo we re assessed on pain and
function
Pain and walking dista nce reduced in bot h treatment
groups; however, the unloader brace group out perfor med
the foot orthotic group. There were slightly more com-
plications with the kn ee brace
The unloader knee brace is more effective at
treating medial knee osteoar thritis than lat eral
wedge foot inso les
Dessery et al
(2014)27 In vitro Prospective
cohort trial
Patients with medial knee osteoarthritis were asked
to wear thr ee diffe rent bracesa valgus brace, a
valgus and external rotation unload er brace, an d an
ACL brace. Pain relief, comfor t, and gait an alysis
were performed with each brace
All braces al leviate d knee pai n but the unloader an d ACL
brace allowed for a reduction in peak adduction moment
which was si gnicant. There w as a decrease in gait velocity
with the valgus brace. Patients were less inclined to wear
the braces du e their bulkiness, although the unl oader was
the most co mfortable and had the best compliance rate
When assess ing for pain reduction, discomfort,
and knee addu ction moment, ther e was little
difference betwe en the knee braces
Moyer et al
(2017)28 In vitro Prospective
cohort trial
Patients with media l osteoarthritis were given a
valgus bra ce and lateral wedg e foot orthotic. Gai t
analysis was performed on these patients with no
brace or or thotic; wi th just the brace; with just the
orthotic; and then with the or thotic and brace
together. During this analysis pat ients were
assessed to walk up and dow n stairs
There was a reduction in knee adduction moments in all
intervention groups during stair descent, more so in the
brace and insole group , but no difference in stair ascent.
There were less gait decomp ensatio ns with the combined
intervention group too
This suggests that using knee braces and foot
orthotics together to correct gait in knee
osteoar thritic patients is more ef fective th an
using just one but no con clusions can be ma de as
to whether th ese inter ventions shift biomecha-
nical load
Lee et al
(2017)1Clinical Prospective
cohort trial
8 y of data was collected fro m patients with
unicompar tmental osteoa rthritis. A qua lity of life
questionnaire was collected at enrol ment and while
wearing the brace. Cost and quality -adjusted life
years (QALYs) were then compared with total knee
replacement with 8 y of follow-up
There was an average increase of 0.42 after wea ring the
brace for 26.1 mo in the qua lity of life questionnaire.
Compared w ith no trea tment, th e unload er was co st
effective at 4 mo or more. At 8 y, the unl oader br ace had
QALY gains of 0.43 and was a lot more cost effective than
total knee rep lacement s by £6,467
Unloader kn ee braces are cost effective for
unicompartment al osteoarthrit is managem ent.
The brace co uld potentially delay or even replace
surgery
Abbreviations: SF-12, 12-Item Short Form Health Survey; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al. e113
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
6 weeks.17 They found a decrease in symptoms, as judged by
the Western Ontario and McMaster Universities Osteoarthri-
tis Index (WOMAC) scoring system, and a decrease in pain
during walking.17 They also generally found a reduction in
peak varus moment around t he knee during gait an alysis and
this effect was more pronounced in patients with worse
alignment.17
Ramsey et al18 analyzed 16 patientsgaits, with medial
knee osteoarthritis, while wearing knee braces. They also
looked at the electromyography of muscles around the knee
to evaluate the muscle co-contractions (vastus lateralis with
lateral hamstrings and vastus medialis with medial ham-
strings).18 They tested patients when unbraced as a baseline,
then with bracing to neutral alignment (after wearing for
2 weeks) and with bracing to 4° of valgus (again after wearing
for 2 weeks but with a 2-week unbraced period before).18
Pain and function were also assessed using questionnaires.
Nine of the 16 patients reported instability and pain before
the study, but this dropped to one after wearing the brace for
2 weeks in neutral alignment.18 After the washout period
and then wearing t he brace for 2 weeks in valgus alignment, 6
reported instability.18 Knee adduction moments during the
gait analysis was reduced in both types of bracing and muscle
co-contractions signicantly improved in both types, but
more so when valgus bracing was adopted.18 Conclusions
that can be drawn from this include that unloader braces are
effective at alleviating pain, but also that using these braces
to align the knee to neutral rather than overcompensating
into valgus alignment, may be just as effective.18
A study performed by Fantini Pagani et al19 in 2010, was
fairly similar to Ramsey et als18 study. Fantini Pagani et al19
found 16 male patients with varus knee alignment and
analyzed their gait during walking and running with a valgus
brace. The brace was adjusted to neutral, 4° valgus and 8°
valgus.19 They found that the knee brace took away some of
the load (due to a reduction in the adduction moments of the
knee) during the stance phase of walking and running.19
Again, Schmalz et al20 looked at gait analysis in patients
with medial osteoarthritis. Schmalz et al20 had a cohor t of 16
patients, all of whom had worn the brace for 4 weeks. During
walking, their ndings agreed with those of Ramsey et al18
and Fantini Pagani et al19 that there is a reduction in knee
adduction moments caused by wearing the brace and this,
they suggested, could be the mechanism which led to a
reduction in symptoms in these patient. They also found
that the walking speed increas ed signicantly in their cohort,
which again could be due to pain relief.
