Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 23, Issue 7, pp 1964–1970 | Cite as

Valgus bracing in symptomatic varus malalignment for testing the expectable “unloading effect” following valgus high tibial osteotomy

  • Philipp Minzlaff
  • Tim Saier
  • Peter U. Brucker
  • Bernhard Haller
  • Andreas B. Imhoff
  • Stefan Hinterwimmer



The purpose of this study was to evaluate whether the expectable postoperative pain relief following valgus high tibial osteotomy (HTO) is reliably predictable with the temporary use of an unloading knee brace preoperatively.


Fifty-seven patients with symptomatic varus malalignment were treated with a valgus producing unloading knee brace for 6–8 weeks. The pain intensity in the respective knee compartment was monitored using the visual analogue scale (VAS) before and following this treatment. A “positive” Brace-Test was defined as a pain relief medially without initiated symptoms laterally. In these cases, a valgus HTO was suggested as a promising surgical option. Patients who were subsequently operated were clinically re-evaluated 1 year postoperatively to compare the postoperative outcome with the result of the Brace-Test.


The mean VAS score decreased from 6.7 [standard deviation (SD) 1.6] to 2.5 points (SD 1.7) (p < 0.001) following the Brace-Test. Overall, 48 patients had a positive test. A valgus HTO was performed in 29 of them. The mean postoperative VAS score was 1.9 (SD 1.7) points with no difference to the result of the test (n.s.). Nineteen patients with a positive test initially decided for a conservative treatment. In three of nine patients with a negative test, a total knee replacement was performed.


This study shows that the temporary use of an unloading valgus producing knee brace may well predict future outcome of HTO surgery in terms of expectable postoperative pain relief. The Brace-Test gives both the patient and the orthopaedic surgeon more detailed preoperative information, especially in critical or borderline indications. Thus, it is a useful tool to test the unloading effect before indicating an HTO.

