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

Stephanie R Filbay; Matthew Dowsett; Mohammad Chaker Jomaa; Jane Rooney; Rohan Sabharwal; Phil Lucas; Andrew Van Den Heever; James Kazaglis; Justin Merlino; Mick Moran; Maggie Allwright; Donald E K Kuah; Ra Durie; Greg Roger; Mervyn Cross; Tom Cross

doi:10.1136/bjsports-2023-106931

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

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

Authors

Stephanie R Filbay¹, Matthew Dowsett², Mohammad Chaker Jomaa³, Jane Rooney⁴, Rohan Sabharwal⁵, Phil Lucas⁵, Andrew Van Den Heever⁵, James Kazaglis⁶, Justin Merlino⁶, Mick Moran⁶, Maggie Allwright⁷, Donald E K Kuah⁸, Ra Durie⁹, Greg Roger^{10

11}, Mervyn Cross¹², Tom Cross¹²

Affiliations

¹ Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia stephanie.filbay@unimelb.edu.au.
² School of Medicine, Sydney Campus, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia.
³ School of Public Health, University of Sydney Medical School, Sydney, New South Wales, Australia.
⁴ Lifecare Prahran Sports Medicine Centre, Melbourne, Victoria, Australia.
⁵ PRP Diagnostic Imaging, Sydney, New South Wales, Australia.
⁶ Stadium Sports Physiotherapy, Sydney, New South Wales, Australia.
⁷ Northern Beaches Hospital, Sydney, New South Wales, Australia.
⁸ New South Wales Institute of Sports, Sydney, New South Wales, Australia.
⁹ Sportsmed Manawatu, Palmerston North, New Zealand.
¹⁰ The University of Sydney School of Biomedical Engineering, Darlington, New South Wales, Australia.
¹¹ Vestech Medical Pty Ltd, Sydney, New South Wales, Australia.
¹² The Stadium Sports Medicine Clinic, Sydney, New South Wales, Australia.

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.

MeSH terms

Anterior Cruciate Ligament Injuries* / surgery
Anterior Cruciate Ligament Injuries* / therapy
Anterior Cruciate Ligament* / surgery
Female
Humans
Knee Joint / surgery
Magnetic Resonance Imaging
Male
Quality of Life
Treatment Outcome