An RCT by van Raaij et al21 conducted in 2010 randomized
91 patients with medial knee osteoarthritis, into either a
valgus knee brace treatment group or a 10-mm lateral-
wedge shoe insole group. Their outcomes included pain,
severity, and function.21 Patients were asked to use the
treatment for 6 hours a day every day.21 After 6 months,
there were improvements in pain, severity, and function of
the knee in both treatment groups and both performed
equally, compared with the baseline data.21 This paper shows
knee braces to be effective in treating some of the symptoms
of knee osteoar thritis and improving function.21 It states that
insole wedges could be used as another effective treatment
for this condition.21 Unfortunately, they did not use a control
group (no treatment or conservative treatment) which
would have allowed assessment of how much each treat-
ment improved pain and function.21
In 2012, a study was performed looking into the change in
quality of life and knee function, if any, before and after 39
patients were treated with a knee brace.22 Briggs et al22
followed up their cohort at 3 weeks, 6 weeks, and 6 months.22
They found an improvement in quality of life, pain, stiffness,
and functi on when patients were given a knee br ace. Patients
found that they were able to do more recreational activity
while being treated with an unloader brace.22 Briggs et al22
also looked at the expectations of patients suffering from
knee osteoarthritis, as well as investigating unloader knee
braces. They identied that two outcomes patients expected
as a result of treatmentreturn to recreational sports and
pain reduction (over half of these patients expected all the
pain to cease).22 Other important things were reduction in
knee stiffness, knee swelling, and improvement in walking.22
They summarized patientsexpectations as having con-
dence in the knee, avoiding further deterioration in the
future, and maintaining general health.22
While most of these studies were fairly short term, one of
the rst long-term studies on knee braces was conducted by
Wilson et al23 in 2011. They only looked at 30 patients, and
followed their progress at an average of 2.7 and 11.2 years.23
The majority of patients reported pain relief, increased
function, decreased stiffness, and swelling after exercise
and 41% were still using the brace at the rst follow-up.23
However, at 11.2 years, none of the patients were using the
knee brace and over half had had a total knee replacement.23
Of the patients who had a total knee replacement, on average
there was 3.9 years between the initial assessment for a knee
brace and them having the surgery.23 They concluded that
while the brace, in the short term, was an effective treat-
ment, patients preferred choice was to have a knee replace-
ment instead of continuing with the brace for long term.23
In 2013, Larsen et al24 conducted a prospective study
which looked into the effect valgus knee braces have on
activities of daily living with their primary focus being
walking and sit-to-stand/stand-to-sit activities. Their
patients had been wearing the brace for 2 months during
the study.24 In patients with low and moderate knee osteoar-
thritis, they found an increase in activity while using the
brace.24 This was coupled with a decrease in pain too, which
may have contributed to the increase in activity level.24 With
regards to walking, their patients had a nonsignicant
improvement in knee adduction but they found that they
were able to push off with more power.24 This suggests that
the brace, by redistributing the loading forces in the knee, is
aiding the strengthening of muscles in the leg.24 This then
leads to increased function and activity levels found in this
study, including improvements in sit-to-stand and stand-to-
sit exercises.24 Overall, they could only conclude that valgus
bracing in medial knee osteoarthritis could lead to short-
term improvements in function of the knee in patients with
mild to moderate osteoarthritis.24 Unfortunately, they did
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al.e114
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
not look at patients with severe osteoarthritis and their
study only lasted 2 months, so no long term conclusions
could be drawn from this; however, they did state that the
brace has the potent ial to delay to avoid surgical in tervention
in these patients.24
Niazi et al25 in 2013 conducted a case series study to
assess any change in pain and function in the knee in 80
patients with medial knee osteoarthritis using an unloader
knee brace. Their outcomes included pain severity, walking
distance, and knee function scores (using WOMAC scoring
system).25 Four patients were lost to follow-up.25 Pain
severity and walking di stance signicantly improved in these
patients after 6 months of brace use and they also found that
patients used less pain killers as a result and knee function
scores improved.25 They stated that unloader bracing is an
effective treatment for unicompartmental knee osteoarthri-
tis and can be used in patients who are less keen on or
contraindicated against surgery.25 Niazi et al25 concluded
that it should be considered in all patients with this condi-
tion along with standard medical treatment, and surgical
intervention should not be considered unless a patient has
tried to use an unloader brace.
Iqbal26 (part of a similar team to Niazi et al25) conducted
an RCT comparing unloader knee braces with lateral wedged
insoles,26 similar to van Raaij et al.21 In total, 120 patients
were involved in the study by Iqbal.26 Patients were
instructed to wear the brace for 3 to 4 hours for the rst
week then as long as they could during the day after that.26
Their main outcomes, like their previous paper, was pain and
walking distance (using the second section of the Lequesne
scale).26 Four patients using insoles and two using braces
were lost to follow-up and three in the insole group and two
in the brace group changed treatment because of lack of
symptomatic relief or complications.26 The baseline differ-
ences in pain and severity between the two groups were
insignicant; however, after 6 months of treatment, the
brace groups pain score was 3.97 and the insole groups
score was 4.53.26 For walking distance, the brace group was
also better with a score of 1.93 on the Lequesne scalean
improvement of 0.43 compared with the lateral wedge insole
group, and ther e was an improvement in activity levels in th e
braced group; these differences between the two groups
were statistically signicant.26 It was concluded by Iqbal26
that despite improvements in both groups, the unloade rk nee
brace outperformed lateral wedge insoles in all outcomes;
however, there were a few more complications associated
with bracing; ve patients experienced leg swelling.
Dessery et al27 looked at 24 patients with medial knee
osteoarthritis, each tried three different knee braces for
2 weeks before assessment. They assessed pain relief, com-
fort, and gait analysis.27 The three braces in question were a
valgus brace, an unloader brace with valgus and external
rotation functions, and a functional knee brace for ligament
injuries (ACL-brace).27 All three braces alleviated pain imme-
diately but the unloader brace and ACL brace allowed for a
signicant decrease in load during the stance phase.27 The
valgus brace saw a decrease in gait velocity.27 They only show
pain relief differences from the braces in the short term and
focused more on the biomechanical analysis of the gait.27
They also reported patients were less inclined to wear the
braces for long periods due to their bulkiness but the
unloader brace was the most comfortable of the three.27 In
conclusion, they stated that all three braces were similar in
terms of pain and function improvements.27
Most Recent Research in 2017
Moyer et al28 looked at 35 patientsgait during stair ascent
and descent. At rst, the patients were tested with no
mechanical aids, then with just a custom-t valgus knee
brace, then a lateral wedge foot insole, and then both the
brace and foot insole.28 During stair descent, there was a
reduction in knee adduction moments in all intervention
groups compared with the control, more so in the brace and
insole group, but no difference in stair ascent.28 Gait speeds
were similar across all conditions during both ascent and
descent.28 Overall, there were fewer gait compensations
during descent compared with ascent.28 In summary, the
knee brace and lateral wedge insole had the best biomecha-
nical effect on gait during stair descent and almost half the
patients (17 patients) preferred this treatment, although it
did not have the same effect on stair ascent.28 This study
again looked at a very little number of patients and did not
look at patients over the long term which makes it hard to
clinically relate this study to practise.28
A prospective study conducted by Lee et al1followed
patients up for over 8 years while they were treated with
the Ossur Unloader One knee brace. It is one of the rst
studies to provide long-term evidence about unloader knee
brace use and followed 63 patients with end-stage knee
osteoarthritis (irrespective of the affected compartment)
one patient withdrew.1Patients on average wore the brace
for 26 months, with some opting out of surgery and instead
preferring to use the knee brace for long term.1At the nal
follow-up, 40% of patients did not require surgery; excluding
these, of the remaining 38, the average brace use was 8.6
months.1Their analysis showed that if patients were able to
tolerate the unloader brace for 2 years their chances of having
surgery decreased signicantly; in fact, in the study, anyone
who wore the brace for more than 2 years, did not go on to
have surgery.1Wearing the brace for 6 months halved the
chance of a patient having to need surgery compared with
those who wore the brace for 3 months or less.1Their results
suggested that unloader knee braces are cost effective in
patients who are awaiting surgery.1
Analysis of their results showed that there was no differ-
ence in how long patients wore the brace, depending on
certain patient demographics including gender, age, body
mass index (BMI), socioeconomic group, leg, or compart-
ment.1So, potentially all patients could benetfromunloa-
der braces if they have unicompartmental osteoarthritis.
