Jane Rooney

Welcome, everyone. We'd like to acknowledge the Turrbal and the Jagera peoples of the Meanjin as the original owners and custodians of the lands on which we meet, work and learn. We pay our respects to elders past, present and emerging. My name is Doctor Jane Rooney. I'm a specialist sports and exercise physiotherapist with a subspecialty in the knee. I'm also an associate clinical professor at Swinburne University and I am a clinician and clinical director at Parahn Sports Medicine Centre in Melbourne. I also was the recipient of a Churchill Fellowship in 2016, travelling in 2018 for three months around the world looking at management algorithms, non operative pre-operative post-operative and ACL prevention programs. I'd like to now introduce Doctor Christopher Vertullo and also Doctor Stephanie Filbay. So over to you, Chris.

Chris Vertullo

Thanks very much, Jane. I'm an orthopaedic knee surgeon, obviously specialise in knee surgery and I'm also an adjunct professor at Griffith University where we do a lot of ACL injury research. I'm also an associate professor at Bonn University, where we do a lot of more research on total knee outcomes. I'm also a general director and Treasurer of the Australian Orthopaedic Association and also one of the Deputy directors of the Australian Orthopaedic Association National Joint Replacement Registry. And I'm on a number of government committees. Probably the most important is the osteoarthritis clinical care standards, which I'm currently a member of as well. So I'd like to be very grateful and thanks the APA for inviting me to speak in this podcast about what is a very important topic.

Stephanie Filbay

Thanks, Chris. Yeah, I'll introduce myself as well. So my name's Steph Filbay, a physiotherapist and a senior research associate at University of Melbourne. My research focuses on ACL injury and optimising outcomes, particularly long term outcomes, as well as evaluating and comparing different management strategies with a look at promoting evidence based management.

Two of the projects I'm leading at the moment when one of which is designing a patient decision aid to improve management of ACL injury in Australia and the other body of work is around ACL healing, which I believe we'll discuss today where I led some research evaluating ACL healing in the KANON trial, but also leading the paper, Evaluating the cross bracing protocol should also mention that I also do have lived experience as a patient as well as a physio with ACL injury. So I have undergone reconstruction when I was 18 and graft rupture and revision and another graft rupture and I now live with osteoarthritis. 

So yeah, I can draw upon a little bit of lived experience too. I should also mention, since this is a PRF podcast, I am a recipient of a PRF seeding grant back in, I believe it was 2013 to support at the time emerging research in an ACL reconstruction. So I'm very grateful for that initial supportive funding and now to be here today.

Jane 

Thanks, Chris and Steph. I would like to put it to Steph first of all, to maybe summarise the current literature around non operative versus operative outcomes for people with ACL injury.

Stephanie

So yeah, that could be a topic of a five hour podcast, but I'll try to summarise it pretty briefly. So let's put the healing research which is more recent aside and prior to that. So let's say 2022, before the two more recent papers were published, there's a number actually a wealth of systematic reviews showing that on average outcomes are similar, whether you're managed with rehabilitation alone or early ACL reconstruction. And the best evidence we really have to support this is the only two high quality RCT in this area. So the KANON RCT the Compare RCT, both of which found no additional benefit of early ACL over initial rehab and optional delayed surgery. And that was a two and five year follow up. It's important to note that that is optional. So it's commencing rehabilitation and then evaluating whether you're a good candidate for ACL reconstruction typically after around three months. Yeah. So that's a summary of the current evidence, as I see it.

Jane 

And in Australia we were known to have quite high operative rates up to 90%. So how do you think that this evidence is being interpreted or you know, is it being considered, I suppose, in people's management decisions?

