Knee osteoarthritis (OA) is a progressive and debilitating condition that is estimated to account for over 80% of the osteoarthritis burden. In cases of end-stage osteoarthritis, surgical intervention is the desired option, however, less severe cases may warrant the use of nonoperative modalities. Knee braces are becoming increasingly popular as an adjunct to the standard treatment and have shown promising results in reducing pain, improving function, and mitigating disease progression. Moreover, bracing has the added benefit of being able to include other noninvasive modalities as a means to augment recovery and delay the need for surgery. Prior studies have demonstrated that the medial compartment of the knee joint sustains 62% of loading forces during the stance phase of regular gait, whereas the lateral compartment receives the remaining 38%. It is hypothesised that this distribution of loading forces is why the medial joint compartment is more frequently damaged relative to the lateral compartment. Reduction of these stresses can be accomplished by the use of medial compartment unloader braces, which incorporate distraction forces and rotation with the purpose of increasing the medial joint space and providing pain relief. These devices have the potential to correct the characteristic gait changes associated with knee OA and enhance patients' functional status. Therefore, our main purpose is to assess the efficacy of the various types of knee braces used for the treatment of osteoarthritic knee pain as well as offer perspective regarding the use of knee braces at our institution

Knee osteoarthritis (OA) is a debilitating and progressive condition that accounts for over 80% of the total osteoarthritis burden. Surgical intervention is the suitable option in end-stage osteoarthritis, however, in cases of less severe disease, it may be warranted to use non-operative methods. Knee braces have recently become a popular option as an addition to conventional treatment, and have displayed good results in improving function, reducing pain, and attenuating disease progression. Furthermore, other non-invasive modalities can be supplemented to bracing as a means to improve recovery and delay the need for surgery. Studies have indicated that the medial compartment of the knee sustains 62% of loading forces during the stance phase of regular gait, meanwhile the lateral compartment receives the remaining 38%. It is postulated that this distribution of knee loading forces is the reason why the medial compartment is more frequently deteriorated as compared to the lateral joint compartment. The use of medial compartment unloader braces can reduce these stresses by the means of distraction and rotation of the knee joint with the goal of increasing the medial joint space and producing pain relief. Knee bracing has the capability to enhance patients’ functional status, and even correct the gait changes associated with knee OA. Therefore, our goal is to assess: 1) the use of knee braces at our institution, and 2) the effectiveness of the various types of knee braces in treating OA associated knee pain

The prevalence of knee osteoarthritis (OA) in The United States is approximately 40 million cases, and this number is expected to rise to 60 million by the year 2020. Multiple non-operative treatment options are available for patients, including bracing. Braces can also be used for “pre-habitation” prior to total knee arthroplasty (TKA), after TKA, after traumatic sports injuries, and in neurologic patients. Although, the AAOS recommendations for brace use for treatment of knee osteoarthritis (OA) are “inconclusive”, recent studies have shown improved functional outcomes with the use of off-loader braces for the treatment of uni-compartmental knee OA. In addition, supplemental modalities such as transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) have demonstrated improved subjective and functional outcomes. These off-loader braces and supplemental modalities are easy to use, may decrease pain, delay TKA, and improve clinical outcomes following surgery. In addition, they may decrease the use of other costly knee OA treatment options such as pain medications and intra-articular injections

There are a number of different non-operative management options for patients with a painful knee secondary to osteoarthritis (OA). In 2013 the American Academy of Orthopaedic Surgeons developed an evidence-based clinical practice guideline addressing treatment of osteoarthritis of the knee. Strength of recommendations were designated as strong, moderate and inconclusive. Strong recommendations included: self-management program, NSAIDs or tramadol and no acupuncture, no glucosamine and chondroitin sulfate and no hyaluronic acid. The “No” recommendations for hyaluronic acid and glucosamine and chondroitin sulfate were quite controversial because orthopaedic surgeons argued that some of their patients benefited from these treatments. Moderate strength recommendations included weight loss, lateral wedge insoles and needle lavage. The evidence-based data was inconclusive with respect to valgus force unloading brace, manual physical therapy, acetaminophen, opioids and pain patches. The effectiveness of corticosteroid and platelet rich plasma (PRP) injections were also inconclusive. Unloader braces are available to decrease pressure on the involved compartment. There is data showing that these braces can be effective for some patients. However, there are concerns with patient compliance because of poor fit and discomfort. These braces seemed to be tolerated best when used for sports activities in patients with medial compartment arthritis. Oral anti-inflammatory agents are effective in relieving pain and are a good first line agent for patients with OA. There is significant interest in the use of PRP injections for management of patients with knee OA particularly when patients have already received a steroid and/or a hyaluronic acid injection. To date there are no appropriately powered multi-centered randomised trials demonstrating that PRP is effective in decreasing pain and function in knee OA. However, there are some studies that suggest PRP can be helpful for patients with OA. Further studies to determine the indications for PRP injections are necessary. PRP injections are not covered by insurance in the United States. In summary, the management of patients with painful OA of the knee needs to be individualised based on patient symptoms and expectations. Non-operative management can be effective in limiting pain and enhancing function

