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ACL Treatment Decisions

Following acute injury to the ACL, until recently there have been two main treatment options, rehabilitation and surgery. There is now a third option, the Cross Bracing Protocol.
  1. Surgery
  2. Non surgical options
    • Rehabilitation alone
    • The Cross Bracing Protocol

For more detail on the Cross Bracing Protocol, refer to the 2023 British Journal of Sports Medicine article

The Three Pathways of Treatment

Practitioners will see Indications and Contraindications when logged in

Dr.Mervyn Cross assisted in the operating theatre by Dr. Tom Cross, during an ACL reconstruction. 1997-2012

1. Surgical options

ACL Reconstruction, using graft material from the patient or a donor, has been practiced for decades, is well understood and offers reliable results in the hands of trained knee surgeons.

There is also the potential for repair of a partially ruptured ACL. This is an evolving area with less long-term follow-up and certainty. It is also an area that can be offered to a limited number of patients with an injured ACL.

Reconstruction more often than not uses either hamstring tendons or a part of the patella tendon as graft material. This is fixed in place at the origin and insertion of the patient’s ACL. The procedure requires the removal of any remaining ACL tissue and the points of fixation of the graft material do not exactly match the pattern of attachment that the native ACL enjoyed.

Advantages:

  • A long history (over 40 years) of results giving a measure of outcome certainty.
  • Immediate commencement of rehabilitation
  • Other knee injuries, such as meniscal tears, can be addressed simultaneously.

Disadvantages:

  • An invasive procedure
  • Expensive
  • 15% re-rupture rate, although it should be noted that this has not been excluded or studied with the CBP as yet.
  • 30% re-rupture rate in patients less than 20 years old.
  • Requires a long period of rehabilitation . Return to sport is not recommended before 12 months.

2. Rehabilitation alone

The ACL is arguably the most important ligament that stabilises the knee to facilitate a broad range of movements and activities.

Rehabilitation alone is widely practiced, especially in northern Europe, where the public health authorities, after extensive research, deem this is the preferred initial management of acute ACL injury. This is also practiced  by default in the UK where the wait time for any reconstructive surgery is at least one year. Patients adopt this treatment and those that suffer recurrent knee instability and/or significant symptoms (pain, swelling, loss of function) “cross-over” to delayed ACL reconstructive surgery.

Advantages:

  • Non-invasive
  • A degree of efficacy found in clinical trials
  • Less expensive
  • Surgery still an option for those that do not get a result that is adequate for their needs and condition.

Disadvantages:

  • Possible poorer resultant knee kinematics overall
  • Lower likelihood of return to sport at the same level
  • Long period committed to the process

3. The Cross Bracing Protocol (CBP)

The Cross Bracing Protocol (CBP) is a form of rehabilitation where the chance for the ACL to heal in a functional fashion is facilitated and enhanced.

This outcome is achieved through careful selection of the type of injury to the ACL, and through the bracing protocol which puts the injured ACL in a position to heal naturally and protects it while this healing is happening. In effect this is an extension of Rehabilitation alone, an extension which can be offered to about half of all acutely injured ACL patients. The half of patients that have  an injured ACL who are unlikely to benefit from the CBP can be offered surgery in the first instance or to consider adopting “rehabilitation alone”.

Advantages:

  • An anatomically healed ACL is hypothesised to be as strong as the patient’s original ACL tissue.
  • Non-invasive
  • A degree of efficacy found in clinical trials
  • Less expensive
  • Surgery still an option for those that do not get a result that is adequate for their needs and condition.

Disadvantages:

  • Long period committed to the process
  • The need to wear a knee brace for twelve weeks. This is both challenging and inconvenient. The analogy that a ruptured ACL is equivalent to a fractured tibia that will heal without surgery, but there is a need for immobilisation (a plaster cast for the fractured tibia) and crutches.
  • Requires a long period of rehabilitation . Return to sport is not recommended before 12 months.

Your attending doctor will help guide you through each of these decisions and help you select the best outcome for your knee.

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WELCOME TO HEAL ACL. A COUPLE OF THINGS TO NOTE...

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