Can a knee brace be used to manage contracture in a patient with an infected knee?

Knee Bracing for Contracture with Infected Knee

A knee brace should NOT be used for contracture management in the setting of an active knee infection, as the infection must be definitively treated first through surgical debridement and/or staged revision procedures before any mechanical interventions for contracture can be safely considered.

Critical Priority: Infection Control First

The management of an infected knee requires immediate focus on infection eradication, not contracture management. The available evidence on infected knee prostheses demonstrates that:

• Active infection requires surgical intervention (debridement, one-stage or two-stage revision) combined with appropriate antibiotic therapy as the primary treatment 1, 2, 3
• Two-stage exchange arthroplasty achieves 82-100% success rates in infection eradication and is considered the gold standard for chronically infected knee arthroplasties 2, 4
• Infection control takes absolute precedence over any mechanical interventions for contracture, as uncontrolled infection leads to progressive tissue destruction, sepsis risk, and potential limb loss 3

Why Bracing is Contraindicated During Active Infection

Bracing an infected knee creates multiple serious risks:

• Skin breakdown and pressure necrosis from brace contact on compromised, infected soft tissues increases the risk of spreading infection 5
• Trapped moisture and warmth under a brace creates an ideal environment for bacterial proliferation
• Delayed recognition of worsening infection as the brace obscures visual inspection of the knee
• Mechanical stress on infected tissues may propagate infection into deeper structures or cause pathologic fracture through weakened bone

The Appropriate Treatment Sequence

The correct algorithmic approach is:

1. Diagnose and stage the infection using tissue cultures, fluid analysis, and serology 2
2. Perform surgical debridement within 2 weeks of infection onset if acute, or staged revision if chronic 3
3. Administer appropriate intravenous antibiotics based on culture sensitivities 2, 3
4. Achieve documented infection eradication through repeat cultures and inflammatory markers 2, 4
5. Only after confirmed infection resolution, address any residual contracture through physical therapy, serial casting, or dynamic splinting

Spacer Use During Two-Stage Revision

If the patient requires two-stage revision for an infected knee prosthesis:

• Static or articulating antibiotic-impregnated cement spacers are used between stages, which serve an entirely different purpose than bracing 2, 4, 6
• These spacers deliver local antibiotics and maintain some joint space, but are temporary surgical implants, not external braces 6
• Articulating spacers may preserve better range of motion (median 100° flexion achieved) compared to static spacers, potentially reducing subsequent contracture 2, 4
• Spacers are removed at second-stage reimplantation once infection is controlled 2, 6

Post-Infection Contracture Management

Only after documented infection eradication:

• Contracture management can begin with physical therapy and progressive range-of-motion exercises 2
• If mechanical support is eventually needed for instability (not contracture), functional knee braces may be considered, but only in the absence of active infection 5, 7
• Functional braces are indicated for instability support, not contracture correction 5, 7

Critical Pitfall to Avoid

Never attempt to manage contracture with bracing while infection is present. The guideline evidence clearly lists "unstable knees requiring operative therapy" as a contraindication to knee bracing 5, and an infected knee absolutely requires operative therapy. Attempting conservative contracture management delays definitive infection treatment, risking progression to sepsis, bone destruction, or amputation 3.