Novel Design of an Anterior Cruciate Ligament Injury Prevention Brace

D. Greenshields
1
, R. Porter
1
, J. Killewald
1
, and EG. Meyer
1

1 Lawrence Technological
University, Southfield, MI


Introduction
Approximately 200,000 anterior cructiate ligament (ACL) injuries occur in the United States annually. In sports
such as soccer or basketball, females have an increased risk of ACL injury compared with males, which may be due
to intrinsic differences of knee alignment or neuromuscular patterns. [1] Most ACL injuries occur without direct
contact from another player and commonly cited injury mechanisms include: knee hyperextension or valgus
bending, internal rotation of the tibia, and tibiofemoral compressive loading. [2] Although some athletes wear braces
to reduce the risk of ACL injury, those braces are designed to protect against hyperextension and valgus bending.
[3] Another type of knee brace is a unicompartmental osteoarthritis brace. These braces typically function to reduce
the pressure on the medial compartment by offloading some of the tibiofemoral compressive load to the lateral
compartment. [4] On the other hand, valgus knee position was recently shown to reduce the tibiofemoral
compressive force required to produce ACL injury in cadaver knees. [5] This is likely due to the steeper and
therefore more unstable posterior tibial slope on the lateral versus the medial compartment. [6] The objective of this
project was to redesign the hinge mechanism of a prophylactic knee brace to shift part of the tibiofemoral
compressive force from the lateral to the medial compartment of the knee.

Materials and Methods
The design goals of the knee brace with a modified hinge included; 1) continuing to protect against or reduce the
severity of ACL injuries due to hyperextension and valgus bending while allowing knee range of motion during
athletic movements, 2) position the knee in a slightly varus bending angle compared to the baseline anatomy, 3)
convert part of the vertical ground reaction force into a lateral brace displacement when the knee is near full
extension. These specifications should create a varus bending angle of the knee during jump landing or rapid
deceleration movements which would stabilize the knee joint by partially unloading compression across the lateral
compartment, therefore reducing the risk to the ACL.
The four conceptual ideas to achieve the design goals were a spider gear, wedge pad, four bar linkage, or a leaf
spring setup. The list of specifications included: weight, manufacturability, safety, strength, effectiveness to control
lateral movement and ease of modification. The wedge pad was selected as the design that best achieved the
specifications and had the fewest negative attributes. The design process started with multiple rough drawings of the
hinge design and function (Figure 1). The basic parts and functioning mechanisms were included in the initial
sketches. Following, an AutoCAD version of the conceptual hinge was prepared to better represent the hinge and all
of the moving parts. The AutoCAD file included all the appropriate dimensions set to scale. Next, a rough hinge
prototype was fabricated from steel. Steel was chosen as the material for the rough prototype due to its relative
inexpensive cost and the ability to determine if the functioning mechanisms would work. The final hinge was
fabricated out of aluminum due to the lighter material, strength to weight ratio and ease in fabrication. To decrease
the effort required during the fabrication process, some of the parts from the original medial hinge were used. Once
all fabrication processes were complete, the hinge was attached to the medial side of a right-legged Donjoy Armor
knee brace.











Figure 1. Hinge design/prototype process from left to right: control brace, rough drawing, CAD drawing, steel
prototype, aluminum hinge, modified hinge brace.

Biomechanical human participant
testing (with IRB approval) was
conducted with three experimental
tests to validate the modified brace
function compared with an unmodified
brace. A male and a female participant
were used for the biomechanical
testing to validate the hinge design.
Three dynamic, experimental tests
were selected based on previous ACL
injury literature [7-10]. These
experiments consisted of a step-off,
drop (30 cm) landing with two legs, a
step-off, drop landing on one leg, and a
run-stop-jump landing on both legs
(Figure 2). Five repeated trials of each
experiment were recorded with an
eight camera Vicon 3D motion capture
and two forceplate system. Reflective markers were attached to the participants as designated in the full-body Plug-
in-Gait model. The model was then used to analyze each trial to determine the knee kinematics and kinetics.
Parameters of interest were; vertical ground reaction force, knee flexion angle, knee ab/adduction angle, and knee
valgus/varus moment during the landing phase of each experiment. After normalizing the independent variable time,
graphs showing the average and standard deviation for the five trials were created and the magnitudes for each
parameter at the time of the maximum vertical ground reaction force were tabulated.

