The Cross Bracing Protocol
The Cross Bracing Protocol is an advanced non-surgical method that promotes and enhances functional healing in Anterior Cruciate Ligament (ACL) injuries.
medi and The Cross Bracing Protocol with Dr Tom Cross - Live from Sydney
Join us Friday May 31st at 6:00pm for an international event live with Dr Tom Cross streamed online from Australia to the world.
Dr Tom Cross will discuss his work in the non-operative management of ACL injuries, his experience with The Cross Brace protocol and the research currently underway.
Following the presentation, there will be a Q&A session.
Registration required.
Please click below to register.
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Anterior Cruciate Ligament (ACL) injuries - A new and promising approach
Why is the ACL the lone ligament we don’t trust in its ability to self-repair, and why is it not reduced and allowed to heal naturally, like other musculoskeletal structures?
Not all patients benefit from conservative treatment of ligament injuries, nor is surgery always the optimal solution.
So, what is possible for conservative management?
This new approach to the healing of an injured ACL led to satisfactory healing in approximately 88% of patients chosen for the new process and approximately 50% of all injured ACLs*
The Cross Bracing Protocol involves immobilising the patient's knee in a brace set at a fixed angle of 90 degrees for four weeks following an ACL injury. Subsequently, each week permits increased extension: first to 60 degrees, then 45 degrees, then 30 degrees, 20 degrees, and finally 10 degrees. The brace is removed after 12 weeks, followed by a comprehensive follow-up including MRI and clinical examination.
This achievement stems from identifying the particular type of ACL injury and implementing the bracing protocol, which facilitates natural healing and safeguards the injured ACL during this process. Essentially, this extends the scope of rehabilitation for approximately half of all acutely injured ACL patients. The remaining half is unlikely to benefit from the Cross Bracing Protocol (CBP), with either surgery or a "rehabilitation alone" approach recommended.
The Cross Bracing Protocol was pioneered by Australian Sports and Exercise Medicine Physician Dr Tom Cross and Orthopaedic Surgeon (and Tom's father) Dr Mervyn Cross, with support from Doctor and Bioengineer Dr Greg Roger and a dedicated team of researchers.
This collaborative endeavour created a new and promising ACL injury protocol by utilising extensive expertise developed over numerous decades, including clinical assessment, innovative knee surgery, exploration of non-surgical interventions, and thorough medical and bioengineering research.
A Timeline of the Cross Bracing Protocol
The Cross Bracing Protocol stands as a testament to the vision and perseverance of Dr Tom Cross, spanning over five decades of pioneering work in ACL management that commenced with his father's 1973 foundational anatomical studies, whose surgical innovations propelled ACL reconstruction forward, revolutionising treatment methods.
1973
Dr Mervyn Cross does anatomic studies on the knees of cadavers.
1979
The American Journal of Sports Medicine publishes the results of these studies.
1974-2012
Dr Mervyn Cross reconstructed thousands of Anterior Cruciate Ligaments, assisted in the final 15 years by his son, Dr Tom Cross.
2014
Patient #1 is braced at 90 degrees for four weeks and gradually extended over the next four weeks.
2014-2019
16 patients adopt the early "Cross Bracing Protocol".
2020
Dr Tom Cross presents early results of 16 patients who adopted the CBP, at Canberra's Sports Medicine Conference.
2021
Dr Mervyn Cross presented the CBP at the meeting of the Herodicus Society, a specialist knee surgery group in the US.
2020 –2023
Dr. Tom Cross collaborated in submitting to the BJSM the results of the first 80 patients to adopt the CBP.
2014-2023
Over 460 patients have been enrolled in Dr Cross' research and continue treatment with this novel Cross-bracing technique.
JUNE 2023
Publication of the first 80 patients in the British Journal of Sports Medicine.
2023
Ongoing clinical implementation of the CBP, research and more publications of the findings.
2024
medi manufactures specialised 'wedges' for the M4s Comfort to extend the CBP across 90 countries.