Level of evidence



High tibial osteotomy Malalignment Osteoarthritis Unloading brace Brace-Test 


  1. 1.
    Aglietti P, Buzzi R, Vena LM, Baldini A, Mondaini A (2003) High tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study. J Knee Surg 16(1):21–26PubMedGoogle Scholar
  2. 2.
    Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H (2008) The long-term outcome of high tibial osteotomy: a 10- to 20-year follow-up. J Bone Joint Surg Br 90(5):592–596PubMedCrossRefGoogle Scholar
  3. 3.
    Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ, Felson DT (2007) A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis. Arthritis Rheum 56(4):1198–1203PubMedCrossRefGoogle Scholar
  4. 4.
    Braun S, Minzlaff P, Hollweck R, Wörtler K, Imhoff AB (2008) The 5.5-year results of MegaOATS–autologous transfer of the posterior femoral condyle: a case-series study. Arthritis Res Ther 10(3):R68PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Brinkman J-M, Lobenhoffer P, Agneskirchner JD, Staubli AE, Wymenga AB, van Heerwaarden RJ (2008) Osteotomies around the knee: patient selection, stability of fixation and bone healing in high tibial osteotomies. J Bone Joint Surg Br 90(12):1548–1557PubMedCrossRefGoogle Scholar
  6. 6.
    Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RM, Reijman M, Pols HA, Bierma-Zeinstra SM (2007) Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum 56(4):1204–1211. doi: 10.1002/art.22515 PubMedCrossRefGoogle Scholar
  7. 7.
    Brouwer RW, van Raaij TM, Verhaar JA, Coene LN, Bierma-Zeinstra SM (2006) Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthr Cartil 14(8):777–783PubMedCrossRefGoogle Scholar
  8. 8.
    Cooke TD, Harrison L, Khan B, Scudamore A, Chaudhary MA (2002) Analysis of limb alignment in the pathogenesis of osteoarthritis: a comparison of Saudi Arabian and Canadian cases. Rheumatol Int 22(4):160–164PubMedCrossRefGoogle Scholar
  9. 9.
    Dennis DA, Komistek RD, Nadaud MC, Mahfouz M (2006) Evaluation of off-loading braces for treatment of unicompartmental knee arthrosis. J Arthroplasty 21(4 Suppl 1):2–8PubMedCrossRefGoogle Scholar
  10. 10.
    Fantini Pagani CH, Potthast W, Brüggemann G-P (2010) The effect of valgus bracing on the knee adduction moment during gait and running in male subjects with varus alignment. Clin Biomech 25:70–76 (Bristol, Avon)CrossRefGoogle Scholar
  11. 11.
    Felson DT, Zhang Y (1998) An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum 41(8):1343–1355PubMedCrossRefGoogle Scholar
  12. 12.
    Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P (2013) Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc 21(1):170–180PubMedCrossRefGoogle Scholar
  13. 13.
    Guillemin F, Rat AC, Mazieres B, Pouchot J, Fautrel B, Euller-Ziegler L, Fardellone P, Morvan J, Roux CH, Verrouil E, Saraux A, Coste J (2011) Prevalence of symptomatic hip and knee osteoarthritis: a two-phase population-based survey. Osteoarthr Cartil 19(11):1314–1322PubMedCrossRefGoogle Scholar
  14. 14.
    Haladik JA, Vasileff WK, Peltz CD, Lock TR, Bey MJ (2013) Bracing improves clinical outcomes but does not affect the medial knee joint space in osteoarthritic patients during gait. Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-013-2596-7 PubMedGoogle Scholar
  15. 15.
    Hayes MHS, Patterson DG (1921) Experimental development of the graphic rating method. Psychol Bull 18:98–99Google Scholar
  16. 16.
    Hinterwimmer S, Beitzel K, Paul J, Kirchhoff C, Sauerschnig M, von Eisenhart-Rothe R, Imhoff AB (2011) Control of posterior tibial slope and patellar height in open-wedge valgus high tibial osteotomy. Am J Sports Med 39(4):851–856PubMedCrossRefGoogle Scholar
  17. 17.
    Horlick SG, Loomer RL (1993) Valgus knee bracing for medial gonarthrosis. Clin J Sport Med 3:251–255CrossRefGoogle Scholar
  18. 18.
    Hui C, Salmon LJ, Kok A, Williams HA, Hockers N, van der Tempel WM, Chana R, Pinczewski LA (2011) Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am J Sports Med 39(1):64–70PubMedCrossRefGoogle Scholar
  19. 19.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Kirkley A, Webster-Bogaert S, Litchfield R, Amendola A, MacDonald S, McCalden R, Fowler P (1999) The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am 81(4):539–548PubMedGoogle Scholar
  21. 21.
    Komistek RD, Dennis DA, Northcut EJ, Wood A, Parker AW, Traina SM (1999) An in vivo analysis of the effectiveness of the osteoarthritic knee brace during heel-strike of gait. J Arthroplasty 14(6):738–742PubMedCrossRefGoogle Scholar
  22. 22.
    Krohn K (2005) Footwear alterations and bracing as treatments for knee osteoarthritis. Curr Opin Rheumatol 17(5):653–656PubMedCrossRefGoogle Scholar
  23. 23.
    LaPrade RF, Spiridonov SI, Nystrom LM, Jansson KS (2012) Prospective outcomes of young and middle-aged adults with medial compartment osteoarthritis treated with a proximal tibial opening wedge osteotomy. Arthroscopy 28(3):354–364PubMedCrossRefGoogle Scholar
  24. 24.
    Maillefert JF, Hudry C, Baron G, Kieffert P, Bourgeois P, Lechevalier D, Coutaux A, Dougados M (2001) Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis: a prospective randomized controlled study. Osteoarthr Cartil 9(8):738–745PubMedCrossRefGoogle Scholar
  25. 25.
    Minzlaff P, Feucht MJ, Saier T, Schuster T, Braun S, Imhoff AB, Hinterwimmer S (2013) Osteochondral autologous transfer combined with valgus high tibial osteotomy: long-term results and survivorship analysis. Am J Sports Med 41(10):2325–2332PubMedCrossRefGoogle Scholar
  26. 26.
    Müller M, Strecker W (2007) Arthroscopy prior to osteotomy around the knee? Arch Orthop Trauma Surg 128(11):1217–1221PubMedCrossRefGoogle Scholar
  27. 27.
    Outerbridge RE (1961) The etiology of chondromalacia patellae. J Bone Joint Surg Br 43-B:752–757PubMedGoogle Scholar
  28. 28.
    Pham T, Maillefert JF, Hudry C, Kieffert P, Bourgeois P, Lechevalier D, Dougados M (2004) Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis. A 2-year prospective randomized controlled study. Osteoarthr Cartil 12(1):46–55PubMedCrossRefGoogle Scholar
  29. 29.
    Pollo FE (1998) Bracing and heel wedging for unicompartmental osteoarthritis of the knee. Am J Knee Surg 11(1):47–50PubMedGoogle Scholar
  30. 30.
    Pollo FE, Jackson RW (2006) Knee bracing for unicompartmental osteoarthritis. J Am Acad Orthop Surg 14(1):5–11PubMedGoogle Scholar
  31. 31.
    Pollo FE, Otis JC, Backus SI, Warren RF, Wickiewicz TL (2002) Reduction of medial compartment loads with valgus bracing of the osteoarthritic knee. Am J Sports Med 30(3):414–421PubMedGoogle Scholar
  32. 32.
    Self BP, Greenwald RM, Pflaster DS (2000) A biomechanical analysis of a medial unloading brace for osteoarthritis in the knee. Arthritis Care Res 13(4):191–197PubMedCrossRefGoogle Scholar
  33. 33.
    Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA 286(2):188–195PubMedCrossRefGoogle Scholar
  34. 34.
    Waller C, Hayes D, Block JE, London NJ (2011) Unload it: the key to the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 19(11):1823–1829PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Philipp Minzlaff
    • 1
  • Tim Saier
    • 1
  • Peter U. Brucker
    • 1
  • Bernhard Haller
    • 2
  • Andreas B. Imhoff
    • 1
    • 3
  • Stefan Hinterwimmer
    • 1
  1. 1.Department for Orthopaedic SportsmedicineTechnische Universitaet MuenchenMunichGermany
  2. 2.Institute of Medical Statistics and EpidemiologyTechnische Universitaet MuechnenMunichGermany
  3. 3.Orthopaedic Surgery and Traumatology, Department of Orthopaedic Sports Medicine, Klinikum Rechts der IsarTechnische Universität MuenchenMunichGermany

Personalised recommendations