The anterior cruciate ligament (ACL) injury most common ligament injury in the knee joint, especially among sports person the incidence of ACL rupture recently estimated at 0.5–1 per 1,000 inhabitants [12], and reconstruction of the ligament is one of the most commonly performed surgery in the entire musculoskeletal apparatus [13,14]. Due to the fact that cruciate ligament ruptures are now a significant socioeconomic factor in our healthcare system, post-operative rehabilitation must take the cost-benefit ratio into account. Even though the benefits of using a stabilizing knee brace after surgery have never been satisfactorily established, the practice is nevertheless common [15,24]. Various biomechanical studies have shown that functional braces may have positive effects on stability [22,18,19], protection of the ACL and muscle activation or proprioception [21,20]. Clinical studies, however, have yielded inconclusive results with regard to subjective and objective scores [8,22,25,26,27], so that the most effective way to use a brace in the course of rehabilitation following ACL reconstruction remains unclear. Over the last two decades, significant progress has been made in knee ligament surgery. Numerous grafts, the timing of procedures, surgical methods, fixation types, and customized rehabilitation regimens-such as those with and without braces-have all been the subject of studies. The results were reported at two months by Melegati [29] while Brandsson [6], Kartus [25], McDevitt [16], Risberg, Moller [32] and Feller [23] published 2-year results, and Harilainen [22] described the outcome after 5 years. In this case, using a brace for after treatment did not result in a significantly better subjective or objective outcome, according to any of the cited studies. Therefore, it was decided to investigate whether postoperative application of a knee brace after ACL reconstruction can still be regarded as beneficial. A 4-year follow-up prospective randomized trial was initiated to ascertain the benefits and drawbacks of post-operative brace-free therapy. Against the backdrop of increasing demographical changes and cutbacks in health care, the aim was to show one way in which costs can be reduced. It was hypothesized that there is no clinical or functional difference in the 4-year results comparing patients treated with or without a brace after ACL reconstruction.

In a retrospective study, 32 consecutive patients aged 21–65 underwent an arthroscopically assisted ACL reconstruction with autograft between May 2019 and December 2021. All operations were performed at the same hospital, patients grouped into two groups with 16 patients in each group. Group 1 with patients who used functional knee brace postoperatively Group 2 patients who used extension knee brace postoperatively. All patients followed a predefined of rehabilitation program for 6 weeks after surgery, the only difference being that those in one group wore a functional knee brace had a constant gradual increase in degree of knee flexion during this period of time. Patients in both the groups who underwent meniscal repair were kept non-weight bearing during the period of rehabilitation. Instruments for result assessment were the IKDC 2000 forms [33,34], quantify the performance of the knee joint [35]. Follow-up examinations were performed 1 after operation.

