Postoperative Knee Bracing After MPFL Reconstruction with Osteochondral Fragment Fixation
Use a hinged knee brace rather than a rigid immobilizer, but recognize that even the hinged brace may not be necessary and could potentially delay rehabilitation—the key is immediate mobilization with early range of motion exercises starting within the first week postoperatively.
The Evidence Against Immobilization
The most recent and highest-quality evidence strongly argues against rigid immobilization after knee ligament reconstruction:
Immediate mobilization without bracing is superior: The American Academy of Orthopaedic Surgeons and British Journal of Sports Medicine both recommend against routine postoperative knee immobilizer use following ACL reconstruction, as immobilizers provide no benefit and may impede rehabilitation progress 1, 2.
Bracing shows no outcome benefit: After isolated MPFL reconstruction, a 2024 study demonstrated that patients who did not use a brace achieved faster return of quadriceps function (41 vs 44 days to straight leg raise without lag, p=0.01) and had significantly lower reoperation rates (0% vs 12.1%, p=0.001) compared to braced patients 3.
Early motion is critical: The accelerated early rehabilitation protocol characterized by early unrestricted motion and weight-bearing without an immobilizing brace, combined with early strength training, is the evidence-based standard 4.
If You Must Use Bracing: Choose Hinged Over Rigid
When surgeon preference or patient anxiety dictates some form of bracing, a hinged knee brace is preferable to a rigid immobilizer:
Hinged braces allow controlled motion: Functional knee braces with hinges permit early range of motion exercises while providing psychological reassurance and some stability during the healing phase 4, 5.
Duration should be minimal: If used, the brace should only be worn until return of quadriceps function (typically 4-6 weeks maximum), as determined by the treating physical therapist's assessment of straight leg raise without extensor lag 3.
Avoid prolonged use: Extended bracing beyond the early postoperative period (>6 weeks) provides no additional benefit and may contribute to muscle weakness and delayed functional recovery 3.
What You Should Do Instead: The Optimal Rehabilitation Protocol
Start rehabilitation on the day of surgery with immediate knee mobilization:
Immediate range of motion: Begin active knee flexion and extension exercises within the first week postoperatively, as early mobilization improves early phase knee range of motion without compromising knee laxity 4.
Early quadriceps activation: Initiate isometric quadriceps exercises including static quadriceps contractions and straight leg raises during the first 2 postoperative weeks, which confers advantages for faster recovery of knee range of motion without compromising stability 4, 2.
Progressive weight-bearing: Allow immediate weight-bearing as tolerated from day one, which reduces hospital length of stay and improves both pain and function compared to delayed mobilization 1.
Early strengthening: Start leg press exercises at 3 weeks to improve subjective knee function and functional outcomes 4.
Special Considerations for Your Case
Given the combination of osteochondral fragment fixation with MPFL reconstruction in an 18-year-old:
The osteochondral fragment is the limiting factor: While the MPFL reconstruction alone would not require bracing based on current evidence 3, the fixation of the medial-facet osteochondral fragment requires protection during initial healing (typically 6-8 weeks for bone healing) 5.
Hinged brace with motion limits: If you choose to brace, use a hinged knee brace with adjustable range of motion limits (starting at 0-30° and progressively increasing) rather than a rigid immobilizer, allowing controlled early motion while protecting the osteochondral fixation 4, 5.
Weight-bearing restrictions matter more: Focus on appropriate weight-bearing restrictions (typically touch-down weight-bearing for 4-6 weeks) rather than rigid immobilization, as this protects the osteochondral fragment while allowing beneficial early motion 5.
Common Pitfalls to Avoid
Don't continue bracing based on tradition: The American Academy of Family Physicians warns against continuing bracing based on surgeon preference when evidence doesn't support benefit 2.
Don't delay mobilization: Immobilizers may delay rehabilitation and impede early mobilization, which is critical for optimal outcomes 1.
Don't confuse psychological reassurance with clinical necessity: Many patients report subjective improvements with bracing that exceed objective measurements, but this false sense of security should not drive clinical decision-making 4.
Monitor for anterior knee pain: When starting early strengthening exercises, anterior knee pain should be monitored closely, with load progressed appropriately 4.