Overall, Lee et al1showed the unloader knee brace to be a
cost-effective management option for unicompartmental
osteoarthritis, as it can delay or reduce the frequency of
surgery.
A summary of this evidence can be found in Table 1.
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al. e115
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Discussion
The aim of thisreview was to give an update on the literature in
the past 10 years on unloader braces including the more recent
articles in 2017. We presented 14 pieces of original research.
Lee et als1study was the only piece that looked at a large cohort
of patients over the long term to investigate unloader knee
brace use. They found that knee braces were cost effective but
importantly could replace the need for surgery, if not delay it
over 8 years. The other long-term study, by Wilson et al,23 was
retrospective and only used 30 patients, so while their results
are important, their conclusions are not as strong as Lee et als.1
The majority of studies also agreed that unloader braces
were a valuable treatment for unicompartmental knee
osteoarthritis, whether that be in reducing pain or looking
more specically at the knee adduction moments during
walking. Unfortunately, many have short follow-up periods,
small sample sizes, and most focus on medial compartment
osteoarthritis. This means we cannot draw similar conclu-
sions from these st udies like we can in Lee et als,1such as the
fact that unloaders are able to delay surgery over the long
term. Only three papers were RCTs,16,21,26 which carry the
highest level of evidence. All three showed patients bene-
tted from unloader brace treatment compared with con-
servative management.
Our results concurred with other literature studies, so are
not novel ndings but reinforce the same conclusions. Ramsey
and Russel,29 in 2009, concluded that unloader knee braces are
good at helping pain relief in unicompartmental knee osteoar-
thritis. With regards to practice, it should be used in conjunc-
tion with other conservative treatment and be considered
beforeany type of surgicalintervention, a point emphasized by
Lee et al1and Niazi et al.25 A meta-analysis conducted by
Moyer etal30 in 2015 looked at the evidence presented in eight
RCTs on valgus knee bracing for medial compartmental
osteoarthritis. They concluded that they were able to make a
strong recommendation about improvements with pain in
patients with valgus knee braces and a weak recommendation
for improvement in function.30 Petersen et al31 focused on
knee adduction moments and 20 out of the 24 articles they
looked at concluded that unloader braces reduced the knee
adduction moment. The evidence from this reviewand others
combined should be enough to encourage further the use of
knee unloader braces in clinical practice.
Wilson et al23 determined that patients preferred to opt for
surgery over knee braces in the long term, although this is in
disagreementwith Lee et al,1which found long-term use of the
brace could delay or potentially nullify the need for surgery.
One of the reasons for lower rates of use, especially long term,
could be due to the complications of using knee braces. Lee
et al1reported that 43% of patients in their study had soft tissue
injuries which could be due to poor tting. Moyer et al,30 in
their meta-analysis, found compliance rates varied from 45 to
100%. Minor complications mentioned in this review include
that the brace was bulky; its tting was constraining or it
slipped; and it caused swelling, blistering, and skin irritation.30
Iqbal26 reported 5 out of the 60 patients wearing bracing
reported leg swelling. With regards to major complications,
there have been very few reported, although there have been
cases of thrombophlebitis and venous thromboembolism.32,33
To improve compliance, Lee et al1suggested regular follow-
up appointments, in a nurse-led clinic, at 1, 3, and 6 months to
address any issues. This way, complications can be monitored
and the health care service can check the patient is tting the
brace correctly, which was suggested as the cause formany soft
tissue issues. If there were any problems with tting, these
could be corrected to avoid worsening of the problem and
increasing the chances of successful treatment.1
There were several studies present which also looked at
lateral wedge foot insoles as a potential treatment for uni-
compartmental knee osteoarthritis too. While two studies
suggested that they could be as good as knee braces,21,28
Iqbals26 RCT showed that knee braces outperformed foot
insoles in improvements in pain and walking distance, so
they may not be as suitable, despite the fact they had slightly
less complications. More patients in Iqbals26 study wanted
to change from foot insoles due to lack of effect , than wanted
to change to knee braces.
