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. 2023 Dec;57(23):1490-1497.
doi: 10.1136/bjsports-2023-106931. Epub 2023 Jun 14.

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol

Stephanie R Filbay  1 , Matthew Dowsett  2 , Mohammad Chaker Jomaa  3 , Jane Rooney  4 , Rohan Sabharwal  5 , Phil Lucas  5 , Andrew Van Den Heever  5 , James Kazaglis  6 , Justin Merlino  6 , Mick Moran  6 , Maggie Allwright  7 , Donald E K Kuah  8 , Ra Durie  9 , Greg Roger  10   11 , Mervyn Cross  12 , Tom Cross  12
Affiliations

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol

Stephanie R Filbay et al. Br J Sports Med. 2023 Dec.

Abstract

Objective: Investigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP).

Methods: Eighty consecutive patients within 4 weeks of ACL rupture were managed with CBP (knee immobilisation at 90° flexion in brace for 4 weeks, followed by progressive increases in range-of-motion until brace removal at 12 weeks, and physiotherapist-supervised goal-oriented rehabilitation). MRIs (3 months and 6 months) were graded using the ACL OsteoArthritis Score (ACLOAS) by three radiologists. Mann-Whitney U tests compared Lysholm Scale and ACL quality of life (ACLQOL) scores evaluated at median (IQR) of 12 months (7-16 months) post-injury, and χ2 tests compared knee laxity (3-month Lachman's test and 6-month Pivot-shift test), and return-to-sport at 12 months between groups (ACLOAS grades 0-1 (continuous±thickened ligament and/or high intraligamentous signal) versus ACLOAS grades 2-3 (continuous but thinned/elongated or complete discontinuity)).

Results: Participants were aged 26±10 years at injury, 39% were female, 49% had concomitant meniscal injury. At 3 months, 90% (n=72) had evidence of ACL healing (ACLOAS grade 1: 50%; grade 2: 40%; grade 3: 10%). Participants with ACLOAS grade 1 reported better Lysholm Scale (median (IQR): 98 (94-100) vs 94 (85-100)) and ACLQOL (89 (76-96) vs 70 (64-82)) scores, compared with ACLOAS grades 2-3. More participants with ACLOAS grade 1 had normal 3-month knee laxity (100% vs 40%) and returned to pre-injury sport (92% vs 64%), compared with participants with an ACLOAS grades 2-3. Eleven patients (14%) re-injured their ACL.

Conclusion: After management of acute ACL rupture with the CBP, 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL). More ACL healing on 3-month MRI was associated with better outcomes. Longer-term follow-up and clinical trials are needed to inform clinical practice.

Keywords: Anterior Cruciate Ligament; Knee injuries; Orthopedics; Physical Therapy; Rehabilitation.

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Conflict of interest statement

Competing interests: SRF served on the Osteoarthritis Research Society International (OARSI) Board of Directors in 2022-2023, and received funding (for travel and accommodation) to attend two board meetings. MA received reimbursement to attend and speak at Smith and Nephew symposium at The Combined TOSSM & APKASS conference in Thailand, October 2022. TC has formed a non-financial relationship with Bauerfeind, Germany, and Bauerfeind, Australia, to select a knee brace that optimises patient comfort and compliance. This relationship has had no impact on the completion of this study. After the completion of this study, Bauerfeind, Germany, donated 100 braces to TC for use in clinical practice. Donated braces were not used with participants in this study.

Figures

Figure 1
Figure 1
Participant flow chart. ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; CBP, Cross Bracing Protocol; DVT, deep vein thrombosis; MCL, medial collateral ligament.
Figure 2
Figure 2
MRI images demonstrating MRI evidence of ACL healing for five participants. ACL, anterior cruciate ligament; ACLOAS, Anterior Cruciate Ligament OsteoArthritis Score.
See this image and copyright information in PMC

References

    1. Scapinelli R. Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10:151–62. 10.1002/(SICI)1098-2353(1997)10:3<151::AID-CA1>3.0.CO;2-X - DOI - PubMed
    1. Toy BJ, Yeasting RA, Morse DE, et al. Arterial supply to the human anterior cruciate ligament. J Athl Train 1995;30:149–52. - PMC - PubMed
    1. Yoshida M, Fujii K. Differences in cellular properties and responses to growth factors between human ACL and MCL cells. J Orthop Sci 1999;4:293–8. 10.1007/s007760050106 - DOI - PubMed
    1. Nguyen DT, Ramwadhdoebe TH, van der Hart CP, et al. Intrinsic healing response of the human anterior cruciate ligament: an histological study of reattached ACL remnants. J Orthop Res 2014;32:296–301. 10.1002/jor.22511 - DOI - PubMed
    1. Witkowski J, Yang L, Wood DJ, et al. Migration and healing of ligament cells under inflammatory conditions. J Orthop Res 1997;15:269–77. 10.1002/jor.1100150217 - DOI - PubMed

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