The Use of Unloader Bracing in the Management of Knee Osteoarthritis: A Modified Delphi Consensus Study.

Purpose

To develop international expert consensus on the role of unloader bracing in the management of tibiofemoral osteoarthritis (OA) by addressing indications, contraindications, clinical evaluation, perioperative applications, and research priorities using a modified Delphi methodology.

Methods

A modified Delphi process was conducted in line with the Arthroscopy consensus methodology guidance. Twenty-nine knee preservation specialists across 5 continents participated. An evidence review meeting with consensus breakout discussions informed the development of 57 initial statements, which were rated anonymously across 3 survey rounds using a 5-point Likert scale. Predefined consensus thresholds were ≥70% agreement and <20% disagreement for rounds 1 and 2 and ≥75% agreement and <10% disagreement in round 3. Statements were iteratively refined with feedback until consensus was achieved after 3 rounds.

Results

All 29 experts completed all 3 rounds (100% response rate). All 42 of the statements in round 3 achieved consensus. There was strong agreement that unloader bracing reduces ipsilateral compartment contact pressures and should be considered within a multimodal management pathway for tibiofemoral OA. Consensus supported bracing for symptomatic unicompartmental OA, particularly in those with correctable alignment on clinical examination. Experts endorsed the use of unloader braces as a screening tool prior to osteotomy, for symptomatic management while awaiting surgery, and as a postoperative adjunct in symptomatic patients with ipsilateral malalignment. A minimum 6-week diagnostic trial and a 6-month therapeutic period were agreed on for use. Future research priorities included standardized bracing protocols and high-quality randomized trials.

Conclusions

This modified Delphi consensus study provides expert-derived recommendations for the use of unloader bracing in the management of knee OA, across nonoperative, preoperative, perioperative, and postoperative contexts. Although unloader bracing should not replace definitive surgical options where indicated, it may serve as a valuable adjunct or alternative treatment in selected patients, particularly those with unicompartmental disease with correctable malalignment. LEVEL OF EVIDENCE Level V, expert consensus.