Briggs et al22 identied that two outcomes that patients
expected as a result of treatment were return to recreational
sports and pain reduction. From the evidence above, it shows
that knee bracing may be able to manage these expectations
(fully or partially), but it is surprising that there have been
reports that unloader knee braces are not regularly pre-
scribed in clinical prac tice. A study by Li et al34 found that less
than 12% of patients, suffering from unicompartmental
osteoarthritis, had tried knee bracing as part of their treat-
ment. Although this st udy was in 2004, it is backed up by two
more recent studies showing big inconsistencies between
clinical practice and guidelines for knee osteoarthritis
management.32,35
Future research needs to look into the disparity in volume
of evidence between medial and lateral unicompartmental
knee osteoarthritis. Most of the studies in this review were
also short term (around 6 months) and more evidence is
required to validate unloader braces over a longer period
of time. Two studies did look at the braces over 8 years1and
11 years,23 but if unloader braces can actually delay the need
for surgery then they need to be effective over at least a 5-
year period and the evidence needs to reect this. Also, there
were very few studies looking at knee bra ce use for end-stage
knee osteoarthritis, so more research may be needed here to
see how exactly they could be used for this stage of the
condition. More research will be needed to identify the
optimal patient who would benet from unloader knee
braces (with regards to gender, age, BMI, compartment,
etc.), although there are suggestions that every patient could
benet. A limitation from this study include that we looked
at a mix of studies with different outcomes, so they were
slightly harder to compare.
Conclusion
Current research has demonstrated the effectiveness of
unloader braces in the management of unicompartmental
knee osteoarthritis over the short term; only two papers
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al.e116
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
studied the braces over a long period (8 and 11 years).
Unloader braces are a cost-effective management option to
potentially delay the need for surgery for young patients or
those on long waiting lists. It has been shown to dramatically
affect a patients quality of life and should be combined with
other standard treatments as stated in the guidelines for
knee osteoarthritis management. More investigations are
needed into why prescription rates are low. Although we
have explored some complications and issues with compli-
ance, these issues do not justify not considering an unloader
brace in every patient presenting with unicompartmental
knee osteoarthritis. One reason for this may be lack of
awareness, and therefore more education on unloader braces
may be required. A nurse-led clinic for follow-up has been
demonstrated to be an effective approach to monitor com-
pliance and complications. These conclusions are not novel
but support existing literature and this review can be added
to the ever-growing pool of evidence on the use of unloader
braces. This evidence combined with previous studies and
reviews should lead to an increased uptake, acceptance, and
usage of the braces.
Patients with unicompartmental knee osteoarthritis
should be managed with a multidisciplinary approach, an
unloader knee brace, standard conservative management
plus a follow-up clinic lead by nurses; with the overall aim
being to aid patientsquality of life and to reduce the rates of
knee replacements.
Conict of Interest
None.
Acknowledgments
None.
References
1Lee PYF, Wineld TG, Harris SRS, Storey E, Chandratreya A.
Unloading knee brace is a cost-effective method to bridge and
delay surgery in unicompartmental knee arthritis. BMJ Open
Sport Exercise Med 2017;2(01):e000195
2Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The
role of knee alignment in disease progression and functional
decline in knee osteoarthritis. JAMA 2001;286(02):188195
3NICE. NICE guidelines: Osteoarthritis - Care and Management;
2014. Available at: https://www.nice.org.uk/guidance/cg177/
chapter/1-Recommendations#non-pharmacological-manage-
ment-2. Accessed May 24, 2017
4Dakin H, Gray A, Fitzpatrick R, Maclennan G, Murray D, Group
KATT; KAT Trial Group. Rationing of total knee replacement: a
cost-effectiveness analysis on a large trial data set. BMJ Open
2012;2(01):e000332
5Li CS, Bhandari M. Cost-effectiveness of unicompartmental knee
arthroplasty, high tibial osteotomy, and KineSpring® Knee
Implant System for unicompartmental osteoarthritis of the
knee. J Long Term Eff Med Implants 2013;23(2-3):189198
6NHS W. Annual Patient Episode Database Wales (PEDW) Data
Tables; 2016. Available at: http://www.infoandstats.wales.nhs.
uk/page.cfm?orgid¼869&pid¼40977. Accessed May 24, 2017
7Furnes O, Espehaug B, Lie SA, Vollset SE, Engesaeter LB, Havelin LI.
Early failures among 7,174 primary total knee replacements: a
follow-up study from the Norwegian Arthroplasty Register 1994-
2000. Acta Orthop Scand 2002;73(02):117129
8Labek G, Thaler M, Janda W, Agreiter M, Stöckl B. Revision rates
after total joint replacement: cumulative results from worldwide
joint register datasets. J Bone Joint Surg Br 2011;93(03):293297
9Williams DP, Price AJ, Beard DJ, et al. The effects of age o n patient-
reported outcome measures in total knee replacements. Bone
Joint J 2013;95-B(01):3844
10 McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines
for the non-surgical management of knee osteoarthritis. Osteoar-
thritis Cartilage 2014;22(03):363388
11 Jordan KM, Arden NK, Doherty M, et al; Standing Committee for
International Clinical Studies Including Therapeutic Trials ESCI-
SIT. EULAR recommendations 2003: an evidence based approach
to the management of knee osteoarthritis: report of a Task Force
of the Standing Committee for International Clinical Studies
Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;62
(12):11451155
12 Lindenfeld TN, Hewett TE, Andriacchi TP. Joint loading with valgus
bracing in patients with varus gonarthros is. Clin Orthop Relat Res
1997;(344):290297
13 Kirkley A, Webster-Bogaert S, Litcheld R, et al. The effect of
bracing on varus gonarthrosis. J Bone Joint Surg Am 1999;81(04):
539548
14 Katsuragawa Y, Fukui N, Nakamura K. Change of bone mineral
density with valgusknee bracing. Int Orthop 1999;23(03):164167
15 Ossur UKO. Unloader One; 2017. Available at: https://www.ossur.
co.uk/oa-solutions/oa-products/oa-knee/oa-knee-braces/unloa-
der-one. Accessed May 24, 2017
16 Brouwer RW, van Raaij TM, Verhaar JA, Coene LN, Bierma-Zeinstra
SM. Brace treatment for osteoarthritis of the knee: a prospective
randomized multi-centre trial. Osteoar thritis Cartilage 2006;14
(08):777783
17 Gaasbeek RD, Groen BE, Hampsink B, van Heerwaarden RJ,
Duysens J. Valgus bracing in patients with medial compartment
osteoarthritis of the knee. A gait analysis study of a new brace.
