Helwan universityfaculity of engenerringBiomedical department

Name Shaimaa adel sayed

Supervisor

Ahmed Agamya/DR

Safaa/Eng

Rehabilitation results following anterior cruciate ligament

reconstruction using ahard brace compared to a fluid-

filled soft brace

The aim of paper

The purpose of this study was to compare the clinical outcomes of rehabilitation after ACL reconstructionusing a water-filled soft brace to those using a hard brace.

Introduction

With a prevalence of 1/3000 in the USA [1], or about 200,000 new injuries every year [2], rupture of the anterior cruciate ligament (ACL) is a common injury in recreational and competitive sports, as well as other activities.

The method used in this study was a prospective randomised clinical trial including 36 patients wearing ahard brace and 37 patients wearing a water-filled soft brace for 6 weeks after surgery.

postoperative (seven examinations) clinical evaluation within a follow-up period of 1 year

Surgical procedure

The ACL reconstruction has increased in popularity following improvements in surgical and rehabilitative procedures. Many surgeons now use hamstring technique (double or quadruple loop semitendinosus/gracilis autograft) instead of bone–patellar tendon–bone (BPTB) reconstruction of the ACL. The hamstring autograft offers several advantages. The most crucial one, as suggested by a variety of studies, is decreased donor site morbidity compared to the patella tendon autograft

Surgery on all patients was performed by two equally experience surgeons (more than 3000 ACL reconstructions each), using authors copically assisted quadrupled hamstring technique. The semitendinosus and gracilis tendon autograft was harvested from the ipsilateral knee through a 3–4 cm incision with a tendon stripper. Bioresorbable pins were used for proximal, bioresorbable interference screws for distal graft fixation

It is now widely accepted that, given proper graft placement and fixation, the hamstring technique offers stability of the knee joint comparable to that achieved with the bone–patellar tendon–bone technique and some studies suggest it may even cause fewer complications [6,9,13,25–28]. This is why we chose to use hamstringACL reconstruction for the study.

Braces

Hard braceThis commonly applied standard brace has a basic aluminium frame. Collateral stabilisers are connected by an arch from the ventral thigh to the dorsal calf. Collateral polycentric hinges can be set to permit a certain range of motion. The brace, fitted by means of five or six individual padded Velcro straps, was first applied directly aftersurgery

Water-filled soft brace

The front part of this custom made brace is hollow and can be filled with fluid via a jack at the top of the device. In this study water was used. Collateral stabilizers are woven into the synthetic material. Collateral hinges can be set to permit the range of motion desired by the surgeon. The brace, fitted by means of a one-piece breathablebackstrap merging into three Velcro side straps, is first applied immediately after the operation, loosely covering the elastic bandage.

After surgery Patients in both groups were advised towear their brace all day for12 months .

During this period each patient was examined at 1 day, 5 days , 12 days , 6 weeks , 12 weeks , 6 months , and 12 months after surgery.

Results after examination

Exclusion, loss to follow-up

At the 6-week examination, five patients in group A and onepatient in group B admitted to not having worn the brace as directed. These patients were excluded from further examination.Two patients (one in each group) were lost to follow-up 12 weekspostoperatively. Neither of them could be contacted then or later.

Effusion and swelling

On the first postoperative day, the groups showed no significantdifference in effusion. On the 5th day after operation, group A hadsignificantly more effusion than group B (p=0.002). There weresimilar findings at 12 days and 6 weeks postoperatively (bothpb0.001). The 12-week examination also showed significantly lesseffusion in group B (p=0.024). There was no significant difference ineffusion between the two groups at 6 months or 12 months afteroperation. For further details see Fig. 2.

Fig. 2. Effusion: mean status with standard deviations and significance.

knee circumference

knee circumference at the proximal patellar margin could be detectedon the first postoperative day, with mean side-to-side differences of

0.3 cm (SD=0.8) and 1.7 cm (SD=1.0) in group A and 0.1 cm)SD=0.8 (and 1.5 cm (SD=1.1) in group B (confidence interval — CI:

−0.18 to 0.55 and −0.24 to 0.74.(At 5 days after operation, the mean side-to-side difference in group B,

at 2.8 cm (SD=1.1), was significantly less than in group A, 3.5 cm

)SD=1.3, p=0.013 (with a confidence interval of 0.15 to 1.25. Theexaminations at 12 days and 6 weeks demonstrated similar findings,

with 2.7 cm (SD=1.2) and 1.2 cm (SD=1.1) for group A and 1.7 cm)SD=1.2 (and 0.3 cm (SD=0.9) for group B (p=0.001 at both time

points; CI: 0.44 to 1.56 and 0.34 to 1.27.(At 12 weeks, 6 months and 12 months postoperatively there wasno significant difference between the groups, although with p-valuesof 0.056 (6 months) and 0.051 (12 months) a tendency in favour ofgroup B could be suggested.

Fig. 3. Midpatellar circumference of the knee: mean differences in cm with standard deviations and significance.

IKDC data

Subjective knee evaluation was documented using the standardizedIKDC 2000 form (Fig. 4). Differences in mean subjectiveevaluation were non-significant at 1, 5 and 12 days after operation.

Six weeks postoperatively the mean IKDC subjective knee score wassignificantly greater in group B (p=0.020, CI: −10.0 to −0.9), but at

12 weeks after surgery the difference was again non-significant.At 6 months postoperatively, with a confidence interval of−11.9 to

−0.7 ,there was a significant difference in favour of group B)p=0.029 .(The 12-month examination revealed a highly significant

difference: CI −11.5 to −2.6, p=0.002.

Fig. 4. IKDC score: mean subjective knee evaluations with

standard deviations and significance.

Thigh atrophy

The side-to-side difference in circumference at 10 cm proximal to the upper patellar margin was measured to compare thigh atrophy. No significant differences between the groups were found

ExaminationHard brace

SD((

Soft brace

)SD(

1 day1.41.1

5 days1.31.3

12 days1.41.2

6weeks1.30.9

12 weeks1.41.1

6 months1.21.0

12 months1.21.0

Conclusion

Compared to a standard hard brace in postoperative use, the tested water-filled soft brace was superior regarding effusion, swelling and patient-measured medium-term outcome.The water-filled soft brace presents a safe alternative with several advantages over the classic hard brace