Stephanie  

Yes. I mean, I'd love to hear Chris's opinion on this as well, but we have recently evaluated clinical practice for ACL injury management across Australia from both the perspectives of the patients and clinicians, largely physios. But we asked patients what they had been told about their ACL injury and what they were advised about from each different health care professional. And what we found is people aren't receiving information that reflects the evidence. So there percentages were around about 60% of physios told patients incorrect information and it was as high as 90% of surgeons. But that is mainly around the common belief that surgery is the best treatment if you want to return to sport. And I don't think that's necessarily the surgeons certainly not lying to the patients because I think the evidence itself is complex and a lot of surgical groups are advising that that's the case because it is a common expert opinion when it comes to surgical management. 

We're in the final stages of meta analysis at the moment, which shows no difference in return to sport rates between ACL reconstruction or management with rehab alone. I could go on, but I'd love to hear Chris's thoughts around the 90% surgical rate in Australia.

Chris  

The problem is we don't quite know the exact rates and that's something that we trying to push an ACL registry for because I think there's a lot of ACL injuries that are never actually diagnosed. And you see that we did publish a paper in MJA a few years ago and that was the rates are high and unsustainably increasing. It's important to realise that A there's a prevention side of this. So if you've never actually hurt yourself in the first place, it's much better you don't actually come off the field, have to go to the hospital, have to sit there and have opinions as to whether you should have surgery or not. You just never hurt yourself. And so that's probably the one thing that we pushed in the MJA paper was just the high rate of these preventable injuries. 

That's the first thing that a lot of these are preventable, and that's why the Australian Orthopaedic Association have been pushing for injury prevention now for probably well over 12 years. I agree the rate is too high and the problem is that ACU reconstruction is a preference sensitive decision. You have a discussion with it and the AKS Australian knee society and the AOA had a position statement on this, a consensus, and we tried to and I showed patients it in my rooms. This is the data and you can read this, but it is difficult to convince people who have mindset that they actually want an operation. And not only do I see that in ACL injuries where everyone thinks I had a 65 year old lady recently who was absolutely convinced you needed surgery and it took a long, long time for me to convince her that that would not be a great idea. 

Similarly, I mentioned today during my presentation, my neighbour who was absolutely wanting the surgery, but because she knew me so well, she couldn't really go and see someone else. She was stuck with me as a treating clinician and we treated a non operatively. And the problem is that her outcome she's not totally happy with. But I would argue that she had a better outcome without surgery than if she did. So that's the problem we're facing, is that with those studies at the moment, you have to discount elite athletes and people who've had high grade collateral ligament injuries that need surgical intervention and repair or meniscus tears. It is a preference sensitive undertaking, just like having any surgery really is particularly orthopaedic surgery, and that's where the problem lies. It's actually quite hard to talk people out of an operation who really want one. And there is a mindset in the community that everybody's going to do better with the surgery and I just want it fixed Doctor and so that's the problem surgeons face. 

There is some misinformation there, and people don't quite accept some surgeons that the Kanon trial and the probably mispronouncing it. But also the compare trial are important data to show that people can return to sport successfully, particularly, you know, non-high risk, non high pivoting sports because Kanon excluded people who were sedentary, but it also excluded elite athletes and probably that's the majority of people actually hurting their ACL. So there is a difficulty in the psychological process, patients making decisions and then interpreting that data and that's why Australia really needs an ACL registry. Then we can nest trials in it and we can have better Australian data looking at, okay, you're in this situation, how is the best way to manage this person moving forward? Can they be managed to operate successfully? What will happen if we do that? Do they need surgery? If so, what type of operation? And that's where we really lacking data. So we need a lot better data in this area to make all these decisions because at the moment we just don't have enough data to inform patients really well.

Jane  

You brings some interesting points and very relevant because I think many other countries do have registers. The U.S., New Zealand and it's really needing particularly needed in our country where our ACL rates are so high and predicted to double by 2030, which is very alarming considering that up to 50% of people have long term knee health problems within ten years of a traumatic ACL injury. And I think the other thing that you brought up so relevantly is people's expectations. And I think Steph can probably talk more to this, but there's a large percentage of people that have very unrealistic expectations of their knee function following a traumatic knee injury, no matter which way it's it's managed.

