Name: Sean Tickner
Phone: 0273280390
Email: seantickner@yahoo.com
Date: 29/01/2021
Event Number: SMT – 2021-01/23243
Job Details
Start Date:
20/08/2020
Finish Date:
15/01/2021
Referrer/Prescriber:
Orthopaedic Surgeon and General Practitioner.
Brief Patient Description:
66-year-old retired male teacher presented with medial osteoarthritis (OA) of the right knee which was exacerbated by a trip/ fall.
Orthotic/Prosthetic Aims/Requests:
Medial unloading knee brace.
Abstract
Background: Osteoarthritis (OA) of the knee is a common cause of knee pain in the elderly population with various treatment options available.
Aim: To reduce pain and discomfort in a patient with OA through the use of an unloading-type knee brace.
Methods: Case study of the supply and fit of a medial unloading knee brace for a patient with medial compartment osteoarthritis.
Results: Pain relief and increased activity levels due to comfort and compliance with the brace.
Conclusion: Correct brace prescription, fitting and education ensures pain reduction with a medial compartment unloading knee brace.
Initial Assessment
Clinical Presentation:
Subjective:
Patient said he had a fall when jumping over his fence several days ago. Increased pain and tenderness in his knee, mild swelling and painful going up and down stairs at home during the early stages following his fall. He still feels that his knee is swollen but moving around has become easier, still painful when walking longer distances and descending stairs. He enjoys walking and feels he is active, has concerns that the knee pain is restricting his activity levels currently.
He stated the Orthopaedic Surgeon had mentioned mild knee osteoarthritis (OA) and the possibility of surgery for a knee replacement at some stage during his initial consultation. He has a long-standing history of recurring knee injuries and has noticed an increase in knee pain bilaterally with the right worse than the left. No prior diagnosis of OA in the knees.
Objective:
On presentation, he had visible joint effusion in his right knee compared to his left. Mild tenderness when palpating over the medial collateral ligament, medial condyle and medial joint line. No limitations in knee range of motion (ROM) but noticeable guarding on squatting. Single leg squat also elicits discomfort as well as audible crepitus.
Orthotic Aims:
Unload the medial compartment of the right knee to reduce pain and discomfort, improve activity levels and possibly reduce the urgency of surgical intervention.
Orthotic Prescription:
Off-the-shelf dynamic medial compartment off-loading knee orthosis. Low-profile, breathable, simple donning and doffing design to improve compliance and ease of use.
Method/ Plan:
Measurements required for sizing:
Thigh Circumference: 15 cm (6″) above mid-patella
Calf Circumference: 15 cm (6″) below mid-patella
Identify right leg and medial compartment for correct hinge placement.
Brace ordered and fitting appointment scheduled to ensure correct fitting and patient education.
Literature Review
Article 1
Performing a critical appraisal of Feehan et al. (2012, p. 42) indicated my clinical question of interest aligned with their clinical question which was to determine “the effectiveness of knee orthoses in the treatment of pain in unilateral compartment osteoarthritis (OA).” The article is slightly outdated as it was published in 2012, in a peer reviewed journal, however I include it as my primary article as it aligns with my clinical question in population (adults with unilateral OA), intervention (unloader type brace), comparator (no brace) and outcome (pain). They hypothesise: “By documenting the ability of the unloading knee orthosis to reduce pain in those suffering from unilateral OA of the knee through research, the authors of this article may prove what clinical practice has already shown to be effective: that OA unloading knee orthoses are effective in the relief of medial compartment OA knee pain.”
This study design is a systematic review, which is considered the gold standard to assist in clinical decision making. The authors clearly outlined inclusion and exclusion criteria. The study authors used a modified version of the State-of-the-Science Evidence Report Guidelines Quality Assessment Form to assess both internal and external validity of the studies that were included. Of the 15 studies included they found no low-quality studies, 9 moderate quality and 6 high quality studies. From this, we can see the researchers have assessed both bias and confounding factors in the studies included and rated these as negligible allowing us confidence in their synthesised findings. The populations included in this systematic review specifically reflects my case study, who had medial compartment OA, as indicated by their inclusion criteria: “To keep the demographic population consistent, only those studies that investigated medial compartment OA were evaluated. This eliminated variables associated with varus or valgus moments that affect the biomechanics and function of the orthoses and therefore the effect on pain.” There was no meta-analysis performed in this systematic review, the authors instead chose to use a narrative summary of each study however they clearly outline their rationale for why they could not synthesise the data with a meta-analysis. Feehan et al. (2012, p. 42) describe this in their discussion: “Because these studies had different measures of pain, VAS scale, WOMAC index or a modified version of that scale, HSS score, and using different orthoses and different methods in the setup of the studies, the authors were not able to perform any meta-analysis of the combined results.” Therefore, the authors have clearly outlined the limitations in the assessment of their results and do not try to draw conclusions that the evidence does not suggest. In alignment with the case study presented and my choice of bracing with the outcomes of reduced pain, increased mobility and reduced need for surgery. The authors highlight that more studies are needed to address the third outcome of interest: “One thing that was not evaluated in these studies was how many of the participants later underwent corrective surgery, either femoral osteotomy or knee replacement. One way of evaluating the effectiveness of the orthotic intervention is whether or not patients later have to undergo corrective surgery, which always entails risks.”
