Role of orthoses in ligament injuries of the knee]

OBJECTIVE: To review the literature for the benefits of the three different knee braces (prophylactic, rehabilitation, functional) that can be used to treat ligament injuries of the knee. What is their influence on stability? Do they have adverse effects? Is their use justified? METHODS: We searched the Medline and Embase databases with use of the keywords knee, orthoses, brace, proprioception, stability, rehabilitation, physical therapy, and anterior cruciate ligament for reports published between 1980 and 2003 and selected 93 articles, expert reports or literature reviews. RESULTS: Anterior tibial displacement can be controlled with mechanical strains (150 N), which are lower than physiological restraints? (400 N). The control of joint position is improved by increasing proprioception. Soft tissue stiffness influences the control of anterior tibial displacement. The beneficial effects observed are mainly subjective. Our analysis of the literature showed limitations and variations in study methodologies. CONCLUSION: We did not find any justification for use of either prophylactic or rehabilitation braces. Functional braces can improve stability, as reported by the patient, and may be used in some situations.     

Braces and splints for musculoskeletal conditions

Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.     

Bilateral, simultaneous, spontaneous rupture of quadriceps tendons without trauma in an obese patient: a case report

This is a single case report of bilateral, simultaneous, spontaneous rupture of the quadriceps tendon caused by obesity without trauma. The patient was a 52-year-old, 350-pound, morbidly obese man with a sedentary life style whose quadriceps tendons ruptured while he was descending a staircase. He presented with a large deficit superior to the patella and an inability to straighten his knees. After surgery, his knees were immobilized in extension for 6 weeks, followed by gradual weight bearing and gait training with braces. He was weaned off the braces as he increased the range of motion and strength in his knees. The rehabilitation process was protracted, and he returned to full-time work 6 months postinjury. Physiatrists should be familiar with the diagnosis, treatment, and rehabilitation of this rare condition.     

人工全膝关节置换前后的康复治疗

目的：探讨人工全膝关节置换（TKA）术后的康复治疗效果。方法：90例110膝行TKA的患者，在术前后均给予康复指导和训练，并采用美国特种外科医院（HSS）膝关节评分标准进行疗效评定。结果：术后21d独立行走68例（75．6％），扶拐行走22例（24．4％），其中内翻畸形1例（1．1％），无膝过伸；膝关节屈膝90。有75膝（68．2％），100。19膝（17．3％），〉110。12膝（10．9％），510。屈曲畸形4膝（3．6％）；术后疼痛消失86膝（78．2％），明显改善22膝（20％），无改善2膝（8．2％）。临床疗效评定，达优88膝（80％），良15膝（13％），优良率93％。结论：加强患者术前后的康复治疗，有利于减少膝关节疼痛和增加膝关节活动度和肌力。     

Knee Braces - an evaluation of treatment effectiveness after reconstruction of anterior crucial ligament

Background Despite extensive research providing significant progress in rehabilitation treatment of the anterior crucial ligament injuries, the problem concerning the choice of the most advantageous protection after reconstruction operation is still to be solved. Material and method Seventy one patients after reconstruction of anterior crucial ligament of the knee were examined objectively and subjectively to evaluate the effectiveness of three types of Rehabilitation Knee Braces in protecting of knee instability. All patients were examined by using Elgon Electrogoniometr to control dislocation of the knee and by using score test. Results Objective goniometric and subjective score tests gives better stability results of knee braces with strong construction. Conclusions In conclusion I affirmed Knee Braces sufficiently secure the knee against displacement in the joint and effectively protect the anterior crucial ligament against traumatic activity, which justifies their application rehabilitation after surgical reconstruction of anterior crucial ligament.     

