All knee bracing products are not ACL-related, however. Some patients encounter problems with the posterior cruciate ligament (PCL); sometimes there is damage to the meniscus (the "shock absorber" that cushions the knee joint), as well, Sansone explained.
An expanding population is the active osteoarthritic patient who has had meniscal damage or a surgically removed meniscus, he pointed out. The patient's joints have deteriorated as a result of the previous injury and osteoarthritic braces can be used to ease the pain and possibly hinder further deterioration.
Post-op braces are used following surgery to limit extension and flexion and provide some protection to the patient in case of a fall, said Sansone, and about 75 percent of the doctors in his area use such braces post-operatively, generally leaving them on the paŽtient from two to six weeks
Athelete is fitted with an ACL brace by TMC Orthotist Joe Candelario.
Since TMC Brace Place opened its specialized doors three years ago, he and his orthotic practitioners have been serving a patient mix of which about 65-75 percent present sports-related injuries. And of that group, 85 percent are knee injuries.
Overall, Sansone said, roughly 75 percent of all sports bracing is provided for patients with anterior cruciate ligament (ACL) instabilities. ACL injuries are often caused by either hyperextension or by tibial translation, where the tibia moves anteriorly (forward), Sansone explained. The result is a straining, rupturing, or severing of the ligament. "If the ACL is severely torn or severed, and the patient
is relatively active, they will often undergo an ACL reconstruction procedure.
"Currently, there are several types of reconstructive procedures used to repair the ACL. Physicians may harvest a patellar tendon from directly below the kneecap and use that to reconstruct the ligament. They can also use the hamstring from behind the knee; quadriceps grafts are far less commonly used. Once this tendon has been transplanted, it revascularizes and becomes living tissue, replacing the original ligament. We distribute a large number of allografts, or cadaver ligaments that are actually pre-shaped; this prevents the surgeon from having to cut into the patient and decreases the trauma to the area, while decreasing OR time. An estimated 5-10 percent of ACL surgeries are utilizing allografts now," he added.
ACL patients fall into two categories, he explained: those who have had reconstruction surgery to correct ACL injuries, and those who are not candidates for surgery for whatever reason.
Those who have had surgery will need to protect the graft until it is fully healed; those who have not undergone ACL reconŽstruction surgery want to protect the ligament. "John Elway, exquarterback for the Denver Broncos, falls into this category. He played for over 12 years in the NFL wearing a Townsend knee brace, opting not to have an ACL reconstruction. Interestingly, it was a requirement of his insurance company that he wear a brace while playing."
All knee bracing products are not ACL-related, however. Some patients encounter problems with the posterior cruciate ligament (PCL); sometimes there is damage to the meniscus (the "shock absorber" that cushions the knee joint), as well, Sansone explained.
An expanding population is the active osteoarthritic patient who has had meniscal damage or a surgically removed meniscus, he pointed out. The patient's joints have deteriorated as a result of the previous injury and osteoarthritic braces can be used to ease the pain and possibly hinder further deterioration.
Post-op braces are used following surgery to limit extension and flexion and provide some protection to the patient in case of a fall, said Sansone, and about 75 percent of the doctors in his area use such braces post-operatively, generally leaving them on the paŽtient from two to six weeks.
TMC Orthotist Stan Sanderson fits a patient with a functional knee brace.
Functional or sports braces can also be used post-operatively to afford an extra degree of protection, but they also serve patients who have strained the ligaments in the knee yet don't require sur gery, or for some reason aren't a good candidate for surgery. Of the several varieties and types of functional knee braces available, Sansone said he prefers the Townsend Design knee braces.
"When it comes to functional knee braces, there are basically three types," he explained. "An off-the-shelf brace, as the name indicates, comes ready-to-wear in small, medium, and large sizes, for right or left. They're a little heavier and don't quite offer the intimate fit that you can obtain with the custom designs, but these are the least expensive and are covered by most managed care plans."
The custom designs are available in two types, Sansone clarified: (A) the semi-custom, such as the DonJoy, where some sort of tracing or measurements are done, and those dimensions or patterns are used as the basis for fabricating a brace; and (B) the tried and true custom, where the orthotist actually takes a cast mold of the patient, the manufacturer then makes a mold of the patient's leg, and a brace is fabricated to fit the patient's leg.