Operative Technique

Before starting the surgery, an examination under anaesthesia is performed to look for evidences of ACL injury which is clinically indicated by a positive Lachman and pivot shift test. The patient is placed in supine position with leg hanging from the edge of the table supported by a leg holder so that the operative limb can be flexed up to 120 degrees on. A tourniquet is applied and inflated after painting and draping of the surgical site. Once tourniquet is inflated, arthroscopy is performed through the standard anteromedial and anterolateral portals. The suprapatellar pouch, patellofemoral joint, and the lateral and medial gutters are visualized. Keeping the knee in valgus position, the medial meniscus, medial femoral condyle and the medial tibial plateau are visualized. Using the probe via the anteromedial incision, the medial meniscus and cartilage are assessed. Intercondylar notch, ACL and PCL are also assessed. The lateral menisci, lateral femoral condyle and lateral tibial condyle are assessed in the figure of four position. A 3- 4 cm incision is made over the pes anserinus, centered approximately 2 cm medial to tibial tubercle. The Sartorius fascia is incised parallel and distal to the palpable Semitendinosus, thereby exposing the semitendinosus and gracilis tendons. Tendons are separated and each tendon is whip stitched with non-absorbable suture. Using blunt dissection with the index finger, the tendons are freed from surrounding adventitia. Extra tendinous facial bands are excised to completely free up the tendons to their respective sheaths. It is important to incise these facial bands to prevent premature amputation of the tendon while using a tendon stripper. The tendons are then harvested with a blunt ended tendon stripper. The tendons are removed of any residual muscle fibres with the help of blunt end of the blade. The tendon ends are trimmed to achieve uniform size. A whipstitch is placed at both ends of the tendons. Around 3-4 cm of both the ends of the tendon were stitched together. The tendons are looped to give a four stranded graft of ST with gracilis. The graft is then sized in a graft master.  The arthroscope was introduced via the anterolateral portal and joint cavity visualized. The shaver blade is inserted through the anteromedial portal and the joint is debrided of ligamentum plicae, fat pads and synovial reflections that hinder a thorough inspection of the tibial footprint of the ACL and medial surface of the lateral femoral condyle. After intraoperative evaluation and decision is taken regarding the need for notchplasty. The notch is usually deepened by 2 – 3 cm starting anteriorly on the articular surface of the intercondylar notch 2 – 3 cm superior to the margin. The direction of deepening of the notch should be anterolateral. Femoral foot print of ACL, is identified and prepared using currete. Keeping the knee in 120 degree of flexion– femoral tunnel is drilled using a guide pin. The drilling is continued till the tip of the guide wire emerges on the lateral side of the distal thigh at the level of epicondyle of femur, following which the tunnel is drilled using an appropriate reamer corresponding to the size of graft.  The tibial tunnel is made by passing a tibial guide pin through the ACL foot print with the help of a tibial drill guide placed through the anteromedial portal kept 45-55 degree. The tunnel is drilled using an appropriate reamer corresponding to the size of graft.  The beath pin with ethibond at its end was passed via the femoral tunnel The Ethibond suture already present within the joint is pulled out through tibial tunnel. With the help of these sutures, the graft is pulled via the tibial tunnel into the joint and then into the femoral tunnel. Once the estimated length of the graft is within the the tunnel. The Femoral end is fixed first using Endo button. Then the arthroscopic visualisation of the graft is done to look for any signs of graft impingement, alignment, etc. The knee is taken through several cycles of to and fro motion. The tibial side of the graft is fixed with interference screw (titanium or bioscrew) of appropriate length. The graft is fixed to the tibial side using an interferential screw maintaining it in tension. A thorough joint lavage is given and the wound is closed using staples. The ports and the graft harvest site wound are closed in layers. Sterile compressive dressing is then applied. The limb is immobilized with the use of knee brace.

Post-Operative Treatment

On the primary day after operation, the two randomized group of patients were given the same treatment, with drain, physiotherapy and mobilization on forearm crutches. . Following the first change of bandage on the second postoperative day, the patients of the group 1 received a prefabricated knee-stabilizing brace. The brace restricted knee joint mobility to extension/flexion of 0-90. The restrictions on knee joint mobility were lifted to 120 degree after 4 weeks, and the brace was removed at 6 weeks. Patients of the group 2 were treated according to the same mobility plan. Fractional load-bearing on forearm crutches, with suitable measures to avoid thrombosis, was suggested to all patients. Both groups taken after the same standardized post-operative 6-week treatment protocol.

Knee Brace

A functional knee brace with multiple angle fixation starting from 0 to 120 degree of flexion and extension is kept in 0-degree fixation was used. Each patient had the brace fitted by an orthopaedic technician. The brace comprises of an aluminium outline secured with engineered fabric and is accessible for cleared out and right knees. Patients were inquired to wear the brace 24 h a day for the primary 2 weeks; from there on, it can be removed at night and for physiotherapy.

Extension knee brace consist of well-padded semi rigid posterior bars limits knee flexion and semirigid mediolateral bars provided for mediolateral stability. Velcro closures in the front and additional strap above the patella. Patients were asked to wear the brace 24 h a day for the first 2 weeks and removed only during physiotherapy. Thereafter it is worn only during forearm crutches mobilization.