The effects of ankle bracing on motion of the knee and the hip joint during trunk rotation tasks

BACKGROUND: The use of prophylactic ankle braces is common during athletic activities since the ankle is one of the most commonly injured joints. Past studies have focused on the effects of ankle braces on ankle movement restriction, preventing injuries, proprioception, balance and athletic performance. However, the influence of ankle restriction on other joints has not been studied. The constraint of ankle movement may lead to an increased loading on the knee joint, which could be a potential risk of knee injuries during athletic activities. The primary goal of the current study was to determine quantitatively the effect of an ankle brace on the knee axial rotation during two different trunk turning tasks. METHODS: Ten healthy subjects performed trunk turning movements while standing on one leg: turning sideways to catch a ball and turning sideways to touch a target with the shoulder. The tasks were performed with and without an ankle brace worn on the supporting leg. The trunk axial rotation in reference to the floor and three dimensional joint angular motions of the ankle, knee and hip were determined. FINDINGS: The use of an ankle brace resulted in reduced trunk axial rotation during the ball catching tasks, and increased knee axial rotation during the target touching tasks. INTERPRETATION: The results of this study showed that the effect of the ankle brace on the knee axial rotation depended on the context of the tasks performed. Under situations that required forceful trunk turning movement while standing on a single leg, the ankle braces may cause an increase in the knee axial rotation indicating higher risk of knee injury.     

Noninflammatory knee joint effusions in spinal cord-injured and other paralyzed patients. Four case studies.

Four patients with knee effusions are described. Three had spinal cord injuries and the fourth had Guillain-Barrè syndrome. Of the spinal cord-injured patients, the effusions were unilateral in one case and bilateral in another. The third patient developed effusions on two separate occasions with bilateral involvement once and unilateral involvement once. The patient with Guillain-Barrè syndrome had bilateral knee joint effusions. All effusions were tapped and revealed type I synovial fluid except for one joint that contained some blood cells. Two of the three spinal cord-injured patients had heterotopic ossification at the knees documented by 99mTe bone scans and two were lying prone for the treatment of decubitus ulcers. Similar knee joint effusions have been described by several authors in the past. The etiology is unknown; however, we offer the hypothesis that paralysis of the muscles adjusting intra-articular knee joint structures may be the cause. It is important for clinicians to recognize that benign knee joint effusions are likely to be encountered in paralyzed patients. They can be evaluated with a simple synovial fluid analysis.     

Agility and perturbation training for a physically active individual with knee osteoarthritis

BACKGROUND AND PURPOSE: People with knee osteoarthritis (OA) sometimes report episodes of knee instability that limit their activities of daily living. The episodes of instability are similar to those reported by people with knee ligament injuries. The authors believe that modifications of interventions that are used to promote knee stability in individuals with knee ligament injuries can be used to enhance knee stability and function in people with knee OA. The purpose of this case report is to describe the development and implementation of an agility and perturbation training program that was used in conjunction with traditional rehabilitation activities for a patient with knee OA. CASE DESCRIPTION: The patient was a 73-year-old woman with a diagnosis of bilateral knee OA. Her chief complaints were knee pain and episodes of partial "giving way" at the knee during walking, stair climbing, and participation in tennis and golf. The patient participated in 12 treatment sessions at a frequency of 2 visits per week. The rehabilitation program consisted of lower-extremity stretching, strengthening and endurance exercises that were supplemented with a variety of walking-based agility training techniques, and perturbation training techniques. OUTCOME: At the completion of rehabilitation, the patient was able to walk on level surfaces and stairs and return to playing golf and tennis without episodes of instability and with reduced pain. DISCUSSION: Supplementing rehabilitation programs for people with knee OA with a modified agility and perturbation training program may assist them in returning to higher levels of physical activity with less pain and instability following rehabilitation. Further research is needed to determine the role of agility and perturbation training in people with knee OA.     