Stephanie  

Yeah, absolutely. And I think, Chris, also it's interesting. Certainly probably the most prevalent belief is that, you know, if you want to return to high level cutting, pivoting spots, let's say, to well, take professional athletes out because they have, you know, quite a range of external influences on their decisions, that surgery is the best option for that and that really isn't supported by the evidence, you know, as we're finding in our meta analysis. But I like to refer to the study by HG Windham and where they matched patients at baseline who were managed with rehab and managed with ACL reconstruction and they compared the rates of return to sport. But returning to level one sports or level one cutting, pivoting sports, and those who were treated with rehab were actually advised you shouldn't return to level on sports, because at the time it was like, oh, we don't think that's safe. Whereas the reconstructive group were encouraged to. And despite that, those exact same rate that returned to level one, cutting and pivoting sports between groups and that seems to be what we're seeing. 

So then someone may say, well, okay, well, maybe the return to sport, right, isn't different, but the rate of re injury must be different. You must be more at risk of injuring your meniscus if you don't have surgery. And that's actually not supported by the evidence we have at the moment anyway, as proven in a recent systematic review. So I definitely agree we need more research. But there's also these key beliefs which aren't at the moment supported by evidence which are really shaping current management, especially in Australia. And that's what we found in this recent Australia wide survey. 

So I think I think the proportion of surgeons is growing that have very balanced and are providing great information to patients, but there's still a substantial proportion out there that are telling patients and we know this because we've found it in studies that telling patients, look, you know, you could do nonsurgical management if you're happy running in straight lines, but if you want to go back to sport, I should fix your knee or oh, well, if you're happy being inactive or having a sedentary lifestyle, you can do non op management. But if you want to go back to sport and once a patient's told this, you know people with ACL injury, for the vast majority of people, that's their priority. That's what they want to do is go back to sport. So I think it's such an important area of research and we do need really high quality data exploring this exact thing, the risk of injury and return to sport rights at cutting, pivoting sports.

Jane 

If we go back to the surgical decision making information and I'd like to pass over to Chris and so you can talk to us about who do you think is appropriate for early ACL reconstruction and why.

Chris 

So really, if you exclude the people who, you know, like you don't need to repair a collateral structure or reconstruct it or they don't have a repairable meniscus, then you're down to and I exclude elite athletes who look after elite athletes and you know, the studies exclude them. But I suspect that probably will change that. Maybe we can manage some of the elite athletes, even with non operative management. Then it really boils down to a preference sensitive decision. I say to the patient, These are your options, this is the data. And then the patient usually makes an informed decision around that. 

The downside of having surgery is that is that AKS Australian knee Society consensus statement says that if you push everyone into having a reconstruction, probably 50% of those people would be satisfied without surgery. And I do say to them that the evidence is that the younger patients are those under 18. There's not really any great data there. It's so active, it's really hard to control what they're doing. And the other problem of young people is that they keep changing their sports. If you're 12, you've probably not given up playing the same sport when you're 20, as you say, but once you hit 30 or 40, you're not going to change sports. And that's an important and something to assess. So don't have a discussion with them what their expectations are. And then I talk about the two options and I talk about the options they have. And then people usually make a decision which way they want to go, and it's really up to them as an individual. 

I'm all about a shared decision making process and I tell them what I think the risks of one pathway is over the other. And I say, Look, we don't have great data, we don't have Australian data, we're using a lot of data from overseas and that can be problematic. But generally everyone agrees that this is probably what's going to happen. And if you go down the delayed optional pathway, 50% will cross over and have a reconstruction because of feelings of being dissatisfied with their joint. That doesn't mean they actually should have had the surgery or they're going to be benefit from it. This means they were dissatisfied with how they ended up, and that could be that, you know, they had a bad miniskirt control injury. They're not going to be really satisfied with whatever outcome they're going to have. You know, and that's the difficulty we have. 