In summary, a critical appraisal of this systematic review indicates a high-quality article which presents summarised information on outcomes relevant to the patients included in this case study. The conclusion of the systematic review back up the recommendations for the use of these braces with this patient population as is noted in their conclusion. Feehan et al. (2012, p. 42) conclude: “On the basis of the articles reviewed, an OA or unloading knee orthosis is an effective way to relieve pain in the osteoarthritic knee. Pain relief was documented to help in 98.6% of patients fitted with unloading orthoses for medial compartment OA of the knee. With decreased pain comes increased function and quality of life. When compared with surgery, these orthoses are a cost-effective means of treating OA.”
Reference:
Feehan, N. L., Trexler, G. S., & Barringer, W. J. (2012). The Effectiveness of Off-Loading Knee Orthoses in the Reduction of Pain in Medial Compartment Knee Osteoarthritis. JPO Journal of Prosthetics and Orthotics, 24(1), 39–49. https://doi.org/10.1097/jpo.0b013e318240af8d
Article 2
Performing a critical appraisal of Petersen et al. (2016, p. 655) indicated my clinical question of interest aligned with their clinical question “Is there any effect of valgus unloader braces on the knee adduction moment?”. The article was published recently, in 2016, in a peer-reviewed journal. The authors clearly presented their hypothesis: “we hypothesized that unloader braces are able to reduce the adduction moment of the knee.”
This study design is a systematic review, which is considered the gold standard to assist in clinical decision making. The authors clearly outlined inclusion and exclusion criteria although they performed no assessment for bias within the studies included. Therefore, it is difficult to assess the quality of the studies that make up this systematic review and in addition the strength of evidence of this systematic review. This limitation is acknowledged by the authors “A limitation of the present review is that that the quality of the included studies was not assessed or graduated respectively. However, to our knowledge, a quality assessment tool for biomechanical studies does not exist.” But this is clearly a limitation within our field of study. Therefore, my appraisal of this article is that the authors have followed good methodological practice and all though the evidence is not strong it is the only evidence currently available with the limitations which we are faced with.
The aim of this study was to systematically synthesise the effect of the use of unloader-type braces in live individuals with primary outcome measure of reduction in knee adduction moment and secondary outcome measure of reduction in pain and tertiary outcome measure of patient movement. Methods employed were standard systematic review methods and the relevant findings for my clinical question of interest aligned with the outcome measures. This systematic review looked at the biomechanical effects of an unloader brace for treatment of medial OA of the knee. With a total of 20 out of 24 articles showing evidence of valgus unloader braces significantly decreasing the knee adduction moment and seven of those studies reporting a decrease of pain in braced patients as a secondary outcome measure. Petersen et al. (2016, p. 655) concluded “… this systematic review could demonstrate evidence that valgus bracing can unload the medial compartment in patients with medial OA by reduction of the knee adduction moment. Beyond this this systematic review could reveal other effects of valgus bracing than reduction of the knee adduction moment. The most important clinical effect was pain reduction. Other biomechanical effects include increased walking speed, increase in step length or increased gait symmetry.”
In summary, this article supports the choice of intervention for this case study. The support comes in the fact that it provides evidence that this brace in OA patients reduces knee adduction moment which helps reduce loading of the damaged compartment thus reducing pain and improving activity levels and therefore quality of life and one hypothesises this could reduce the need for urgent surgical intervention. Although I recognize the evidence presented in this systematic review is weak as it has clear limitations due to the inability to measure quality of the studies and therefore further higher studies and a new systematic review with an accepted quality and risk of bias assessment and evidence grading would be needed to be performed to confirm this.