Influence of functional bracing on the kinetics of anterior cruciate ligament-injured knees during level walking

BACKGROUND: Use of functional knee braces has been suggested to provide protection and to improve kinetic performance of the knee in anterior cruciate ligament-injured patients. However, the efficacy of knee bracing in achieving these goals is still controversial. The purpose of this study was to examine the immediate effects of functional bracing on the three-dimensional kinetics of the knee in individuals with anterior cruciate ligament injuries during level walking. METHODS: Fifteen anterior cruciate ligament-deficient and 15 anterior cruciate ligament-reconstructed subjects were each fitted with a DonJoy Goldpoint brace and walked at a self-selected pace, first without and then with the brace. Kinematic and kinetic data were measured and three-dimensional joint moments and angular impulses at the knee were calculated and compared between bracing conditions and between limbs. FINDINGS: Functional knee bracing did not significantly affect the kinetics of the unaffected knees for either group. Bracing significantly increased the peak abductor moments in anterior cruciate ligament-deficient knees and reduced the bilateral kinetic asymmetry in the coronal plane. For the anterior cruciate ligament-reconstructed group, bracing increased peak moments and impulses of the abductors and extensors. It also reduced bilateral kinetic asymmetry in the sagittal and coronal planes. INTERPRETATION: Effects of the knee brace were apparent in the coronal plane for both anterior cruciate ligament-deficient and anterior cruciate ligament-reconstructed patients, and in the sagittal plane for anterior cruciate ligament-reconstructed patients. Functional bracing can be recommended for anterior cruciate ligament-reconstructed patients to assist in achieving better bilateral kinetic symmetry during gait. For anterior cruciate ligament-deficient patients, apart from bracing, additional emphasis on the rehabilitative training for better kinetic knee performance in the sagittal plane is needed.     

手术治疗漂浮膝45例临床分析

目的:探讨不同手术方法治疗漂浮漆的疗效.方法:回顾分析2005年3月~2010年12月收治的45例下肢漂浮漆损伤患者的临床资料.结果:45例经12~56月(平均30个月)随访,疗效评定采用Karlstrm及Olerud标准,骨折愈合率100%,45例膝关节的平均活动度108°,优良率80%.结论:漂浮漆损伤应积极实行手术固定,术后康复治疗也非常重要.     

全膝关节置换术后早期康复配合CPM机锻炼对膝关节功能恢复的影响

目的观察全膝关节置换术（TKA）后早期康复配合持续被动活动（CPM）机锻炼对膝关节功能恢复的疗效。方法23例TKA术后患者（28膝）随机分为治疗组（15膝）和对照组（13膝），治疗组实施早期康复功能锻炼配合CPM机锻炼，对照组仅进行CPM机锻炼。结果术前治疗组膝评分和功能评分与对照组差异无显著性意义（P〉0.05），术后两周评分与对照组差异有非常显著性意义（P〈0.01）。结论TKA术后早期康复功能锻炼配合CPM机锻炼可促进膝关节功能恢复。     

CPM机在全膝人工关节置换术后应用的效果研究

目的 研究连续被动运动（continuous passive motion，CMP）在全膝人工关节置换术后的应用价值。方法将32例行全膝人工关节置换的患者分为研究组和对照组。观察2组患者术后膝关节以不痛为原则最大屈曲角度。结果研究组的膝关节屈曲角度达到最大值时间明显短于对照组。2组相比差异有显著性（P〈0．01）。结论CPM用于全膝人工关节置换术后的康复是值得临床推广的一种持续被动运动方法。     

Efficacy of knee braces and foot orthoses in conservative management of knee osteoarthritis: a systematic review

A systematic analysis was conducted on the effectiveness of knee braces and foot orthoses in conservative management of knee osteoarthritis. The methodologic quality of the randomized clinical trials, controlled clinical trials, and observational studies were systematically reviewed using the Structured Effectiveness Quality Evaluation Scale. Twenty-five studies met the inclusion criteria. The orthoses used in the studies included Generation II osteoarthritis knee brace, valgus knee braces, functional off-loading knee braces, knee sleeves, lateral-wedged insoles with subtalar strapping, medial-wedged insoles, and specialized footwear. Results suggest that knee braces and foot orthoses are effective in decreasing pain, joint stiffness, and drug dosage. They also improve proprioception, balance, Kellgren/Lawrence grading, and physical function scores in subjects with varus and valgus knee osteoarthritis. Knee braces and foot orthoses could be cautiously considered as conservative management for relief of pain and stiffness and improving physical function for persons with knee osteoarthritis. The conclusions of this review are limited by methodologic considerations like poor quality of trials and heterogeneity of interventions.     