Now, the problem is timing. We talked about today about elite athletes, that they're basically down to days. They've got the whole thing planned out if you. They want surgery right here and they've got all mapped out moving forward. And so it might take a different mindset to move towards a way that you have to. You can treat them, not operatively. So I give them the options. I talk about the pros and cons of both approaches. And then, you know, I say to them, Look, you could tear your meniscus even if you have a reconstruction, which I see quite frequently, or versus you may tear it if you don't and there's some conjecture around is a meniscus tear a binary event that is you tear it or not in some of these studies or how much meniscus loss there is, but that's really not the end of the day. 

I think it's more important about what the patient expectation is and how they're going to end up. It really boils down to their personal belief systems like they really are where they're at in their lives. It's interesting that in the beginning of the process, they all want to return to that pivoting sport and then the end of it. Not that many actually. Even at the end of the day, they come back, a significant proportion decided it's too hard, particularly someone who's playing, you know, elite, or non eliet say netball who's got hyperextension, family history of ACL rupture, a whole bunch of risk factors like generalised ligaments, laxity. That person, no matter what you do, is at a high risk. If I go back to netball and the question is, should they be playing some of these sports, you know, where you see people have had multiple ACL ruptures in the family, both parents, they're all playing touch football. They arrive with their 13 year old daughter who's just ruptured playing touch football. They're all super keen. Their entire family lives are revolves around playing touch football. And every person they know has had a reconstruction. That's a difficult ship to turn around saying, do you really think that this primary aim here is to go back to these high risk sports that you are playing because Australians play high risk sports all year. You know, all of our sports, we ski in icy, terrible conditions. So just looking at the risk of skiing in Australia, New Zealand, you're basically super high risk of tearing your ACL. And then we play AFL and then we take high risk individuals, a women who are much more likely to tear their ACL and we encourage them all to play AFLW and then there's no surprises that they have one of the highest rupture rates possible and then the whole thing is around getting them back to playing sport. 

But the step back question is should they really be going back to playing sport given, you know, they've ruptured it, the sisters ruptured, It was the second rupture on the other side. All these things that really aren't taken into account and it's a really confronting undertaking because they've just come off the field and hurt themselves and suddenly have to question their entire choice of sport and their whole social circumstances and their belief system. So it really is a complex area.

Stephanie 

Yeah, I'd agree with that. We've done some research showing that whether someone returns to sport after ACL reconstruction is a key determinant of their quality of life 5 to 25 years later. So you'd think, you know, years is past decades passe surley it doesn't matter anymore. It does. And it's a subgroup of people that have these more competitive needs. And if they don't go back to their sport, it can really impact their quality of life. So there's more factors to consider that than just the joint health. But it is so important to inform patients about that and it's irrespective of treatment. Look, if you go back to AFL, your risk of reinjury, irrespective of a non-surgical or surgical route, is going to be higher and they need to be aware of that so they can make an informed decision about returning to sport. But for that person and for a lot of people, that's I don't care. It's everything to me. It's who I am. I'm going back, but at least they've got that information to make What I hope is an informed decision at the time.

Chris 

Just this week had a couple of situations where this belief system, the patient came into play and one was a young 18 year old who'd already had an ACL injury on the opposite side, reconstructed, who was trying to get into an elite level national competition, who had failed bracing technique and fortunately didn't work out. She had a re injury and the discussion from her was really about timing. When you can do it, when I've done this absolutely as soon as possible. The second was graft choice and whether I was going to next particular procedure, but I was thinking should really be going back to this sport and what's the rush to happen to reconstruction? Because say in the NRL, for example, it's highly unlikely if you've torn your ACL as an adolescent that you're going to make it. be able to play an elite level. The individuals who play NRL and AFL and elite level, they are uncommon, have torn their ACL. Normally they do it later in their career and they can often keep playing, but the ones who tear it as an adolescent They've already singled themselves out as a high risk individual because most of these are non-contact events. They're just running along, having a game with their friends and then they misstep and then bang, they're down on the ground and they're off to the hospital. And life changes forever. And it does change forever. 

