Functional Knee brace

1. Osteoarthritis:
Knee osteoarthritis is a common type of arthritis, especially among the elders.
Post-traumatic knee osteoarthritis is common after the ACL injury (data and data).
The commonness of this disease is expected to increase as the population ages.
Osteoarthritis is one of the most frequent causes of disability among elders.
Symptomatic knee osteoarthritis affects about 12.5% of elders( > 60 years) in both
UK and US.

Patients with OA will ultimately require total knee replacement which is in high cost
and limited mobility.

Symptoms of OA occurs with activity and external adduction moment and

malalignment of the knee are risk factors.

In many cases, the disease affects only one condyle of the knee, usually the medial
condyle, as most of the joint load during the stance phase of the gait is transmitted
through the medial condyle of the knee. Such pattern of arthritis is termed as
unicompartmental osteoarthritis.

During the stance phase of gait, humans are submitted to an external knee adduction
moment and lead to an increased load in the medial knee compartment.

The knee brace is regarded as one effective non-surgical intervention to reduce the
plainness for the elders without non-traumatic OA. (The unloader knee brace is
recently treated as the most promising way as nonpharmacological approaches.)

In cases of medial compartment osteoarthritis, the unloader brace applies an external

valgus moment to the knee, unloading the medial compartment and thereby reducing
the contact pressure.

[Aim] The knee brace is needed to provide opposite external abduction and valgus
moment to the knee in order to redistribute load from the medial to the lateral
compartment. (E. Cusin, 2018)

reduces the knee joint

maximum flexion
abduction angles
adduction moment.

Currently: knee brace should provide a changeably valgus moment in order to obtain
a mechanical effect (three-point pressure) solely during knee extension and ti be
inactive during knee flexion (swing phase).
2. The development of knee brace history:
There is a big controversy for the function of knee brace because many clinicians
support the use of a brace while others think it has little effect.
There is little understanding of the knee brace used in the muscular flexion and
extension from patients.
OA trials targeting structure modification are challenging.

3. Knee brace- unloader:

Three-point leverage systems have been applied in the knee bracing device to
unload the medial and lateral tibiofemoral compartment during weight-bearing.

Most OA braces consist f a rigid design that increases the brace’s bulk and
potentially reduce comfort over more pliable materials.

Valgus unloader braces, corrects varus alignment by applying an opposite external

valgus moment.

Current brace designs consist of rigid upper and lower thermoplastic cuffs, hinged at
the knee and fastened to the leg by straps. Medial unloading is provided by three-
point leverage. The upper and lower supports combined with the hinge account for
two points of the leverage and an opposing force from a diagonal strap that crosses
over the knee, which creates an abduction moment that “pushes” the knee into
valgus.

Most existing unloader brace designs apply valgus moment using a three-point
bending mechanism accomplished through two distinctive designs.
1) The first design uses a force strap that wraps around the posterior aspect of
the joint. However, when tightened, this strap can cause discomfort to the
patient as it interferes with the blood circulation in the popliteal artery and
applies pressure on the peroneal nerve in the posterior aspect of the knee [7–
9]. Since tightening of this strap is essential for unloading, the patient may
experience discomfort wearing the brace for acute and prolonged lengths of
time. Squyer et al. reported that about 60% of the patients discontinue the
use of unloader braces due to this discomfort [10].
2) uses a condylar pad to apply force against the lateral condyle resulting in
condylar pain and discomfort during prolonged use [11].

4. Pros and cons:

Pros:
No side effect
 Allows pain-free rehabilitation and muscle strengthening just by simply walking in the
device for up to 3 hours per day might be quite beneficial for patients.

Cons:

High Clinical Cost + Material Cost

1. Details about the size and function of your knee

2. The doctor or physical therapist will provide you with instructions regarding how
often you should wear your brace, situations when you must wear it, and
situations when you shouldn't.

Uncomfortable for the leg muscles.

When the brace extends back, the cloth surrounding the patella shrinks together.

5. Strength Test
Tests were performed by using a computerized isokinetic dynamometer and
consisted of 6 consecutive alternating knee tension and extension.
Lower knee flexion peak torque with brace use in patients. The knee brace did not
affect knee extension strength.

Validate an experimental method for assessing the in situ behaviour of the knee
brace. [valgus and abduction moment]

Pollo et al. report a 5.9 Nm to 11 Nm range for the orthosis moment from 0.03 to
0.102 Nm/kg

Since the knee OA brace must be tightened (strap tension), compression of the
device between the leg and the orthosis is present and likely alters the recorded
forces (offset). Moreover, this offset determination also removes the compression of
the device between the leg and the orthosis due to its thickness.

https://springloadedtechnology.com/2019/04/top-five-unloader-knee-braces/
Test 1: Brian 2000 [Donjoy ]
Measure the force applied to the lateral side of the knee by unloader
Compare the Varus moment at the knee during level gait with and without knee
brace.

A 3-dimensional video-based motion analysis system and force plate information

were used to calculate forces and moments at the knee.

Results of biomechanical analyses on healthy subjects shows that loading in the

knee is 62% on the medial side and 38% on the lateral side during the stance phase
of gait (1–3).

Higher incidence of medial OA

In patients with a Varus deformity, the load in the medial compartment can approach
100% of the total compressive load on the knee joint during gait, which can
accelerate the degenerative process of OA (2).

Each treatment option is designed to reduce the load on the medial side of the joint

Knee brace is designed to apply a valgus force at the lateral joint line in order to
decrease the Varus knee moment or medial joint loading.

[Unloader Varus moment data]Pollo FE, Otis JC, Wickiewicz TL, Warren RF.
Biomechanical analysis of valgus bracing for the osteoarthritic knee. Clinical Gait
Laboratory Conference; 1994 April 7–9; Portland, Oregon.

Varus moment = adduction moment => bow-egged position => greater loading at
medial compartment =.> OA

Unloader = Valgus loading knee brace

This decrease was greatest in the initial stance phase of the gait cycle, but did not
occur where the greatest Varus moment occurs during normal gait.

The Monarch knee brace is designed as an upright unilateral structure with a lateral
double axis hinge. A lateral condylar pad with a variable pressure air bladder, along
with the straps attached to the uprights, is used to apply a valgus force to the knee.

[Systematic Review]

Knee joints with varus malaligement, the ground reaction force vector runs medially
and from the middle of the knee baseline
A large adduction moment shifts the weight bearing line medially within the knee and
leads to increased medial compartment loading

Knee alignment plays an important role for disease progression and functional
decline

non-surgical interventions for unicompatimental OA are knee braces which may alter
the alignment of the lower extremity

These so-called unloader braces apply an external Varus or valgus force to the knee
to shift loads towards the nonaffected compartment
(Controversies) For example, Horlickand Loomer [17] found no significant influence
of an unloader brace on the femoral-tibial angle or joint space. In contrast, Komistek
et al. [21] demonstrated significant condylar separation of the medial compartment
with the use of valgus bracing. These conflicting results may result from differences
in study or brace design

[clinical effect of an unloader brace on patients with osteoarthritis of the knee] (Ossur
UNLOADER 1)

[Does an Unloader Brace Reduce Knee Loading in Normally Aligned Knees?]

(No difference… Problems)

[The effect of unloader knee braces on medial meniscal strain]

Papers Number Proportion (%)
Significant effect 4 15.4
Slight effect 18 69.2
No effect 3 11.5
Gait analysis 19 73.1
Surveys 6 23.1
Other 1 3.8
Large sample (>50) 3 11.5
Medium sample (10>50) 20 76.9
Small sample (<=10) 3 11.5