Department of Epidemiology, ASL RM/E, Rome, Italy. School of Health and Social Care, University of Teesside, Middlesbrough, UK. Faculty of Health, Staffordshire University, Stoke on Trent, UK. Orthopaedic and Trauma Department, “Tzanio” General Hospital of Piraeus, Greece. University of Medical Sciences, Poznan, Poland. Department of Orthopaedic Surgery, Saitama Medical University, Kawagoe, Japan. Thriasio General Hospital, Athens, Greece. To evaluate the efficacy of bracing in adolescent patients with AIS. Cochrane systematic review. The following databases were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINHAL and reference lists of articles. Extensive hand searching of grey literature was also conducted. RCT's and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces were included. Two review authors independently assessed trial quality and extracted data. Two studies were included. There was very low quality evidence from one prospective cohort study including 286 girls. 1. indicating that braces curbed curve progression, at the end of growth, (success rate 74%), better than observation, (34%) and electrical stimulation (33%). Another low quality evidence from one RCT with 43 girls indicated that a rigid brace is more successful than an elastic one (SpineCor) at limiting curve progression when measured in Cobb degrees. 2. No significant differences between the two groups in the subjective perception of daily difficulties associated with brace wearing were found. There is very low quality evidence in favour of using braces, making generalization very difficult. The results from future studies may differ from these results. In the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes as well as measures such as Cobb angles. RCTs and prospective cohort studies should follow both the SRS and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies

The rehabilitative phase of ankle injury management often involves the use of an ankle brace. The aim of this study was to ascertain the effects of such braces on the forces through the foot and the timing of peak loads in the gait cycle, in the recovering ankle and the uninjured ankle, in order to understand better the mechanism by which such braces enhance ankle stability. Twenty four adults with recurrent ankle injuries and an aspiration to return to sporting activity were studied. Each was in the rehabilitation phase of recovery from ankle injury. Controls were 17 adults who regularly took part in sporting activity, without ankle injury. Assessment of peak force in three orthogonal axes (% body weight) during walking was carried out using the Kistler foot plate; the times taken to reach the maxima were recorded. Subjects were assessed in bare feet, training shoes and wearing one of two types of commonly available stirrup-type ankle braces. Results showed that the ankle braces did not alter peak loads compared to training shoes alone (one-way analysis of variance, p< 0.05) and were consistent in both the injured and un-injured subjects. There were no significant differences between the two braces tested (p< 0.05). The time to reach peak load was not significantly different between the braced or non-braced ankles in either the injured or control groups. Conclusions are that stirrup type ankle braces do not alter the peak forces through the foot during walking. The effectiveness of stirrup-type ankle braces appears not to depend on their modification of medial forces during gait

The rehabilitative phase of ankle injury management often involves braces. Our aim was to ascertain the effect of both a brace on both ankle range of movement and the timing of peak loads in the gait cycle, to understand better the mechanisms by which such braces enhance ankle stability. We recruited 24 adults who were in the rehabilitation stage following ankle injuries, and in whom there was an aspiration to return to sport. Controls were 17 adults who regularly played sport, but had no recent history of injury. Assessment of range of movement was carried out using the Biodex isokinetic dynamometer to measure inversion, eversion, flexion and extension of the foot, with the subject in training shoes, and wearing one of two common stirrup-type ankle braces. Assessment of peak force in three orthogonal axes (% body weight) was performed using the Kistler footplate. The subjects were observed in bare feet, trainers and stirrup braces. Results showed that the ankle braces restricted inversion (mean reduction 9 degrees, SD 8 degrees) compared to training shoes alone in both the injured and non-injured sunjects, but the restriction in range of movement in inversion /eversion was not significantly different between the braced injured and un-injured ankles (t test p< 0.05).The ankle braces did not alter peak loads compared to training shoes alone (one way analysis of variance, p< 0.05);these findings were consistent in both groups. The time to reach peak load was not significantly different between the braced or un-braced ankles in either the injured or control groups. We conclude that stirrup type braces reduce the range of inversion/eversion in the normal and injured ankle, reducing the movement by a similar amount in both of these groups, but they do not alter peak forces through the foot during walking