Reference:
Petersen, W., Ellermann, A., Zantop, T., Rembitzki, I. V., Semsch, H., Liebau, C., & Best, R. (2016). Biomechanical effect of unloader braces for medial osteoarthritis of the knee: a systematic review (CRD 42015026136). Archives of Orthopaedic and Trauma Surgery, 136(5), 649–656. https://doi.org/10.1007/s00402-015-2388-2
Visit details
Visit 1 (initial meeting)
Patient fell and damaged the medial aspect of the right knee; he is having ongoing discomfort and pain on activity. He requires a low-profile unloading knee brace to reduce pressure on the medial compartment. This type of brace is ideal as it provides compressive support, ease of use and dynamic off-loading for mild to moderate activity levels in order to reduce pain.
Patient has mild joint effusion in his right knee compared to his left.
Mild tenderness when palpating over the medial collateral ligament, medial condyle and medial joint line. No limitations in knee range of motion (ROM) but noticeable guarding on squatting. Single leg squat also elicits discomfort as well as audible crepitus.
Referral states OA but injury more than likely exacerbated it.
Measurements –
Circumferential
48.5cm – above knee
40.5 – centre of knee
42cm – below knee
Mediolateral calliper – 11.5cm
Measures as a RIGHT MEDIAL MEDIUM
Surgeon referred for a GII Unloader, there is no such brace, opted for the Ossur OA Formfit Ease knee brace.
Management Notes: Job# 17683
TO ORDER.
Ossur OA FORMFIT Ease knee brace
RIGHT MEDIAL MEDIUM
Visit 2
Supply and fitting of unloading knee brace – Right Medial Medium Ossur OA Formfit Ease knee brace.
Fitted well. Patient advised how to fit and adjust, as necessary. He felt comfortable and confident in applying the brace by himself and felt relief from the brace in a very short period.
Advised him to wear it in over a period to get accustomed to the feel of the brace and to contact us immediately with any concerns.
Visit 3
Patient has returned, he has found that his right knee is no longer causing discomfort, he finds the brace comfortable and easy to use and has increased his walks in both distance and time. He has now been referred for another brace for his left knee to reduce OA related pain and discomfort in that knee. Due to his favourable response to the first brace fitted to his right knee, he would like the same one for his left.
Supply and fitting of unloading knee brace – Left Medial Medium Ossur OA Formfit Ease knee brace.
Due to ongoing use of the brace, he is aware of correct fitting and adjustment required.
No follow-up scheduled, to contact us with regards to possible repeat of referral and any concerns relating to the braces.
Critical Appraisal of Case Study
What have you learned from this case?
Learnings from this case include the understanding of supplying the best option for the patient on an individual basis as well as ensuring the end goal of the prescriber and you are aligned in order to allow the best possible outcomes for your patient. Being able to assess the patient’s individual requirements and managing expectations while providing a type of brace that has published benefits gives us the ability to pursue a higher level of professionalism and belief in what we provide as orthotists. Understanding the clinical benefits of an unloading type knee brace and how it can improve a patients quality of life is paramount in providing the best possible solution when it comes to medial compartment OA of the knee.
What could have been done better?
Communication with the referring surgeon to ensure he was aware of the variety of unloading knee braces can be improved upon.
Funding applications can be streamlined, during the initial stages there was confusion relating to providers, although this does not directly relate to the brace and its efficacy, it does have serious implications on patient experience and timeline for their management.
Does this study contribute to orthotic research/evidence?
There is high quality published orthotic evidence relating to medial OA and non-surgical intervention with unloader type orthoses and although this evidence can be expanded for better understanding of types of braces and situations, the study designs for this would ideally be randomised controlled trials not case studies. However, the findings related to patient experience should contribute to orthotic research as future streamlined funding would result in faster and more efficient services for patients and therefore one would hypothesise better health outcomes in these patients.
References
Feehan, N. L., Trexler, G. S., & Barringer, W. J. (2012). The Effectiveness of Off-Loading Knee Orthoses in the Reduction of Pain in Medial Compartment Knee Osteoarthritis. JPO Journal of Prosthetics and Orthotics, 24(1), 39–49. https://doi.org/10.1097/jpo.0b013e318240af8d
Petersen, W., Ellermann, A., Zantop, T., Rembitzki, I. V., Semsch, H., Liebau, C., & Best, R. (2016). Biomechanical effect of unloader braces for medial osteoarthritis of the knee: a systematic review (CRD 42015026136). Archives of Orthopaedic and Trauma Surgery, 136(5), 649–656. https://doi.org/10.1007/s00402-015-2388-2
Formfit® OA Ease. (n.d.). Https://Www.Ossur.Com/En-Au/Bracing-and-Supports/Knee/Formfit-Oa-Ease. Retrieved January 29, 2021, from https://www.ossur.com/en-au/bracing-and-supports/knee/formfit-oa-ease
