4 ms·

The highlights, as I understand them: -In November 2022, the principal investigator on this study published the results of a different study which found MRI ev

The highlights, as I understand them: -In November 2022, the principal investigator on this study published the results of a different study which found MRI evidence of ACL healing in 30% of patients who were randomized to physical therapy with optional delayed ACL reconstruction. [0] -When an ACL is fully torn, the gap between the ruptured ends inhibits healing. Since the ruptured ends are in closest proximity at 90°-135° of knee flexion, this study investigated whether bracing the knee at 90° would facilitate ACL healing. -This study lasted five years and involved 80 patients. All participants had full-thickness ACL tears (complete discontinuity of the ACL on MRI). The protocol involved four weeks of bracing the knee at 90°, followed by progressive brace adjustments that slowly increased knee range of motion. The brace was removed at 12 weeks. -At three months, 90% of patients showed evidence of ACL healing on MRI. Moreover, MRI evidence of ACL healing was associated with better outcomes. This is monumental. [0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9872245/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9872245/

tomcam 3y ago
So 90% of patients who wore the knee brace instead of getting a surgery healed properly?
- trogdor 3y ago
  There is no definition of “healed properly” in relation to ACLs, in part because it is (hopefully soon was) commonly believed that a ruptured ACL has limited healing capacity. Patients were eligible for this study if they presented within one month of acute ACL rupture confirmed on MRI. The MRI had to show full discontinuity of ACL fibers. “After management with the Cross Bracing Protocol, 72 out of 80 (90%) participants with complete discontinuity of the ACL at baseline had signs of ACL healing (ACL continuity) on 3-month MRI.” The paper explains the rating scale they used to evaluate ACL healing on MRI.
  - tomcam 3y ago
    Thanks for the closer reading!
- DoingIsLearning 3y ago
  They didn't heal, a full rupture is a full rupture. They showed that for younger patients they can, through physical therapy, replace the ACL stability function with overcompensated proprioception and musculature. I wonder what the outcome of this would be as patients get older and start to lose muscle mass.
  - silisili 3y ago
    I had a tear sometime in the 90s, and then not surgery until the 2000s, the good old cut your kneecap in half kind. The doctor I saw once a year prior seemed to imply this. He implored me to do specific weight exercises, and claimed if I did it right 'you wont even need that surgery.' So it must have been at least a working theory for a while?
  - trogdor 3y ago
    They did heal.
  - SketchySeaBeast 3y ago
    > After management with the Cross Bracing Protocol (CBP), 72 out of 80 (90%) participants with complete discontinuity of the ACL at baseline had signs of ACL healing (ACL continuity) on 3-month MRI. Seems pretty definitive as healing to me.
toomuchtodo 3y ago
Huge for reducing unnecessary surgical procedures. In what situations would surgery still be required? Edit: would imaging be able to delineate?
- tryptophan 3y ago
  Having 10% not heal isn’t great… Since surgery is much more reliable I see it still being standard of care.
  - ntonozzi 3y ago
    How reliable is surgery?
  - collinc777 3y ago
    Surgery is invasive and recovery is rough. Not sure what the data says but I would’ve liked this option
  - Robotbeat 3y ago
    Standard of care could be bracing followed by surgery if it's not taking.
  - pgreenwood 3y ago
    No, 90% is massive if true. Speaking from experience the surgery is an absolutely brutal experience. Even though my graft was successful, if I had my time over I'm very much not sure I would make the same choice. I would at least explore other avenues. Many people do fine without an ACL. In my case my cartilage went from, in my surgeons words, pristine (post injury and before surgery), to tricompartmental osteoarthritis 18 months after the operation.
  - SketchySeaBeast 3y ago
    Surgery involves taking strength from another ligament (and attached muscle group) and a long and painful recovery process.
    - 3y ago
anitil 3y ago
The patients were 26+-10 years, so possibly less applicable later in life, but still fantastic
chakintosh 3y ago
Monumental especially for football players who are usually never the same after an ACL surgery which often leads to the shortening of the tendon, limiting its efficacy and putting it at a greater strain which leads to an inevitable relapse.
- tomtheelder 3y ago
  I’d think for athletes a 10% chance of failure would make it a total non starter.
  - compscigirl 3y ago
    This is an odd take. From what I understand from the article it’s a 90% chance of healing, after which you can still get surgery — which doesn’t heal but restores some functionality by grafting from another tendon. I’d imagine athletes would be particularly interested in trying this new treatment prior to considering surgery.
    - tomtheelder 3y ago
      My assumption was that the original comment was about professional athletes. For them any delay to returning is generally considered disastrous, and reconstruction success rates for them are near 100%, their recovery timelines are extremely quick, and doing PT all day isn’t really that different from what they normally do. Recovered performance is also incredibly good these days in most cases. This conservative approach could become the default for most everyone else, but for professional athletes 90% success is not going to fly. If the original comment was about casual athletes then none of this applies.

