PURPOSE: To establish an international expert consensus on the role of unloader bracing in the management of focal tibiofemoral cartilage lesions using Delphi methodology to inform clinical decision-making in both nonoperative and operative contexts and identify future research priorities.
METHODS: A modified Delphi study was conducted with an international expert panel of 29 sports medicine surgeons and researchers in knee cartilage pathology. The panel participated in a structured, in-person evidence review meeting in May 2025 followed by 3 iterative rounds of anonymized online surveys. Draft statements were developed after the meeting, forming the first-round survey. Consensus was defined "a priori" as ≥70% agreement and <20% disagreement in rounds 1 to 2 and ≥75% agreement and <10% disagreement in round 3.
RESULTS: All 29 experts attended the evidence review meeting and completed all 3 rounds of surveys (100% response rate). This meeting generated 97 statements for round 1. After round 1, 41.2% of statements met the criteria for progression. After round 2, 90% of items achieved consensus. In the final round, consensus was achieved for 72 of 73 statements. Key areas of agreement included (1) the biomechanical rationale for unloader bracing, (2) weight-bearing long-leg alignment radiographs and magnetic resonance imaging for evaluation, (3) indications and contraindications across nonoperative and perioperative contexts, and (4) a priority for standardized clinical protocols and high-quality trials to evaluate efficacy.
CONCLUSIONS: This international modified Delphi study showed expert consensus that unloader bracing is a biomechanically rational and clinically useful adjunct in selected patients with symptomatic tibiofemoral cartilage lesions, particularly in the setting of ipsilateral compartment malalignment or neutral alignment. Consensus supported its role in nonoperative management, perioperative cartilage protection, postoperative rehabilitation, and as a screening adjunct prior to alignment-correcting osteotomy. These recommendations provide a structured framework for integrating unloader bracing into cartilage management pathways while identifying priorities for future research.
LEVEL OF EVIDENCE: Level V, expert consensus.
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