Figure 1: Functional knee brace.

Figure 2: Extension knee brace.

Figure 1: Functional knee brace and 16 were treated with Extension knee brace.

32 patients could be examined 1 year after surgery. Sixteen had been treated with a functional knee brace and 16 were treated with Extension knee brace. 50 % of the patients were in the age group between 25-30 years. There were 2 women in each group. Twisting injuries were the most common cause of ACL rupture (40%). No post-operative vein thrombosis or knee infection was seen in the study population. One patient in the Group 1 sustained ankle fracture 3 months post-operative period. Standard pre- and post-operative clinical examination (range of movement, muscle circumference, effusion) and stability testing (Lachman test, pivot shift test, varus/valgus stress test) uncovered no measurably critical contrasts between the groups.

IKDC Score

IKDC score showed no statistically significant difference between the two groups with two tail p value of 0.1128. Mean IKDC score at 1-year postoperative period as demonstrated in the figure.

The key message of this study is that comparable outcomes with regard to subjectively assessed knee joint function and stability one year after ACL reconstruction on post-operative use of a functional knee brace and extension knee brace knee brace. Prescription of a brace causes high costs for the health care system. The adequacy of these gadgets must be inspected basically. It was not completely beyond any doubt that all patients continuously wore their braces as prompted. With the KT1000 instrument alone, objective evaluation of rotational laxity of the knee was not conceivable. Xiong-gang Yang 2019 in his meta-analysis concluded that knee bracing does not appear to improve the clinical outcomes on the function and stability for ACL-reconstructed knees. On the contrary, some negative influence on the knee out-come and additional cost may be caused in the rehabilitation process with braces. Hence, bracing for patients treated with ACL reconstruction ought to not be prescribed routinely. . May Arna Risberg in 1999 in his prospective study with 2 years follow up said that there was no evidence that had an effect on knee joint laxity, range of motion, muscle strength, functional knee tests, patient satisfaction, or pain, in comparison to no brace after ACL reconstruction. However, the Cincinnati knee score improved significantly in the brace group 3 months after surgery, even though bracing significantly increased thigh atrophy early postoperatively. Furthermore, prolonged bracing (1to 2 years after surgery) produced a significant decrease in quadriceps muscle strength compared with bracing for a shorter period. Laurie A. Hiemstra 2006 in a survey of practice conducted in Canada orthopedic surgeons concluded that the lack of consensus reported in the current study and published literature reflects a lack of scientific evidence in the area of post-operative knee immobilization. The need for a randomized clinical trial to assess the efficacy of knee immobilizer use after ACL reconstruction is evident. The authors recommend using peri-operative pain as an outcome measure in future studies investigating immobilization in the immediate post-operative period. E. Carlos Rodríguez-Merchán, MD 2015 in his review article said that some studies in the literature are in favor of the use of a postoperative brace after ACL reconstruction, current survey found that a few orderly audits and other reports on the subject don't back the utilize of a postoperative brace after ACL reconstruction. Postoperative bracing after ACL reconstruction does not appear to assist torment, work, recovery, and soundness. There's inadequately prove to illuminate current practice. Good quality randomized trials on the subject are warranted. Dai Sugimoto in review of studies proposed that there is inconsistent evidence of a functional knee brace on joint-position improvement after ACL reconstruction. More investigate is required to supply adequate prove on the impact of a useful knee brace on joint-position sense after ACL reconstruction. Therefore, future studies with advanced instruments are required. Development of knee osteoarthritis depending on residual laxity and restricted range of motion has not yet been observed after 1 year. It would be an important objective of a long-term follow-up study to verify such correlations.

Results of the current study show no significant differences in subjective assessment 1 year post-operatively between patients who wore a functional knee brace and extension knee brace for 6 weeks after surgery. Both groups achieved similarly positive outcomes. The study has got limitations as the study were assessed using subjective scores and not based on objective assessment and longer duration of follow up required to assess the long-term outcome.

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