Approaching the ruptured anterior cruciate ligament

Anterior cruciate ligament (ACL) disruptions are common injuries that currently hold a fearsome reputation among athletes of all abilities and disciplines. Indeed, if the diagnosis is missed at first presentation, it is difficult to attribute ongoing instability and recurrent injury to an ACL tear. Classically, patients then often improve shortly before repeatedly reinjuring their knee. At some point, the knee may lock, necessitating an arthroscopic meniscectomy. Tragically, this then hastens the progression of joint arthrosis and the decline of the joint function. While the burden of responsibility does not lie solely with the junior doctor or the general practitioner, it is often at the first consultation that the natural history of this devastating injury is decided. The ability to recognise, institute early management and reassure patients with ACL tears about the future is an invaluable asset to the non-specialist junior doctor. Once diagnosed, the responsibility of advising and further counselling of patients with ACL injuries is best left to the orthopaedic knee specialist. Family practitioners and emergency room doctors should not feel pressured to offer advice on specialist areas such as return to sports without reconstruction or indeed the need for reconstruction. Indeed, decisions to return to sports with ACL-deficient knees have all too often led to disastrous reinjury events to the articular cartilage and/or the menisci.     

The effect of orthotic devices on knee adduction moment,pain and function in medial compartment knee osteoarthritis: a literature review

Background Knee braces and foot orthoses are commonly used to improve knee adduction moment, pain and function in subjects with knee osteoarthritis (OA). However, no literature review has been performed to compare the effects of foot orthoses and knee braces in this group of patients. Purpose The aim of this review was to evaluate the effects of foot orthoses and knee braces on knee adduction moment, pain and function in individuals with knee OA. Study design Literature review. Method The search strategy was based on the Population Intervention Comparison Outcome method. A search was performed in PubMed, Science Direct, Google Scholar and ISI web of knowledge databases using the PRISMA method and based on selected keywords. Thirty-one related articles were selected for final evaluation. Results The results of the analysis of these studies demonstrated that orthotic devices reduce knee adduction moment and also improve pain and function in individuals with knee OA. Conclusion Foot orthoses may be more effective in improving pain and function in subjects with knee OA. Both knee braces and foot orthoses reduce the knee adduction moment in knee OA and consequently patients typically do not need to use knee braces for a long period of time. Also, foot orthoses and knee braces may be more effective for medial compartment knee OA patients due to the fact that this treatment helps improve pain and function.

• Implications for Rehabilitation

• Knee braces and foot orthoses are commonly used for improving knee adduction moment, pain and function in subjects with knee osteoarthritis (OA).

• Orthotic devices can reduce knee adduction moment, pain and improve function in knee OA.

• The combined use of a knee braces and foot orthoses can provide more improvement in knee adduction moment, reduced pain and increased function.

     

自我效能理论在老年人工全膝关节置换术后康复训练中的应用

目的探讨自我效能理论在老年人工全膝关节置换术康复训练中应用的临床效果。方法接受人工全膝关节置换术老年患者26例（45膝）,入院后随机分为研究组13例（23膝）和对照组13例（22膝）,两组患者均采用骨科人工全膝关节置换术常规护理,研究组在此基础上运用自我效能理论指导护理实践。治疗前和治疗后1个月、3个月分别对两组采用一般自我效能感量表进行自我效能评价,同时运用HSS膝关节评分标准对两组进行膝关节评分。结果研究组患者术后1个月及3个月自我效能评分及HSS评分与对照组比较差异具有统计学意义（P〈0.05）。结论自我效能理论应用于全膝关节置换术患者的康复训练,能充分调动患者自身潜能,增加自信心,提高训练效果,促进患者膝关节功能早日康复。     