Valgus knee unloader braces are often prescribed as treatment for knee osteoarthritis (OA). These braces are designed to redistribute the loading in the knee, thereby reducing medial contact forces. Patient response to bracing is variable; some patients experience improvements in joint loading, pain, and function, others see little to no effect. We hypothesised that patients who experienced beneficial response to the brace, measured by reductions in medial contact force, could be predicted based on static and dynamic measures. Participants completed a WOMAC questionnaire and walked overground with and without an OA Assist knee brace in a motion capture lab. Eighteen patients with medial compartment OA (8 female, 53.8±7.0 years, BMI 30.3±4.1, median Kellgren-Lawrence grade 4 (range 1–4)) were evaluated. The abduction moment applied by the brace was estimated by multiplying brace deflection by the pre-determined brace stiffness. A generic musculoskeletal model was scaled for each participant based on standing full length radiographs and anatomical markers. Inverse kinematics, inverse dynamics, residual reduction, and muscle analysis were completed in OpenSim 3.2. A static optimisation was then performed to estimate muscle forces and then tibiofemoral contact forces were calculated. Brace effectiveness was defined by the difference in the first peak of the medial contact force between braced and unbraced conditions. Principal component analysis was performed on the hip, knee, and ankle angles and moments from the unbraced walking condition to extract the principal component (PC) scores for these variables. A linear regression procedure was used to determine which variables related to brace effectiveness. Potential regressors included: hip-knee-ankle angle and medial joint space measured radiographically; KL grade; mass; WOMAC scores; unbraced walking speed; and the first two principal component scores for each of the unbraced hip, knee, and ankle joint angles and moments. KL grade, walking speed, and hip adduction moment PC1, which represented the magnitude of the first peak were all found to be correlated with change in medial contact force. The brace was more successful in reducing medial contact force in subjects with higher KL grades, faster self-selected walking speeds, and larger peak external hip adduction moments. The R2 value for the overall regression model was 0.78. The best predictor of brace effectiveness was the hip adduction moment, indicating the need to consider dynamic measures. Participants who had hip adduction moments and walking speeds similar to those of their healthy counterparts saw a greater reduction in medial contact force. Thus, those who responded to bracing had more severe OA as measured by the KL grade but had not experienced changes in their hip adduction moment due to OA. The results of this study suggest that there is potential for an objective criterion for valgus knee brace use to be established

Introduction: There has been an increasing use of orthotic knee braces in the management of knee injuries. To ensure the biomechanics of the knee are not adversely affected, it is important that orthotic knee braces accurately provide the desired angle of immobilisation. The objective of our study was to measure the actual knee flexion angles for a lockable orthotic knee brace, and measure the resulting knee flexion moment. Materials and methods: Eight healthy male volunteers participated in the study looking at six different types of knee immobilisation: locked in 0, 10, 20, 30 degrees of knee flexion, with the brace unlocked, and without a brace. Force and 3-dimensional motion data were collected using a single Kistler force plate and an eight-camera Qualisys ProReflex motion analysis system. Results: The kinematic knee flexion angles were significantly different when compared with the angles set at the orthotic knee brace for 0 degrees (p=0.001) and 10 degrees (p=0.011). The kinematic knee flexion angle when no brace was used was significantly different from the angle for the unlocked orthotic knee brace (p= 0.003). The knee flexion moment was directly proportional to the knee flexion angle. There was a statistically significant difference between the knee flexion moment for the six types of immobilisation (p< 0.001). Discussion: The knee flexion angles measured using the kinematic data did not always correspond with the angle set at the orthotic knee brace. These findings highlight inadequacies in the design of lockable orthotic knee braces, especially at low flexion angles of 0 and 10 degrees. The resulting higher actual knee flexion angles were associated with greater knee flexion moments and joint reaction forces at the tibiofemoral and patellofemoral joints. This can, at best result in increased energy expenditure and decreased agility, and at worse potentially augment injuries to the knee

Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64).

Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2).

There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”.

Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5).

We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night.

Osteoarthritis (OA) is a highly prevalent disease that has a debilitating role in every day function and activity. In 2002, the indirect cost of OA was 5 billion dollars, secondary to absenteeism and loss of productivity. There are multiple management options available for OA, with surgery usually being a last resort. Total knee arthroplasty (TKA) provides a long-lasting treatment option with excellent results. However, a high proportion of patients still express dissatisfaction following surgery, possibly due to a combination of pain, continued limitation of function, and high expectations. The use of bracing provides a non-operative treatment option as well as a useful therapy adjunct in patients who undergo TKA. Bracing may aid in rehabilitation prior to TKA as well as postoperatively, and it also plays a beneficial role in problematic situations, such as patients who have undergone revision surgery or who have extensor mechanism problems. They are thought to aid in gait ‘retraining’, quadriceps muscle strengthening, improving joint alignment, and increasing stability of the joint. Although the American Academy of Orthopedic Surgeons remains inconclusive on the role of bracing, multiple studies have highlighted that they may be of benefit. The use of valgus bracing has been shown to provide short-term treatment for activity, bracing for uni-compartmental OA has shown an improvement in outcome measures, and the use of an unloader brace has led to improved general physical health and function outcomes, as measured by the SF-12 and WOMAC, respectively.

Purpose: Does the postoperative abduction brace facilitate healing after rotator cuff repair? We have answered this question empirically using, since 1995, a premodelled abduction brace for four weeks for all patients, together with early passive rehabilitation. The purpose of this work was to assess the efficacy of this brace and compare outcome with that in patients treated in 1994–1995 with and without the brace.

Material and methods: This retrospective analysis was conducted in 72 patients, mean age 58 years. Contant functional score and imaging of the tendon healing (arthroscan 56%, MRI 44%) were used as assessment criteria. Four homogeneous groups were identified: Group 1 (40 patients, mean age 55 years) was composed of patients with a distal tear of the supraspinatus; twenty patients in this group were treated with a “elbow-to-body” sling (group 1a) and twenty others with the abduction brace (group 1b); Group 2 (32 patients, mean age 60 years) was composed of patients with an intermediary tear of the supraspinatus, partially extending anteriorly or posteriorly, fifteen patients in this group were treated with a “elbow-to-body” sling (group 2a) and seventeen others with the abduction brace (group 2b).

Results: Mean follow-up was 49 months. The weighted Constant score improved from 57.3% to 89.1%. Imaging demonstrated recurrent tears in 25 patients (35%). In group 1 (distal tear of the supraspinatus), the weighted Constant score at last follow-up was 89% (93% in group 1a and 86% in group 1b). There were eight recurrent tears (20%), (25% in group 1a and 15% in group 1b). Use of the abduction brace (group 1a) had no effect. In group 2 (intermediat tear of the supraspinatus), weighted Constant score was 88% (82% in group 2a and 94% in group 2b). There were seventeen recurrent tears (53%) (71% in group 2a and 41% in group 2b). At last follow-up, there was no significant difference for functional score or tear recurrence.

Discussion and conclusion: These findings suggest the postoperative abduction brace is not beneficial after repair of non-retracted distal cuff tears. On the contrary, for intermediate tears, it allows a clear improvement in the final Constant score and a lower rate of recurrent tears. This study provides information useful for choosing the postoperative management of patients undergoing repair of rotator cuff tears.

Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

Abstract. Introduction. Knee braces are limited to providing passive support. There is currently no brace available providing both continuous monitoring and active robot-assisted movements of the knee joint. This project aimed to develop a wearable intelligent motorised robotic knee brace to support and monitor rehabilitation for a range of knee conditions including post-surgical rehabilitation. This brace can be used at home providing ambulatory continuous passive movement obviating the need for hospital admissions. Methodology. A wearable sensing system monitoring knee range of motion was developed to provide remote feedback to clinicians and real-time guidance for patients. A prototype of an exoskeleton providing dynamic motion assistance was developed to help patients complete their exercise goals and strengthen their muscles. The accuracy and reliability of those functions were validated in human participants during exercises including knee flexion/extension (FE) in bed and in chair, sit-to-stand and stand-to-sit. Results. The knee FE measurement from the sensing system showed high accuracy (correlation coefficient of 0.99°) in human participants. The real-time FE data during exercises showed that the desired exoskeleton rotation fitted well with the participant's knee rotation. This indicated the exoskeleton could coordinate with the participant's knee motion by providing consistent motion assistance. The development of user interfaces to provide feedback is currently underway. Conclusion. A wearable robotic knee brace to monitor and support knee rehabilitation exercises was successfully developed. Further development of this device with the use of artificial intelligence has the potential to aid patient rehabilitation in a variety of knee conditions

