Cross Bracing Protocol

12th Aug, 2024

Key Points

  1. Novel bracing protocol shows promise in ACL healing: The Cross Bracing Protocol (CBP) resulted in ACL healing in 90% of participants within three months.
  2. Patient-reported outcomes improve with more ACL healing: Better knee function, quality of life, and higher return-to-sport rates were associated with more complete ACL healing.
  3. Non-surgical management offers an alternative to ACL reconstruction: The CBP provides a potential non-surgical option for managing ACL injuries.
  4. Clinical implication: The results suggest that ACL healing can occur with appropriate non-surgical management, challenging the notion that ACL injuries always require surgery.
  5. Study limitation: Further research is necessary, including long-term follow-up and clinical trials, to confirm these findings and assess the durability of ACL healing.

What is the current ACL management?

Current management of anterior cruciate ligament (ACL) injuries typically involves either surgical reconstruction or non-surgical rehabilitation. Surgical management, known as ACL reconstruction (ACLR), is often recommended for individuals who are highly active or participate in sports that require significant knee stability. ACLR involves replacing the torn ligament with a graft, which can be taken from the patient’s own tissue (autograft) or from a donor (allograft).

Non-surgical management, on the other hand, focuses on physiotherapy and rehabilitation to strengthen the muscles around the knee and improve knee stability. This approach is generally recommended for less active individuals or those who can adapt their activities to avoid high-risk movements. Non-surgical management may also include the use of braces to support the knee during activity.

The Cross Bracing Protocol (CBP) introduces a new non-surgical approach that aims to facilitate the healing of the ACL by immobilizing the knee in a flexed position to encourage tissue bridging between the torn ends of the ligament.

What is the hypothesis of the study and rationale for bracing the knee at 90˚?

Hypothesis:

The hypothesis of the study is that the Cross Bracing Protocol (CBP), which involves immobilizing the knee at 90˚ of flexion, can promote healing of a ruptured ACL, as evidenced by MRI, and lead to improved patient outcomes such as knee function, quality of life, and return to sport.

Rationale for 90˚ Bracing:

The knee is braced at 90˚ because this position shortens the distance between the torn ends of the ACL, facilitating tissue bridging and healing. The idea is that by minimizing the gap between the ligament remnants, the natural healing process is enhanced, potentially avoiding the need for surgical reconstruction. This approach contrasts with traditional methods that often assume a limited healing capacity of the ACL.

Demographics of the participants

Demographic Characteristic

Details

Total Number of Participants

80

Age Range

10 to 58 years

Mean Age (SD)

26 (10) years

Gender Distribution

39% Female, 61% Male

Concomitant Meniscal Injury

49%

Pre-Injury Activity Level

35% Recreational, 61% Competitive, 5% Professional

Time from Injury to Brace (Median)

5 days (IQR 4-11 days)

Use of Private Health Insurance

69%

Contact Mechanism of Injury

30%

Adherence to Bracing Protocol

96%

Platelet-Rich Plasma (PRP) Injection

18%

What is the Cross Bracing Protocol?

The Cross Bracing Protocol (CBP) is a non-surgical treatment strategy for acute ACL ruptures. The protocol includes the following steps:

  1. Initial Knee Immobilization: The injured knee is immobilized at 90˚ of flexion using a limited range-of-motion brace for the first four weeks following the injury. This position is maintained continuously, including during sleep and showering.
  2. Progressive Range-of-Motion Increases: Starting from week five, the range-of-motion in the brace is gradually increased at regular intervals. By week 10, unrestricted knee flexion is allowed, and the brace is completely removed by week 12.
  3. Physiotherapy-Supervised Rehabilitation: Throughout the bracing period and after brace removal, patients undergo goal-oriented rehabilitation supervised by a physiotherapist. The rehabilitation focuses on lower limb neuromuscular control, muscle strengthening, power development, and functional training.
  4. Return to Sport: Return to sport is generally recommended between nine to twelve months post-injury, contingent upon the completion of rehabilitation and meeting functional criteria for return to sport.

Outcome measures and their interpretation

Outcome Measure

Interpretation

ACL Healing on MRI (ACLOAS Grading System)

90% of participants showed evidence of ACL healing at 3 months. Lower ACLOAS grades (more healing) were associated with better outcomes.

Lysholm Scale Score

A median score of 98 for participants with ACLOAS grade 1 indicates excellent knee function. A score >94 is considered excellent.

Knee-related Quality of Life (ACLQOL)

Higher scores (median 89) in participants with ACLOAS grade 1 indicate better quality of life post-injury.

Passive Knee Laxity (Lachman’s Test and Pivot-Shift Test)

Less knee laxity was observed in participants with better ACL healing (ACLOAS grade 1).

Return to Pre-Injury Sport

92% of participants with ACLOAS grade 1 returned to their pre-injury level of sport, indicating a successful outcome.

Conclusion of the study and implications for treatment decisions post-ACL injury

Conclusion:

The study concluded that the Cross Bracing Protocol (CBP) is associated with a high rate of ACL healing as visualized on MRI. Participants with more complete ACL healing reported better knee function, higher quality of life, and were more likely to return to their pre-injury level of sport. These findings suggest that non-surgical management of ACL injuries using the CBP may be a viable alternative to surgical reconstruction, particularly for those who meet the criteria for this treatment approach.

Clinical Implications:

Individuals with an ACL injury can consider the CBP as an alternative to surgery, especially if they prefer a non-invasive approach or have concerns about the risks associated with surgery. The protocol’s success in promoting ACL healing and restoring knee function offers a potential pathway for recovery that could reduce the need for surgery. However, patients should be aware that the CBP is an experimental treatment and may not be suitable for everyone. Consulting with a physiotherapist or orthopedic specialist is essential to determine the most appropriate treatment based on individual circumstances.

Frequently Asked Questions

What is the ACL?

The anterior cruciate ligament (ACL) is one of the key ligaments that help stabilize the knee joint. It connects the thigh bone (femur) to the shin bone (tibia) and prevents the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.

What is an ACL surgery?

ACL surgery, commonly known as ACL reconstruction, is a procedure to replace a torn ACL. The surgery typically involves using a graft from the patient’s own tissue or a donor to reconstruct the torn ligament, restoring knee stability and function.

What is an ACL tear?

An ACL tear is an injury where the anterior cruciate ligament is partially or completely torn. This type of injury is common in sports that involve sudden stops, changes in direction, or jumping, such as soccer, basketball, and skiing.

How long does an ACL tear take to heal without surgery?

Healing time for an ACL tear without surgery varies depending on the severity of the tear and the individual’s activity level. Non-surgical management, including physiotherapy and bracing, may allow the ligament to heal within several months, but full recovery and return to sports can take nine to twelve months or longer.

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