"Townsend does this (latter) type of brace, as well as the semi custom," Sansone said, "and that's why we prefer the Townsend brace."
Are knee braces forever? Normally, if the patient doesn't undergo surgery to have their ligament repaired, he or she is probably going to wear it for life, he said, "... or until they reach an age where they're not that active anymore."
Many physicians agree that it is not until the first or second year after an ACL reconstruction that a graft is as strong as before the patient's injury, Sansone pointed out. Normally within a year or two they can discontinue wearing the brace.
Sansone observed that sports-injury-related business has fluctuated greatly in the past. "Sports bracing used to be extremely popular - so much so that some of the functional braces were used prophylactically. Numerous studies indicate that it has been difficult to demonstrate a need for this type of bracing. Then in the past, there have also been studies that claimed that knee braces do not offer a large degree of protection. So some physicians quit using the knee braces altogether.
"In the future, I suspect physicians are going to offer these braces just as an insurance policy for a damaged knee. If they surgically repair a knee, and the patient blows out the knee six months or less post-op, then they may have to answer to a patient as to why they didn't give him or her as much protection as was available in the form of a knee brace."
Thus, many physicians are once again offering the functional knee braces, Sansone said - largely in self defense. Due to this factor, coupled with the improvements in today's knee braces - e.g., the quicker turnaround time and decreased costs - a lot more paŽtients are receiving the knee braces, Sansone pointed out.
"One interesting point about these functional knee braces," Sansone noted thoughtfully, "is that O & P providers like myself manufacture almost every custom product that we provide - with the sole exception of the functional knee braces. There are five or six large manufacturers who do such a good job of making functional knee braces affordably that we don't manufacture them ourselves. We've found that while bracing manufacturers' prices may have increased slightly, due to managed care, our reimbursement has significantly decreased."
Sansone believes in a strong team relationship with athletic trainers and physical therapists and identified several different occasions when they get involved in working with these partners in patient care. "Sometimes," he said, "we'll utilize the physical therapist or the PT clinic to assist with compliance, since the physical therapist works hand in hand with the patient on a daily or weekly basis during the rehab process and is much more familiar with his or her needs.
"We try to work with the ATCs (athletic trainers) whenever they are involved in patient care," he added. "It's easy for us to slap a brace on the patient and send them on their way, but the athletic trainer has to deal with the patient and the brace day in and day out in their athletic endeavors. So we work with them, helping them to adjust flexion and/or extension stops, making adjustments to the brace due to atrophy or increased muscle tone, etc. We always get those last-minute calls for broken braces or braces that need adjustment, and we try to be flexible and work with them in such cases."
Is sports medicine a good choice for orthotists seeking to expand their practice or add an area of specialization?
Sansone pointed out that he got into the bracing industry when state licensure hit Texas. "They were going to prevent sales reps (like my sales reps) from fitting braces. It was going to put the sports medicine sales reps out of business. Before this legislation, non-licensed, non-certified sales reps were fitting a majority of the sports medicine braces in Texas. The legislation forced me as a sales rep to either `go legitimate' or quit providing sports medicine bracing. I went legitimate in their eyes by complying with the new state-mandated standards and now I'm one of the largest orthotic providers in Houston, with four locations and six practitioners. There's a huge, growing market out there for qualified practitioners.
"But you can't just slap a brace on patients and send them on their merry way," he warned. "You have to be an integral part of the sports medicine physician's practice. You've got to know when to put what patient in a particular brace; you've got to work with physical therapists and athletic trainers and with the physician. It has helped us immeasurably to be there in surgery with the physician so that we know exactly what he's looking for from a brace. Just letting a patient come into your office with a prescription and fitting him may work with a lot of other braces, but doesn't necesŽsarily work in the sports medicine arena.
"Fortunately, since we have also been providing many of the products they are using in surgery, the physicians depend on us to help them with product selection and assist them with learning about new products," Sansone noted, explaining how they achieved that coveted entree into surgery. "Many O & P practitioners are stuck in an office seeing patients all day; we have been able to bridge that gap.
What goes on in OR gives our practitioners insights not just into what the physician wants in a brace, but what he expects the brace to do. We gain an appreciation for what the surgeon is trying to accomplish and how the brace fits into the entire medical treatment. It makes it easier for us to service our patients and referral sources, and that's why we've been so successful."