Results and Discussion
The medial hinge of Donjoys Armour knee brace
was replaced with a modified hinge while the lateral
hinge remained the same (Figure 2 A & B). The brace
frame was attached to the modified hinge by four rods
that are connected to two wedges. The wedges move
in conjunction with the rods which work to compress
springs when a load is applied. The two wedges move
central to the knee joint and press against a wedge
pad to create a lateral brace movement at the knee
joint that increases the varus bending moment applied
to the knee.
Male and female participant tests revealed no
differences in the vertical ground reaction force or
knee flexion angle between the two braces for any of
the experiments, indicating that the modified brace
did not interfere with athletic performance any more
than the control brace. The average knee ab/adduction
angle was determined based on the Plug In Gait model during the three experimental tests (Figure 4). The
valgus/varus angle was analyzed when the vertical ground reaction force was at a maximum. During all three
experiments for both participants, the knee angle was aligned significantly more varus when wearing the modified,
compared with the control brace. The varus angle was increased by 17 for the male participant during the step-off
landing on both legs tests with the modified brace (Figure 4A). The female participant showed a larger valgus angle
with the control brace compared to the male participant. The varus angle was increased by 28 in the female
participant with the modified brace (Figure 4B). During the step-off landing on one leg tests there were increases in
the varus angles of 8 for the male participant (Figure 4C) and 10 for the female participant (Figure 4D) from the
control to the modified trials. Additionally, during the run stop-jump landing the varus angle increased by just over
10 when the modified brace was worn by the male participant (Figure 4E) and 15 when worn by the female
participant (Figure 4F). Finally, the valgus/varus moment about the knee decreased while using the modified brace
for both the male and female participants in all three experiments; two leg landing: 46Nm & 9Nm, one leg: 39Nm &
47Nm, and run-stop-jump: 16Nm & 13Nm (male and female, respectively).
Figure 2. Female participant with a right knee brace during the
three experimental dynamic landing tests.
Figure 3. Modified brace hinge design; (A) medial
view, (B) front view, (C) slight varus angle induced
due to lateral displacement of the medial brace hinge.
(A) (B) (C)
Step-off landing on both legs Step-off landing on one leg Run and stop jump
M
a
l
e



F
e
m
a
l
e



Figure 4. Male and female Plug In Gait ab/adduction knee angle kinematics in degrees (+ varus / -valgus) during the
landing phase as a percentage of scaled duration. Graphs for each experiment (A&B: Step-off landing on both legs,
C&D: Step-off landing on one leg, E&F: Run and stop jump) show the average and standard deviation during the
five repeated trials (Blue: control brace/ Green: modified brace).

Conclusions
The validation tests show that the modified brace has a full range of motion, stopped hyperextension and created a
varus knee angle. The modified brace is as comfortable to wear during sports activities as the control brace. The
differences in the frontal plane kinematics and kinetics indicate that the modified brace reduced the compressive
load on the lateral compartment of the knee joint. Future work to be done should be more human subject testing to
verify that the two test subjects are not part of an anomaly.

References: [1] Hewett TE, Am J Sports Med 2006;34(2):299-311. [2] Meyer EG, J Biomech 2008;41:3377-83. [3]
France EP, Am J Sports Med 1987;15(5):430-8. [4] Pollo FE, J Am Acad Orthop Surg 2006;14(1):511. [5] Meyer
EG, World Congress Biomech 2014:3105. [6] Marouane H, J Biomech 2014;47(6):1353-9. [7] Blackburn, J Athl
Train 2013;PMID:23768123. [8] Shimokochi Y, Knee Surg Sports Trauma Arth 2012;21(4):888-897. [9] Yu B,
Clin Biomech 2006;21:297-305. [10] Myer GD, Br J Sports Med 2011;45:245-252.
(A) (C) (E)
(B) (D) (F)