Gait Posture 2007;26(01):310
18 Ramsey DK, Briem K, Axe MJ, Snyder-Mackler L. A mechanical
theory for the effectiveness of bracing for medial compartment
osteoarthritis of the knee. J Bone Joint Surg Am 2007;89(11):
23982407
19 Fantini Pagani CH, Potthast W, Brüggemann GP. The effect of
valgus bracing on the knee adduction moment during gait and
running in male subjects with varus alignment. Clin Biomech
(Bristol, Avon) 2010;25(01):7076
20 Schmalz T, Knopf E, Drewitz H, Blumentritt S. Analysis of bio-
mechanical effectiveness of valgus-inducing knee brace for
osteoarthritis of knee. J Rehabil Res Dev 2010;47(05):419429
21 van Raaij TM, Reijman M, Brouwer RW, Bierma-Zeinstra SM,
Verhaar JA. Medial knee osteoarthritis treated by insoles or
braces: a randomized trial. Clin Orthop Relat Res 2010;468(07):
19261932
22 Briggs KK, Matheny LM, Steadman JR. Improvement in quality of
life with use of an unloader knee brace in active patients with OA:
a prospective cohort study. J Knee Surg 2012;25(05):417421
23 Wilson B, Rankin H, Barnes CL. Long-term results of an unloader
brace in patients with unicompartmental knee osteoarthritis.
Orthopedics 2011;34(08):e334e337
24 Larsen BL, Jacofsky MC, Brown JA, Jacofsky DJ. Valgus bracing
affords short-term treatment solution across walking and sit-to-
stand activities. J Ar throplasty 2013;28(05):792797
25 Niazi NS, Niazi SNK, Jafree SBH. Role of un-loader bracing in the
management of medial compartment knee osteoar thritis. Age
(Omaha) 2013;35:982985
26 Iqbal M. Comparison of the effectiveness of knee braces and
lateral wedge insole in the management of medial compartment
knee osteoarthritis. J Med Health Sci 2014;8(01):3740
27 Dessery Y, Belzile EL, Turmel S, Corbeil P. Comparison of three
knee braces in the treatment of medial knee osteoarthritis. Knee
2014;21(06):11071114
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al. e117
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
28 Moyer R, Birmingham T, Dombroski C, Walsh R, Gifn JR. Com-
bined versus individual effects of a valgus knee brace and lateral
wedge foot orthotic during stair use in patients with knee
osteoarthritis. Gait Posture 2017;54:160166
29 Ramsey DK, Russell ME. Unloader braces for medial compart ment
knee osteoarthritis: implications on mediating progression.
Sports Health 2009;1(05):416426
30 Moyer RF, Birmingham TB, Bryant DM, Gifn JR, Marriott KA, Leitch
KM. Valgus bracing for knee osteoarthritis: a meta-analysis of rando-
mized trials. Arthritis Care Res (Hoboken) 2015;67(04):493501
31 Petersen W, Ellermann A, Zantop T, et al. Biomechanical effect of
unloader braces for medial osteoarthritis of the knee: a systema-
tic review (CRD 42015026136). Arch Orthop Trauma Surg 2016;
136(05):649656
32 Beaudreuil J, Bendaya S, Faucher M, et al. Clinical practice guide-
lines for rest orthosis, knee sleeves, and unloading knee braces in
knee osteoarthritis. Joint Bone Spine 2009;76(06):629636
33 Giori NJ. Load-shifting brace treatment for osteoarthritis of the
knee: a minimum 2 1/2-year follow-up study. J Rehabil Res Dev
2004;41(02):187194
34 Li LC, Maetzel A, Pencharz JN, Maguire L, Bombardier C; Commu-
nity Hypertension and Arthritis Project (CHAP) Team. Use of
mainstream nonpharmacologic treatment by patients with
arthritis. Arthritis Rheum 2004;51(02):203209
35 Dhawan A, Mather RC III, Karas V, et al. An epidemiologic
analysis of clinical practice guidelines for non-ar throplast y
treatment of osteoarthritis of the knee. Arthroscopy 2014;30
(01):6571
The Surgery Journal Vol. 4 No. 3/2018
An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis Mistry et al.e118
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
... Unicompartment off-loader braces are a common style of knee brace designed to reduce pain and progressive degeneration of the osteoarthritic knee by redistributing compressive forces away from the diseased medial or lateral tibiofemoral (TF) compartment via joint realignment (Ramsey et al., 2007;Briem and Ramsey, 2013). Although the use of these braces in patients with unicompartmental TF disease is supported by biomechanical (Moyer et al., 2015;Petersen et al., 2016) and clinical studies (Rannou et al., 2010;Mistry et al., 2018), the effectiveness of unicompartment off-loader braces may be limited because the vast majority (>90%) of patients have bicompartmental or tricompartmental disease with patellofemoral (PF) involvement (Duncan et al., 2009;Heekin and Fokin, 2014). ...
... Unloading of joint contact forces is widely recognized as a best practice in the conservative care of knee OA patients and may be achieved through a range of strategies including BW reduction, activity modification, strengthening/exercise, and the use of walking aids or knee braces (Sarzi-Puttini et al., 2005;Zhang et al., 2008;Waller et al., 2011;Messier et al., 2018;Mistry et al., 2018). Joint unloading can result in clinically significant improvements in pain, function, and quality of life (Waller et al., 2011;Messier et al., 2018;Mistry et al., 2018) and may be used as a strategy to delay or prevent surgery (Lee et al., 2017) or even slow the progression of knee OA (Radin and Burr, 1984;Block and Shakoor, 2009;Mastbergen et al., 2013;van der Woude et al., 2017). ...
... Unloading of joint contact forces is widely recognized as a best practice in the conservative care of knee OA patients and may be achieved through a range of strategies including BW reduction, activity modification, strengthening/exercise, and the use of walking aids or knee braces (Sarzi-Puttini et al., 2005;Zhang et al., 2008;Waller et al., 2011;Messier et al., 2018;Mistry et al., 2018). Joint unloading can result in clinically significant improvements in pain, function, and quality of life (Waller et al., 2011;Messier et al., 2018;Mistry et al., 2018) and may be used as a strategy to delay or prevent surgery (Lee et al., 2017) or even slow the progression of knee OA (Radin and Burr, 1984;Block and Shakoor, 2009;Mastbergen et al., 2013;van der Woude et al., 2017). This study analyzed the biomechanics of the knee joint for three different models of a novel TCU brace, which is designed to reduce joint forces in all three knee compartments when the knee is flexed and weight-bearing. ...