Having a reconstruction doesn't mean you knees normal. It just means that you've had a reconstruction. And that's not going to recreate what's happened and the question we have is it the right thing that we should be pushing these young people back to these chosen sport who have generalised ligamentous laxity, hyperextension, all the sort of things that really predispose them to a high rate of injury. And I probably argue not. I was on the SBS show a few years ago insight, and there were young people that had terrible head injuries from playing rugby union, then insisting on going back. One young fellow had broken his neck. There were a couple of ACL injuries and one of them had torn his ACL twice. And the comment I had was, are we subjecting some of our young individuals to risks that I think is unacceptable without a discussion? Is this a sport for you know, all sport has some element of risk, but some sports have particularly high risk for some individuals. And I was the bad guy at this SBS show because I suggested what happens if you take a high risk individual thats a young female with generalised ligamentsous laxity and then they all play say AFL, which is a game that has incredibly high risk because it's 360 degrees and there's so many unanticipated events of injury occurring that the ACL injury rate is astronomically high. And then we're surprised at the outcome that we are seeing higher higher rates of ACL injury and then we are applying the standards of professional athletes to people who are adolescents with immature skeletal systems where they have agents and people pushing them to have surgery where perhaps they don't. So it is a very complex area. 

And I often wonder, are we doing a disservice to our young individuals who are being injured by mimicking what is a professional standard of care, say, a league team? I actually find there's more pressure from the parents of a young elite athlete who's been injured than from an athlete who I'm treating as part of a team. So the team takes a better approach at the professional level and is accepting that there's no rush to an operation, etc.. And I remember when the last ligament, you know, is a terrible artificial ligament that was causing lots of problems that because I would wouldn't do a LARS on a 14 year old which is a young male, is skeletally mature. The father came quite upset and took him somewhere else, which is just crazy. So there is an air here of we should step back and look and think, are we doing young injured Australians a disservice by pushing them down a pathway of of just trying to get them back on the field no matter what.

Jane  

I was interested during my Churchill travels to see in different countries, different management algorithms and different funding models that probably supported those different algorithms such as in the Netherlands, that they had to do a non operative program for three months before actually even seeing a surgeon or indeed getting an MRI in some cases. And the similar in Sweden, which was interesting because if you look at the rates in those countries of ACL reconstruction, they are about 50% compared to our 90%, which I wonder if sometimes our funding models in Australia don't support our non operative management pathways because they are more there seems to be more rebates associated with surgical reconstruction rather than the non operative pathway, whether that's bracing or just physical rehab alone pathway. Just an interesting observation.

Stephanie

Something which we haven't discussed yet as now the more recent research around ACL healing. So historic research showing similar outcomes is between initial rehab. This is without looking at the healing status compared with ACL reconstruction. But when we look back and analyse the MRI's from the Kanon RCT, we look back and looked for signs of healing and we assess that as continuity of the ligament because all those ligaments were discontinuous at baseline. And what we found was at two years in those that were randomised to initial rehab, at least 30% had a continuous ACL on two year MRI, and that's assuming that the 50% who had delayed surgery had a non healing status before they crossed over. In those only managed with rehab it went up to 53%. 

But what was also really surprising is that they report a better two year outcomes not only compared to the non healed group, but also compared to those randomised to early ACL reconstruction and those who crossed over to delayed reconstruction. And this is a really interesting study to look at this in because they weren't aware of the healing status. So that couldn't have impacted their perception of their knee function, which was better than the other groups or their quality of life. So I think that's a very interesting study and it sort of suggests that the missing piece of the puzzle in terms of being able to understand who will have a successful outcome with rehab alone, maybe to look at the status of the ACL in relation to healing.

Jane 

And that is something that you've been involved with with the cross bracing protocol. So talk to me a little bit about what we can see at 12 weeks after the cross bracing protocol.