Non-surgical management with the Cross Bracing Protocol
A common belief among researchers and clinicians is that a ruptured anterior cruciate ligament (ACL) has limited healing capacity. This belief has shaped current management strategies for ACL rupture.
Anatomical studies have demonstrated that the ACL has a rich vascular supply, and histological studies describe ruptured ACLs passing through the typical phases of healing after injury despite a slower rate of healing and reduced healing capacity compared with medial collateral ligament rupture.
An absence of tissue bridging the gap between ligament remnants has been observed, which may inhibit healing of ACL rupture. The distance between the ACL origin and insertion is shortest at 90°–135° of knee flexion.
We have developed the novel Cross Bracing Protocol (CBP), which aims to reduce the gap distance between the ligament remnants by immobilising the knee at 90° of flexion for four weeks after acute ACL rupture. This is done to facilitate tissue bridging and healing between the ruptured ACL remnants.
After four weeks, weekly incremental increases in the knee and the CBP range of motion are combined with physiotherapist-supervised rehabilitation to target lower limb neuromuscular control, muscle strengthening and power, and functional training to enable return-to-sport and recreational activities.
Filbay SR et al. 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;57:1490-1497.
4-point rigid brace with flexion / extension limitations
M.4s® comfort and the Cross Bracing Protocol
The M.4s comfort is a brace that is made for use in the therapeutic field of ACL injuries and has specific product features which make it comfortable to wear everyday over the whole period of rehabilitation.
A brace that fits perfectly on the human leg
The patients ability to be compliant will always be a question for a protocol thati immobilises a limb for such a period. At medi we understand this and we work hard to ensure that every material we use and every design feature that we put into our products, supports the patient through that process.
The Cross Bracing Protocol
The study team concluded that “After management of acute ACL rupture with a novel bracing protocol, 90% of patients had evidence of ACL healing on a 3-month MRI (continuity of the ACL). More ACL healing on a 3-month MRI was associated with better knee function and QOL, less passive knee laxity and a higher return-to-sport rate.”
M.4s®️ comfort features
- Optimal stabilisation using 4-point principle
- Safe collateral stabilisation by riged frame
- Extension and flexion limitation protects against damaging joint movements and relieves injured structures
- Optimal immitation of knee movement by using patented physioglide hinge technology
- Extension limitation: 5 degress Hypex*, 0°, 10°, 20°, 30°, 45°
- Flexion limitation: 0°, 10°, 20°, 30°, 45°, 60°, 75°, 90°, 120°*
- Immobilisation: 0°, 10°, 20°, 30°, 45°, 60° and 90°
1. The hinge design enables the wedges to be changed without using a tool, using tweezers present in each hinge cover.
2. Flat and lightweight frame design ensures that the brace is as comfortable to wear as possible under clothing.
3. The extra extended calf shells provides an improved fit and counteracts potential pressure points.
4. The movable D-rings adjust flexibly upon movement and ensures that the brace fits securely on the leg.
5. Special paddings takes into account the anatomical characteristics of the condyles as well as swelling to maximise fitting and comfort.
6. The physioglide hinge mimics the roll-glide movement of the knee and supports secure fit on the leg.
7. Comprehensive set of wedges for flexible extension and flexion limitation including 5 degree hyperextension wedge.
CBP Wedges
Stop kit set is required for the M.4S Comfort Knee Brace Cross Bracing Protocol.
Literature Summary
The KANON study
In 2010, The KANON study showed that, “In young, active adults with acute ACL tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. The latter strategy substantially reduced the frequency of surgical reconstructions.
Secondary analysis
Secondary analysis of this cohort (n=120, 18–35-year-old) published in 2023 showed, “MRI appearance of ACL healing after ACL rupture occurred in one in three adults randomised to initial rehabilitation and one in two who did not cross-over to delayed ACLR and was associated with favourable outcomes. The potential for spontaneous healing of the ACL to facilitate better clinical outcomes may begreater than previously considered.”
You want to learn more about the Cross Brace Protocol or save all the informations for your mobile device? Download our PDF including all informations here:
Sources:
*Combined with a method of selecting appropriate cases based on MRI appearances and under the care of doctors participating in the trials