Article
Full-text available
Objective: Off-loader knee braces have traditionally focused on redistributing loads away from either the medial or lateral tibiofemoral (TF) compartments. In this article, we study the potential of a novel “tricompartment unloader” (TCU) knee brace intended to simultaneously unload both the patellofemoral (PF) and TF joints during knee flexion. Three different models of the TCU brace are evaluated for their potential to unload the knee joint. Methods: A sagittal plane model of the knee was used to compute PF and TF contact forces, patellar and quadriceps tendon forces, and forces in the anterior and posterior cruciate ligaments during a deep knee bend (DKB) test using motion analysis data from eight participants. Forces were computed for the observed (no brace) and simulated braced conditions. A sensitivity and validity analysis was conducted to determine the valid output range for the model, and Statistical Parameter Mapping was used to quantify the effectual region of the different TCU brace models. Results: PF and TF joint force calculations were valid between ~0 and 100 degrees of flexion. All three simulated brace models significantly ( p < 0.001) reduced predicted knee joint loads (by 30–50%) across all structures, at knee flexion angles >~30 degrees during DKB. Conclusions: The TCU brace is predicted to reduce PF and TF knee joint contact loads during weight-bearing activity requiring knee flexion angles between 30 and 100 degrees; this effect may be clinically beneficial for pain reduction or rehabilitation from common knee injuries or joint disorders. Future work is needed to assess the range of possible clinical and prophylactic benefits of the TCU brace.
... However, after one month, the benefits of using canes could be seen in the form of significant pain reductions and a return to normal energy expenditure because of the adaptation. The cane should be used contra-laterally to significantly reduce the burden on the affected knee while maximizing the benefit [50,66]. ...
... Both therapies can help delay the progression of the disease by reducing knee loading in patients with OA. Action levels are raised when valgus unloader braces are worn [66,69]. ...
... However, after one month, the benefits of using canes could be seen in the form of significant pain reductions and a return to normal energy expenditure because of the adaptation. The cane should be used contra-laterally to significantly reduce the burden on the affected knee while maximizing the benefit [50,66]. ...
... Both therapies can help delay the progression of the disease by reducing knee loading in patients with OA. Action levels are raised when valgus unloader braces are worn [66,69]. ...
Article
Full-text available
The rising prevalence of osteoarthritis (OA) in the general population has necessitated the development of novel treatment options. It is critical to recognize the joint as a separate entity participating in degenerative processes, as well as the multifaceted nature of OA. OA is incurable because there is currently no medication that can stop or reverse cartilage or bone loss. As this point of view has attracted attention, more research is being directed toward determining how the various joint components are impacted and how they contribute to OA pathogenesis. Over the next few years, several prospective therapies focusing on inflammation, cartilage metabolism, subchondral bone remodelling, cellular senescence, and the peripheral nociceptive pathway are predicted to transform the OA therapy landscape. Stem cell therapies and the use of various biomaterials to target articular cartilage (AC) and osteochondral tissues are now being investigated in considerable detail. Currently, laboratory-made cartilage tissues are on the verge of being used in clinical settings. This review focuses on the update of clinical prospects and management of osteoarthritis, as well as future possibilities for the treatment of OA.
... Pain and dysfunction in knee joints are the main clinical manifestations of patients with KOA, and the purpose of treatment should be relieving pain and improving the knee joint function, so as to improve the quality of life of patients [20][21][22][23]. is study showed that the HSS scores of patients with KOA after surgery were significantly higher than the score before surgery (P < 0.05), and the postoperative pain scores increased with time, indicating that the patients' pain was alleviated gradually. is is because TKA can reduce the release frequency of proinflammatory cytokines in patients, especially tumor necrosis factor (TNF-α) and interleukin-1β (IL-1β), which are closely related to the integrity of the articular cartilage tissue. ...
Article
Full-text available
Objective: To explore the safety of total knee arthroplasty (TKA) in the treatment of knee osteoarthritis (KOA) and its impact on patients' postoperative pain and quality of life. Methods: A total of 60 KOA patients admitted to our hospital from January 2019 to January 2020 were selected as the research objects. The knee joint scores (HSS) before and after TKA were compared, and the patients' quality of life was evaluated using the Osteoarthritis Index of Western Ontario and McMaster University (WOMAC). At the same time, the number of patients with complications was recorded, and the efficacy of TKA was comprehensively analyzed. Results: The postoperative HSS score was significantly higher than the preoperative score (P < 0.05), the postoperative pain score increased with time, and the pain gradually decreased. The postoperative WOMAC score was significantly lower than the preoperative score (P < 0.001), and the score at 6 months after surgery was significantly lower than that at 3 months after surgery (P < 0.001). There were no complications such as severe prosthesis fracture, secondary sepsis, and patellar tendon rupture, and the total incidence of complications was 11.7%. The effective rate of treatment at 6 months after operation was 98.3%, which was significantly higher than that at 3 months after operation (P < 0.05). Conclusion: Total knee arthroplasty can improve the knee joint function of patients with knee osteoarthritis, with low postoperative pain, low complication rate, and good quality of life for patients. It is worthy of promotion and application.