Stephanie 

Absolutely. So I'm going to see most listeners that maybe have heard about the cross bracing protocol. So I won't . Go into detail about what that is. But the hypothesis being that bracing the knee in 90 degrees flexion for the first 4 weeks after an acute ACL rupture could facilitate a bridge of connective tissue between the two remnants and subsequent ACL healing. We recently published data from the first 80 consecutive patients treated with that bracing protocol. And what we found is using that same criteria as we used in the kanon trial. So a continuous ligament. At three months after begining the brace and when the brace came off, 90% had a continuous ACL ligament. So within that continuous category, there's some variation. So some of those ligaments are continuous but thinner, continuous and elongated or continuous and thicker at three months. We found that those that were continuous and thicker had better outcomes than the thinner or ruptured group combined, and they reported excellent outcomes. I believe it was atleast a score of 98 over a possible 100. 92 had returned to support by 12 months. Quality of life all had a normal lachmans with their contralateral leg. 

So it provides further evidence of what we're seeing on MRI is relating to better knee function, but also that not all I'm going to say heal in loose terms, necessarily equal. There is a continuum of healing and we do need more information there. So there's now been over 480 patients managed in clinical practice. So we're analysing the data and looking at predictors of healing. And we're also planning two randomised controlled trials, one to compare the bracing protocol to surgery and the other to compare the bracing protocol to rehabilitation alone.

Jane

It's very interesting and it's a very complex area talking about management algorithms. So I'd just like to finish off with a statement from you, Steph, and also from you, Chris, about what would be your in one or 2 minutes summary for clinicians of how they should think about ACL injury management in clinical practice in Australia at the minute with the evidence that we have.

Stephanie

I would say be informed upskill if you need to or referral to a physio you trust. If you don't have the knowledge, you need to let the patient weigh up the pros and cons of each treatment option so they can choose a decision that aligns best with their preferences and their lifestyle. But in order to do that, they need accurate, unbiased, balanced information. And at the moment they're not receiving that. If they go down a non-surgical route, they will still have the option of ACL reconstruction. However, ACL reconstruction, you'll never have the opportunity in natural healing. That's not to say ACL reconstruction. It isn't a good option, but there's pros and cons to weigh up in both directions.

Chris

I think we need to take a holistic approach to it. Not only does the desires and the wishes of the patient need to take into account, but you know, so the concomitant injuries also need to be taken to account. I totally agree. You need to decide if you're a physiotherapist. Is this in your scope of practice because it is complicated. Encourage people to reach out to surgeons who perhaps have a good rapport for who can provide unbiased opinions. You know, like as a knee surgeon, if you ask if you want a hundred different opinions, you just ask 100 different surgeons for an opinion and you'll get 100 different opinions. 

So you need to work with somebody who you trust, who you know, you know, that won't push patients into surgery that probably not required or vice versa. That when something needs to happen, they're going to go and operate as well. And it cuts both ways. I think the holistic part of it is that in Australia we do need better prevention systems. I still see young individuals who are hurt and physiotherapists are strongly involved with teams who probably aren't getting enough agility training. You know, there's a high and it's like 21 RCT showing that agility training reduces ACL injury by 50 to 80%, which I think is really important. And then with the ACL injury, we need to step back and go, okay, have an informed discussion on the pros and cons of each approach. But also really we need to guide young individuals and their families as to what the best approach here is. 

And I think rushing people back to sport who perhaps the chosen sport is not for them is is probably one of the biggest travesties I see. particularly start to get multiple re injuries and the only focus is getting back on the field and they almost develop post-traumatic stress disorder. Some of these young individuals, you know, they've had three months down the track and they have re injured themselves. It's quite a difficult process, no matter what level they're at to go through.

Jane

Well, thank you both. And thanks to the PRF fund for enabling the three knee nerds here to get together discussing ACL injury management. Thank you.