tomcam 3y ago

So 90% of patients who wore the knee brace instead of getting a surgery healed properly?

trogdor 3y ago
There is no definition of “healed properly” in relation to ACLs, in part because it is (hopefully soon was) commonly believed that a ruptured ACL has limited healing capacity. Patients were eligible for this study if they presented within one month of acute ACL rupture confirmed on MRI. The MRI had to show full discontinuity of ACL fibers. “After management with the Cross Bracing Protocol, 72 out of 80 (90%) participants with complete discontinuity of the ACL at baseline had signs of ACL healing (ACL continuity) on 3-month MRI.” The paper explains the rating scale they used to evaluate ACL healing on MRI.
- tomcam 3y ago
  Thanks for the closer reading!
DoingIsLearning 3y ago
They didn't heal, a full rupture is a full rupture. They showed that for younger patients they can, through physical therapy, replace the ACL stability function with overcompensated proprioception and musculature. I wonder what the outcome of this would be as patients get older and start to lose muscle mass.
- silisili 3y ago
  I had a tear sometime in the 90s, and then not surgery until the 2000s, the good old cut your kneecap in half kind. The doctor I saw once a year prior seemed to imply this. He implored me to do specific weight exercises, and claimed if I did it right 'you wont even need that surgery.' So it must have been at least a working theory for a while?
- trogdor 3y ago
  They did heal.
- SketchySeaBeast 3y ago
  > After management with the Cross Bracing Protocol (CBP), 72 out of 80 (90%) participants with complete discontinuity of the ACL at baseline had signs of ACL healing (ACL continuity) on 3-month MRI. Seems pretty definitive as healing to me.

toomuchtodo 3y ago

Huge for reducing unnecessary surgical procedures. In what situations would surgery still be required? Edit: would imaging be able to delineate?

tryptophan 3y ago
Having 10% not heal isn’t great… Since surgery is much more reliable I see it still being standard of care.
- ntonozzi 3y ago
  How reliable is surgery?
- collinc777 3y ago
  Surgery is invasive and recovery is rough. Not sure what the data says but I would’ve liked this option
- Robotbeat 3y ago
  Standard of care could be bracing followed by surgery if it's not taking.
- pgreenwood 3y ago
  No, 90% is massive if true. Speaking from experience the surgery is an absolutely brutal experience. Even though my graft was successful, if I had my time over I'm very much not sure I would make the same choice. I would at least explore other avenues. Many people do fine without an ACL. In my case my cartilage went from, in my surgeons words, pristine (post injury and before surgery), to tricompartmental osteoarthritis 18 months after the operation.
- SketchySeaBeast 3y ago
  Surgery involves taking strength from another ligament (and attached muscle group) and a long and painful recovery process.
  - 3y ago

anitil 3y ago

The patients were 26+-10 years, so possibly less applicable later in life, but still fantastic

chakintosh 3y ago

Monumental especially for football players who are usually never the same after an ACL surgery which often leads to the shortening of the tendon, limiting its efficacy and putting it at a greater strain which leads to an inevitable relapse.

tomtheelder 3y ago
I’d think for athletes a 10% chance of failure would make it a total non starter.
- compscigirl 3y ago
  This is an odd take. From what I understand from the article it’s a 90% chance of healing, after which you can still get surgery — which doesn’t heal but restores some functionality by grafting from another tendon. I’d imagine athletes would be particularly interested in trying this new treatment prior to considering surgery.
  - tomtheelder 3y ago
    My assumption was that the original comment was about professional athletes. For them any delay to returning is generally considered disastrous, and reconstruction success rates for them are near 100%, their recovery timelines are extremely quick, and doing PT all day isn’t really that different from what they normally do. Recovered performance is also incredibly good these days in most cases. This conservative approach could become the default for most everyone else, but for professional athletes 90% success is not going to fly. If the original comment was about casual athletes then none of this applies.