Article
Full-text available
Background: Previous investigations on valgus knee bracing have mostly used the external knee adduction moment. This is a critical limitation, as the external knee adduction moment does not account for muscle forces that contribute substantially to the medial tibiofemoral contact force (MTCF) during walking. The aims of this pilot study were to: 1) determine the effect of a valgus knee brace on MTCF; 2) determine whether the effect is more pronounced after 8 weeks of brace use; 3) assess the feasibility of an 8-week brace intervention. Methods: Participants with medial radiographic knee OA and varus malalignment were fitted with an Össur Unloader One© brace. Participants were instructed to wear the brace for 8 weeks. The MTCF was estimated via an electromyogram-assisted neuromuscular model with and without the knee brace at week 0 and week 8. Feasibility outcomes included change in symptoms, quality of life, confidence, acceptability, adherence and adverse events. Results: Of the 30 (60% male) participants enrolled, 28 (93%) completed 8-week outcome assessments. There was a main effect of the brace (p<0.001) on peak MTCF and MTCF impulse, but no main effect for time (week 0 and week 8, p = 0.10), and no interaction between brace and time (p = 0.62). Wearing the brace during walking significantly reduced the peak MTCF (-0.05 BW 95%CI [-0.10, -0.01]) and MTCF impulse (-0.07 BW.s 95%CI [-0.09, -0.05]). Symptoms and quality of life improved by clinically relevant magnitudes over the 8-week intervention. Items relating to confidence and acceptability were rated relatively highly. Participants wore the brace on average 6 hrs per day. Seventeen participants reported 30 minor adverse events over an 8-week period. Conclusion: Although significant, reductions in the peak MTCF and MTCF while wearing the knee brace were small. No effect of time on MTCF was observed. Although there were numerous minor adverse events, feasibility outcomes were generally favourable. Trial registration: Australian and New Zealand Clinical Trials Registry (12619000622101).
Chapter
Osteoarthritis is the most common form of joint disease, and with an aging population the prevalence is expected to grow. We now have a stronger appreciation of the multiple contributing factors to osteoarthritis and the complicated biochemical process at play. Although radiographic progression is expected to correlate with symptoms, other factors are also involved in determining disability and pain. Management of OA is individualized and starts with disease prevention and education, combining non-pharmacologic and pharmacologic modalities, and lastly surgical intervention.
Chapter
This chapter discusses some of the external devices used in managing knee disorders, both applied directly to the knee or at the foot or ankle.
Article
A multi-site study was conducted to evaluate the efficacy of the Keeogo™ exoskeleton as a mobility assist device for use in the clinic and at home in people with knee osteoarthritis (KOA). Twenty-four participants were randomized in a two-stage cross-over design that evaluated the immediate effects of using the exoskeleton in the clinic and the cumulative effects of training and home use. Immediate effects were quantified by comparing 1) physical performance with|without (W|WO) the device during a battery of mobility tests, and 2) physical activity levels at home (actigraphy) for one month, two weeks W|WO the device. Cumulative effects were quantified as change in physical performance W and WO over time. WOMAC and other self-report scales were measured and usability assessed. There were no immediate effects on physical performance or physical activity at home; however, there were cumulative effects as indicated by improved stair time (p=.001) as well as improved WOMAC pain (p=.004) and function (p=.003). There was a direct relationship between improved physical function and improved WOMAC pain (r=-.677, p<.001) and stiffness (r=.537, p=.007). Weight and battery life were identified as important to usability. A full-scale RCT with more participants, longer study period, and better usage monitoring is warranted.
Article
Full-text available
Background Unloading knee braces can provide good short-term pain relief for some patients with unicompartmental osteoarthritis (UOA). Their cost is relatively small compared with surgical interventions. However, no previous studies have reported their use over a duration of 5 years or more. Methods Up to 8 years of prospective data were collected from 63 patients who presented with UOA. After conservative management with analgesia and physiotherapy, patients were offered an unloading brace. EQ-5D (EuroQol five dimensions) questionnaires were collected at baseline and after wearing the brace. Cost and quality-adjusted life years (QALYs) were compared with a total knee replacement (TKR) with an 8-month waiting duration and 8 years of results. Results Patients experienced a mean increase in EQ-5D of 0.42 with an average duration of wear of 26.1 months resulting in an increase of 0.44 in QALYs with a mean cost of £625. The adoption of an unloader knee brace was found to be a short-term cost-effective treatment option with an 8-month incremental cost effectiveness ratio of £9599. Compared with no treatment, the unloader knee brace can be considered cost effective at 4 months or more. At 8 years follow-up, the unloader knee brace demonstrated QALYs gain of 0.43 and with an incremental cost-effectiveness ratio of -£6467 compared with TKR. Conclusion Unloading knee braces are cost effective for the management of UOA. These findings strongly support the undertaking of further research into the long-term impact of unloading knee brace. The unloader knee brace has benefits to the National Health Service for capacity, budget, waiting list duration, frequency of surgery and reducing the required severity of surgical intervention.
Article
Full-text available
Purpose: There is a lack of consensus regarding biomechanical effects of unloader braces for the treatment of medial osteoarthritis (OA) of the knee. The purpose of this study was to perform a systematic review of studies examining the biomechanical effect of unloader braces. Methods: A systematic search for articles about the biomechanical effect of unloader braces was performed. Primary outcome measure was the influence of the brace on the knee adduction moment. Data sources were Pubmed central and google scholar. Results: Twenty-four articles were included. Twenty articles showed that valgus unloader braces significantly decrease the knee adduction moment. Seven of those studies reported a decrease of pain in braced patients (secondary outcome measure). Positive effects on the knee adduction moment could be found for custom made braces for conventional knee braces and for a foot ankle orthosis. Four studies could not show any effect of knee unloader braces on the knee adduction moment although one of these studies found decreased pain in braced patients. One of these studies examined healthy patients with a neutral axis. Conclusion: This systematic review could demonstrate evidence that unloader braces reduce the adduction moment of the knee. Foresighted, a systematic review about the clinical effect of unloader braces is required.
Article
Full-text available
Osteoarthritis (OA) of the knee is a condition that causes pain and disability. Numerous non-surgical and surgical interventions are available for individuals with OA that result in good pain relief and return of function. The purpose of this economic analysis was to determine the cost-effectiveness of high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) and the KineSpring® Knee Implant System in the treatment of unicompartmental OA of the knee 10 years post-surgery, considering the costs of revisions, conversions, removals, and complications. Estimates of costs and rates of revision, conversion, removal, and complications related to UKA and HTO were obtained from the literature. Internal reports on the KineSpring System were used for calculations on the KineSpring System. The cost-effectiveness of UKA, HTO and the KineSpring System in terms of QALY gained compared to patients without treatment yielded gains of approximately $5150/QALY, $6754/QALY, and $7010/QALY, respectively. Using the accepted standard willingness-to-pay threshold of $50,000 US/QALY gained, the UKA, HTO, and the KineSpring System are economically favorable. Our analysis demonstrates that the KineSpring System, despite a greater initial cost in surgery, has significantly smaller conversion and complication costs compared to UKA and HTO. The 10 years overall expected cost for the KineSpring System ($12,559) is significantly less compared with that of UKA ($17,570) and HTO ($22,825). Future economic analyses regarding this topic should also consider the cost-effectiveness of these procedures on younger, more active individuals who are still working and should take into account productivity loss.
