Braces

The Braces recommendation has been downgraded one level because of heterogeneity.

Four high, four moderate and two low quality studies were included for review, following the application of exclusion criteria by committee (Brouwer 2006; Kirkley 1999; Callaghan 2015; Van Raaij 2010; Thoumie 2018; Hjartarson 2018; Petersen 2018; Niazi 2014; Hungerford 2013; Yu 2016). Three prospective randomized controlled trials compared bracing to control groups for treatment of symptomatic OA of the knee joint and found statistically significant and clinically meaningful improvement in patient symptoms related to symptomatic OA of the knee (Callaghan 2015; Thoumie 2018; Brouwer 2006b). Kirkley et al compared outcomes between valgus offloading brace, neoprene sleeve, and non-brace control for symptomatic OA and Varus alignment. This study reported statistically significant improvement in disease specific quality of life and function in both study groups (Kirkley 1999). The study by Brouwer et al., comparing valgus bracing to a non-braced control, and reported no significant difference in functional assessment, PRO or pain; however, clinically significant improvements were noted in walking distance (1.25km[0.15,2.35]) for the brace group. Subgroup analysis demonstrated greater positive effect of bracing in patients with varus alignment and more severe symptoms. Callaghan et al examined the effects of bracing for patella-femoral OA and found significant improvement from baseline VAS and KOOS pain scores. Finally, Hjartarson et al examined outcomes of bracing vs. placebo by removing valgus tension straps from the control group brace. In their study they reported statistically significant and clinically meaningful improvements in KOOS sub scores: symptoms, ADL, sports and recreation, and quality of life.

Benefits/Harms of Implementation
Braces can provide significant pain relief and improved function to patients that have unicompartmental knee osteoarthritis. Braces can provide a subjective feeling of more normal tibiofemoral kinematics, preventing excessive strain on the affected compartment while protecting against preexistent concomitant  meniscal and chondral injuries. There is also a theoretical benefit of increased confidence in the knee during the different activities by providing a sense of security to the knee. There are almost no harms in trialing a brace besides some skin irritation, or the brace being uncomfortable.

Future Research
Future high-quality studies that are well powered are required to assess the real efficacy of unloader braces vs knee sleeves in a population with similar mechanical axis with a similar degree of OA.