Purpose: Rigid full-time braces are the most common non-surgical treatment for adolescents with moderate severity of scoliosis and demonstrated growth remaining. The Scoliosis Research Society (SRS) has established guidelines on which patients with adolescent idiopathic scoliosis (AIS) should be offered brace treatment. This study surveyed Canadian surgeons on the demographics of patients with scoliosis attending specialty clinics and for their protocols for prescribing braces. Method: An on-line survey of 41 questions was developed to document patient profiles and surgeon protocols for prescribing braces. Surgeons also selected whether they would recommend a brace in females with AIS based on a combination of three levels of maturity, with six levels of curve severity, and whether or not the curve was progressive. The survey was administered between July and November 2008 to the 30 paediatric spine surgeon members of the Canadian Paediatric Spinal Deformities Study Group. After one reminder, the response rate was 70% (21/30), representing 12 Canadian spine centres. Results: The average age of referral to the scoliosis clinic was 11–12 years (10 of 20 respondents) and 13–14 years (nine of 20 respondents). Most (81%) of the centers required radiographs prior to the first clinic visit. All surgeons recommended bracing, but there was broad variation on who they considered should be braced, with three to twenty six of the 36 potential scenarios defined by maturity, progression, and curve severity variables selected. This high variability was also observed among surgeons in the same spine centre. All considered parental or family issues and patient acceptance when recommending a brace. Age and curve severity were criteria for bracing; skeletal maturity was the primary criteria for discontinuing bracing. The majority (81%) of braces prescribed were rigid full-time braces followed by rigid night-time braces (14%). Weaning was common (76%), but protocols varied. Detection of curve progression increased the likelihood of bracing for curves 80% agreement on bracing. Braces were not recommended by > 50% of respondents for females with less than 1 year growth remaining regardless of progression or curve size. Conclusion: In spite of SRS guidelines and general agreement that braces are effective, there is little agreement among surgeons on which females with AIS should receive brace treatment. The likelihood that a female with AIS will be prescribed brace treatment primarily depends on surgeon brace prescription patterns, rather than actual curvature of the spine

Introduction: Braces are the most generally accepted form of non surgical treatment for adolescent idiopathic scoliosis (AIS). Despite decades of usage controversy still exists regarding the efficacy of this treatment. We believe this controversy continues in part because there are few studies describing the mechanical effect of bracing and linking mechanically effective bracing to changes in the natural history of AIS. If braces are effective, is it because they apply significant mechanical support to a collapsing spine or are they effective for other reasons? A first step towards answering this question is to document the mechanical action of braces during activities of daily living. This would enable researchers to examine the effect of mechanical support on progression of the scoliosis. The objective of this study was to determine the temporal pattern of forces exerted by the pressure pad in Boston braces prescribed for the treatment of AIS. Methods and results: A force transducer and a programmable data logger were designed to measure loads exerted by the pressure pad over extended periods of time. The loads were recorded at one minute intervals. Braces were adjusted to a prescribed load level and the patients were asked to set the brace tightness to match this target any time the brace was donned. Brace wear data were stratified into: not worn, worn at less than 80% of target, 80–120% of target and greater than 120% of target. Bracing was considered mechanically effective if the load was at least 80% of the prescribed level. Patients were aware of the study and consented to participate. Thirteen patients were followed from 1 to 16 days, average was 9±5 days. Nine patients were asked to wear their braces 23 hours per day, two for 20 and two for 16 hours per day. Braces were not worn 34±27% of the time logged. When they were worn, patients adjusted the tightness of the brace such that it was < 80% of the target 29±20% of the time, within 20% of target 19±19% and over 120% of target 18±13% of the time. Patients wore their braces at or above the target levels 33% of the time logged or 8 hours in a typical day. Subjects had no difficulties using the data logger and none complained that it interfered with brace wear. Reviewing individual histories suggested that subjects did not alter their brace wear pattern because of the data logger. Conclusion: The mechanical effectiveness of the brace varies considerably over the normal course of wear but seldom does it provide the support intended. While patients wear their braces for about 16 hours per day, it is mechanically effective for 8 hours only