Article
The aim of this study was to investigate the combined and individual biomechanical effects of a valgus knee brace and a lateral wedge foot orthotic during stair ascent and descent in patients with knee osteoarthritis (OA). Thirty-five patients with varus alignment and medial knee OA were prescribed a custom valgus knee brace and lateral wedge foot orthotic. Knee angles and moments in the frontal and sagittal planes were determined from 3D gait analysis completed under four randomized conditions: (1) control (no knee brace or foot orthotic), (2) knee brace, (3) foot orthotic, and (4) combined knee brace and foot orthotic. Additional measures included the vertical ground reaction force, trunk lean, toe out and gait speed. During the combined use of a knee brace and foot orthotic, significant decreases in the knee adduction angle (2.17, 95%CI: 0.50-3.84, p = 0.013) and 2nd peak EKAM (0.35, 95%CI: 0.17-0.52, p < 0.001) were observed during stair descent; and significant increases in the EKFM were observed during stair ascent (0.54, 95%CI: 0.30-0.78, p < 0.001) and descent (1stpk: 0.48, 95%CI: 0.15-0.80, p = 0.005; 2ndpk: 0.55, 95%CI: 0.34-0.76, p<0.001). Fewer gait compensations were observed between conditions during stair descent compared to ascent, except for toe out. Findings suggest greater effects on gait when both knee brace and foot orthotic are used together, resulting in a more normal gait pattern. However, whether or not a true change in knee joint load can be inferred when using these orthoses remains unclear. Further research is required to determine the clinical importance of the observed changes.
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
Aim: To provide the documented efficacy of off-loader knee braces for improving symptomatology associated with painful disabling medial compartment knee OA. Methods: We prospectively enrolled 80 patients with symptomatic medial compartmental knee OA to treatment with valgus knee brace. All patients were assessed at 6 months. 4 patients lost follow up. The primary outcome measure was pain severity as measured on a visual analog scale. Secondary outcome measures were knee function score using WOMAC and correction of varus alignment on AP whole-leg radiographs taken with the patient in the standing position. Results: There were total 80 patients of which 32(40%) were male while 48(60%) were female. The mean age of the patients was 48±8.93. We observed statistically significant differences in mean outcome assessments (pain severity, walking distance) by using un-loader bracing in the management of medial compartment knee osteoarthritis as (P-value<0.05). Conclusion: Off-loader braces are effective in mediating pain relief in conjunction with knee OA.
Article
Aim: To compare the effect of non operative treatment of medial compartment knee osteoarthritis by offloading knee braces and Lateral wedge insole (shoe modification). Methods: We enrolled 120 consecutive patients with symptomatic medial compartmental knee OA, half of the patients were randomly given Valgus knee brace and half were given lateral wedge insoles. All patients were assessed at 6 months. 6 patients lost follow up. The primary outcome measure was pain severity as measured on a visual analog scale. Secondary outcome measures were knee function score using WOMAC. Results: There were total 120 patients of which 52(43.3%) were male while 68(56.7%) were female. Pain severity and walking distance reduced significantly in both lateral wedge and un-loader bracing groups, while more pronounced reduction of the mean outcome assessments was observed in the un-loader brace group in the management of medial compartment knee osteoarthritis (P-value<0.05). Average resting pain of the knee bracing decreased from 6.14 to 4.2, while mean activity level was increases from 35 to 38 on a visual analog scoring scale Conclusion: Both treatments are effective but three point valgus knee brace support had more significant effect on pain reduction, walking distance and pain killer as compared to lateral wedge insoles.
Article
Objective To evaluate the effects of valgus knee bracing on pain and function, and compliance and complications, in patients with medial knee osteoarthritis (OA).MethodsA meta-analysis of randomized controlled trials that compared changes in patient-reported pain and/or function in patients with medial knee OA was performed. Seven databases were searched from their inception to January 2014. Two reviewers independently determined study eligibility, rated risk of bias, and extracted data. Pooled estimates and 95% confidence intervals (95% CIs) for standardized mean differences (SMDs) for the improvement in pain (and function) were calculated. Event rates (proportions) were calculated for studies that reported complications.ResultsSix studies were included in the meta-analysis. Overall, there was a statistically significant difference favoring the valgus brace group for improvement in pain (SMD 0.33 [95% CI 0.13, 0.52], P = 0.001) and function (SMD 0.22 [95% CI 0.02, 0.41], P = 0.03). When compared to a control group that did not use an orthosis, the effect size was moderate for pain (SMD 0.56 [95% CI 0.03, 1.09], P = 0.04) and function (SMD 0.48 [95% CI 0.02, 0.95], P = 0.04). When compared to a control group that used a control orthosis, only a small, statistically significant effect for pain remained (SMD 0.33 [95% CI 0.08, 0.58], P = 0.01). Instructions for brace use varied considerably and compliance ranged from 45% to 100%. Up to 25% of patients reported minor complications with brace use.Conclusion Meta-analysis of randomized trials suggests valgus bracing for medial knee OA results in small-to-moderate improvements in pain. Effect sizes vary based on study design and warrant future research.
Article
To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis, intended to inform patients, physicians, and allied health care professionals worldwide. Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the osteoarthritis (OA) literature, twenty-nine treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OARSI evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using AMSTAR criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical subphenotypes. Consensus recommendations were produced using the Rand/UCLA Appropriateness method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical subphenotypes and accompanied by 1-10 risk and benefit scores. Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical subphenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral NSAIDs (COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical subphenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation). These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.