What is the recommended post-operative management for a patient after ACL (Anterior Cruciate Ligament) repair with TTO (Tibial Tubercle Osteotomy)?

Postoperative Knee Bracing After ACL Repair with TTO

Postoperative knee braces should not be used routinely after ACL reconstruction with tibial tubercle osteotomy (TTO), as multiple high-quality clinical practice guidelines strongly recommend against their use. 1

Evidence Against Routine Knee Bracing

The evidence overwhelmingly indicates that postoperative functional knee bracing does not improve outcomes after ACL reconstruction:

• Five high-quality clinical practice guidelines (NZGG, DOA, MOON, AAOS, and APTA) explicitly recommend against the routine use of postoperative knee braces following ACL reconstruction 1

• Multiple systematic reviews have found no benefit of bracing on:

  • Knee stability
  • Pain reduction
  • Range of motion
  • Functional outcomes
  • Reinjury rates 2, 3, 4

• A 2-year follow-up study of 78 patients showed no significant differences in:

  • KT-1000 stability measurements
  • One-leg hop performance
  • Lysholm scores
  • IKDC classification
  • Return to work timing 5

Recommended Rehabilitation Approach

Instead of bracing, current guidelines recommend:

1. Immediate Knee Mobilization:

   • Begin within the first week post-surgery 1
   • Critical for increasing joint range of motion and reducing knee pain 1
   • Helps prevent soft tissue-related adverse events like extension deficit 1

2. Early Weight Bearing:

   • Progress to weight-bearing as tolerated within the first week 1
   • May reduce patellofemoral pain (from 35% to 8%) compared to non-weight-bearing protocols 1
   • No negative effects on knee laxity or subjective function 1

3. Early Strength Training:

   • Begin isometric quadriceps exercises from the first postoperative week if not causing pain 1
   • Include straight leg raises and static quadriceps contractions in the first 2 weeks 1, 6
   • Progress to concentric and eccentric exercises in closed kinetic chain 1

4. Exercise Progression:

   • Closed kinetic chain exercises should be prioritized in the first postoperative month 1, 6
   • Open kinetic chain exercises (90°-45°) can be added as early as 4 weeks 1, 6
   • Combine strength training with neuromuscular and motor control re-education exercises 1, 6

Special Considerations for TTO

While the evidence specifically addressing ACL reconstruction with TTO is limited, the addition of TTO to ACL reconstruction may warrant some modifications:

• The tibial tubercle osteotomy component may require more careful progression of weight-bearing activities
• Monitor for signs of pain, swelling, or increased temperature when advancing weight-bearing 6
• Ensure proper healing of the osteotomy site before progressing to more advanced exercises

Exceptions to Consider

While routine bracing is not recommended, bracing may be considered in specific circumstances:

• Patients with associated ligament injuries 1
• Based on individual patient preferences 1
• Cases where additional stability is required during early healing phases

Monitoring and Progression

Rehabilitation should be guided by:

• Pain levels
• Swelling response
• Range of motion progress
• Quadriceps activation and control
• Functional performance on clinical tests

Conclusion

The evidence strongly supports avoiding routine knee bracing after ACL reconstruction with TTO. Focus instead on immediate knee mobilization, progressive weight-bearing, and early strength/neuromuscular training for optimal outcomes and faster recovery.