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Joint load correlates with knee OA incidence, symptoms, radiographic, morphologic and biological changes. Available load modifying therapies are clinically effective but have drawbacks. The KineSpringTM (Moximed Inc), an investigational device, is designed to reduce compartment loads while avoiding the limitations of current treatments. We compare load reductions of braces, HTO and KineSpringTM. Literature review and experimental data provide compartment load changes for clinically effective knee braces and HTO. Simulated gait testing was completed on four cadaver knees with early-stage OA. Gait was simulated using a cadaver-based kinematic test system that applies motion and loading patterns dynamically to cadaver specimens. Medial and lateral compartment femoro-tibial pressures were measured throughout testing using thin film dynamic pressure sensors (Tekscan, Inc.) placed inframeniscally. Three conditions were tested: no treatment, applied valgus moments to simulate a valgus moment brace, and implanted KineSpring. Sufficient clinical data exists to support the development of new and novel load modifying therapies for knee OA. Joint load reductions provided by HTO and valgus moment braces provide insight into clinically effective load reduction ranges. Opening wedge HTOs of 5° and 10° are reported to reduce average medial compartment load by 55 N (12 lbs) and 286 N (64 lbs), respectively1. Valgus braces were reported to reduce medial compartment loads an average of 97-280 N (22-63 lbs). From this data we propose a clinically effective load reduction range of 55 to 286N is a valid indicator of the likely clinical success for medial knee load reduction treatments. Gait simulation was successfully completed in all specimens in all test configurations. The valgus moment brace reduced medial compartment load by 58 ±20 N but did not reach statistical significance. The Kinespring reduced medial compartment load by 129±64 N in comparison to the untreated case, a statistically significant reduction. Neither the KineSpring nor the valgus moment brace caused significant changes in the lateral compartment during stance. All treatments reduced medial compartment loads. KineSpringTM reduces loads in what we determined to be the clinically effective range. Additional studies and clinical investigations are warranted to determine the ultimate effectiveness of this implant system

Many nonoperative techniques exist to alleviate pain in unicompartmental osteoarthritic knees including physical therapy, heel wedges and off-loading knee braces [. 1. ]. Arthritic knee braces are particularly effective since they can be used on a regular basis at home, work, etc. Previous knee brace studies focused on their ability to stabilize anterior cruciate ligament (ACL) deficient knees. A standard technique for analyzing brace effectiveness is the use of an athrometer to look at the range-of-motion. Although this is helpful, it is more useful to use X-ray or fluoroscopy techniques to analyze the in vivo 3-D conditions of the femur and tibia. One method for doing this is Roentgen Steroephotogrammetric Analysis, which uses a calibration object and two static X-rays to perform 3-D registration of the femur and tibia. This technique is limited to static and typically non-weight bearing analysis. We have analyzed five patients with moderate to severe osteoarthritis in both step up and step down activities with two different knee braces and also without a knee brace. Fluoroscopy of the five patients performing these activities was obtained as well as a CT scan of the knee joint for each patient. 3-D models of the femur and tibia were obtained from manual segmentation and overlaid to the fluoroscopy images using a novel 3-D to 2-D registration method [. 2. ]. This allowed analysis of 3-D in vivo weight bearing conditions. This work builds off of an analysis where 15 patients were analyzed in vivo during gait with and without knee braces [. 3. ]. All five patients experienced substantially less pain when performing the step up and step down activities with a knee brace versus without a knee brace. It should be noted that none of the five patients were obese, which can limit brace effectiveness. Preliminary results show that medial condyle separation was increased by 1.4–1.6 mm when using a knee brace versus not using a knee brace during the heel-strike and 33% phases of step up and step down activities. Also, the condylar separation angle was reduced by an average of 1.5–2.5°. Finally, consistently less condylar separation was seen during step down versus step up activities (0.5–1 mm), which can be attributed to a greater initial impact force on the knee joint during step down versus step up activities