Australian research provides more evidence for non-surgical ACL treatment, with potential long-term benefits for osteoarthritis.
An Australian study has added to a small but growing body of evidence that ACL injuries can be successfully treated by non-surgical means.
The study, along with other recent research showing better outcomes in non-surgical than surgical treatment of ACL injuries – including potential benefits in reduced risk of developing osteoarthritis – adds weight to recommendations that ACL injuries should first be treated by non-surgical means.
For the current study, published in the British Journal of Sports Medicine and led by Dr Stephanie Filbay of the University of Melbourne, 80 patients with acute ACL rupture were managed with a cross bracing protocol.
The protocol involved a brace that held the knee at 90 degrees for four weeks, with a gradual increase in range of motion over a subsequent eight weeks, followed by physio-supervised rehab.
“The cross bracing protocol aims to facilitate ACL healing by reducing the gap distance between the two torn ends of the ruptured ACL,” Dr Filbay told Rheumatology Republic.
“It was hypothesised that if we could do that – reduce the distance between the ACL by moving the knee to 90 degrees, and then holding that in place with a knee brace – that it might increase the number of people that experience healing,” she said.
After three months, 90% of patients had evidence of healing (a continuous ACL). While evidence of ACL healing was determined by MRI, Dr Filbay pointed out it also translated to patient reported outcomes, such as return to sport, quality of life and knee function scores and knee laxity.
Dr Filbay was lead author on a paper published last year comparing rehabilitation (with the option of delayed surgery) after ACL rupture with early surgery followed by rehab. The researchers found that 53% of people who received rehabilitation alone – exercise therapy and strengthening exercises – had healed, and had better outcomes in terms of sport and recreational function and knee-related quality of life than those who underwent surgery.
This challenges the prevailing belief that all ACL ruptures should be treated with surgery.
“In Australia, 90% of people undergo surgery for a ruptured ACL,” said Dr Filbay.
“A lot of people think surgery is needed if you want to return to sport, and it’s the best treatment option. That’s actually not what the evidence shows.”
While the outcomes included in the current study are relatively short-term, Dr Filbay is also interested in longer term outcomes, in particular post-traumatic knee osteoarthritis.
“This is a really important question: if we can naturally heal the ACL and restore knee function that way, could that reduce the rate of osteoarthritis?” said Dr Filbay.
“A recent umbrella review found a higher rate of osteoarthritis after surgery, compared to non-surgery, at least in terms of radiographic osteoarthritis. We know there’s less evidence when it comes to symptomatic osteoarthritis, that what we see on X ray doesn’t always correlate with people’s knee symptoms. But it suggests that it may be somewhat higher after surgery.”
“We certainly want to look into that in the future. We’ve now had over 360 people that have been braced. And we want to follow those people over time, so 5-10 years, then we can start to understand what happens in terms of knee osteoarthritis.”
The researchers pointed out that it was a pragmatic study, with data collected in the course of clinical practice rather than in a research setting. Adjustments to protocol made along the way and some data were collected by unblinded clinicians.
The researchers have called for randomised clinical trials with larger cohorts and longer follow-up, allowing comparisons with rehabilitation alone and surgery.
“If the benefits of this treatment are supported by a clinical trial, this could result in a paradigm shift, whereby people aim to heal a ruptured ACL rather than reconstruct it with surgery,” Dr Filbay said.
“We are now planning a clinical trial to assess whether this new treatment results in better outcomes than ACL surgery for acute ACL rupture.”