Assessment of functional knee bracing: an in vivo three-dimensional kinematic analysis of the anterior cruciate deficient knee

OBJECTIVE: To describe three-dimensional tibial and femoral movements in vivo and examine the effect of a brace on knee kinematics during moderate to intense activity. DESIGN: Skeletal kinematics of anterior cruciate ligament deficient knees was measured with and without braces during moderate to intense activity. BACKGROUND: Invasive markers implanted into the tibia and femur are the most accurate means to directly measure skeletal motion and may provide a more sensitive measure of the differences between brace conditions. METHODS: Steinmann traction pins were implanted into the femur and tibia of four subjects having a partial or complete anterior cruciate ligament rupture. Non-braced and braced conditions were randomly assigned and subjects jumped for maximal horizontal distance to sufficiently stress the anterior cruciate ligament. RESULTS: Intra-subject peak vertical force and posterior shear force were generally consistent between conditions. Intra-subject kinematics was repeatable but linear displacements between brace conditions were small. Differences in angular and linear skeletal motion were observed across subjects. Bracing the anterior cruciate ligament deficient knee resulted in only minor kinematic changes in tibiofemoral joint motion. CONCLUSION: In this study, no consistent reductions in anterior tibial translations were observed as a function of the knee brace tested. Relevance. Investigations have reported that knee braces fail when high loads are encountered or when load is applied in an unpredictable manner. Questions remain regarding tibiofemoral joint motion, in particular linear displacements. The pin technique is a means for direct skeletal measurement and may provide a more sensitive measure of the differences between brace conditions.     

同时双侧全膝表面置换与单侧全膝关节置换围手术期康复的比较

背景:目前对于双膝严重骨性关节炎行两组同时双侧全膝表面置换的围手术期康复的相关研究尚不多见。目的:比较双膝骨性关节炎两组同时双侧全膝表面置换术与单侧全膝关节置换围手术期康复训练的效果。方法:两组医生对59例(118膝)患者双膝骨性关节炎同台同时全膝表面置换,与同期80例单膝骨性关节炎行单侧全膝关节置换患者(对照组)进行疗效比较。两组患者置换前均进行康复教育及预备康复,置换后康复方法标准一致。结果与结论:同时双侧全膝表面置换组置换前通过压腿平均减小屈曲畸形角度11.2°(5°～22°)。置换后3～6周,股四头肌、腘绳肌肌力5级,较置换前平均增加0.8级;平均ROM≥95°(110±15)°;无痛行走500m以上;独自无痛上下10级楼梯,无肿胀;出院时HSS评分较置换前增加。置换后3个月没有发现松动表现及不良反应,其康复疗效与对照组对比差异无显著性意义。表明,在围手术期对双膝骨性关节炎两组医生行同时双侧全膝表面置换,通过系统而量化的康复,有利于减少置换中截骨量和置换后并发症,促进患者膝关节功能恢复,与单侧全膝关节置换相比康复结果无明显差异。     

Acute knee injuries: use of decision rules for selective radiograph ordering

Family physicians often encounter patients with acute knee trauma. Radiographs of injured knees are commonly ordered, even though fractures are found in only 6 percent of such patients and emergency department physicians can usually discriminate clinically between fracture and nonfracture. Decision rules have been developed to reduce the unnecessary use of radiologic studies in patients with acute knee injury. The Ottawa knee rules and the Pittsburgh decision rules are the latest guidelines for the selective use of radiographs in knee trauma. Application of these rules may lead to a more efficient evaluation of knee injuries and a reduction in health costs without an increase in adverse outcomes.