Helwan university faculity of engenerring Biomedical department Name Shaimaa adel sayed Supervisor Ahmed Agamya/DR Safaa/Eng

Rehabilitation results following anterior cruciate ligament reconstruction using a hard 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 reconstruction using 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 a hard 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 hamstring ACL reconstruction for the study.

Braces Hard brace This 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 after surgery

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 breathable backstrap 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 one patient 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 weeks postoperatively. Neither of them could be contacted then or later.

Effusion and swelling On the first postoperative day, the groups showed no significant difference in effusion. On the 5th day after operation, group A had significantly more effusion than group B (p=0.002). There were similar findings at 12 days and 6 weeks postoperatively (both pb0.001). The 12-week examination also showed significantly less effusion in group B (p=0.024). There was no significant difference in effusion between the two groups at 6 months or 12 months after operation. 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 detected on 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 The examinations 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 was no significant difference between the groups, although with p-values of (6 months) and (12 months) a tendency in favour of group 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 standardized IKDC 2000 form (Fig. 4). Differences in mean subjective evaluation were non-significant at 1, 5 and 12 days after operation. Six weeks postoperatively the mean IKDC subjective knee score was significantly 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

Soft brace (SD) Hard brace SD)) Examination day days days weeks weeks months months

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