Original Article
497
Anterior Cruciate Ligament Reconstruction in Patients Older Than 35 Years Sameh El-Sallakh, MD1,2
Philip Pastides, MRCS3
Panos Thomas, FRCS3
1 Department of Trauma and Orthopaedic Surgery, Tanta University
Hospital, Tanta, Egypt 2 Department of Trauma and Orthopaedic Surgery, Alwakra Hospital, Hamad Medical Corporation, Doha, Qatar 3 Department of Trauma and Orthopaedic Surgery, Whittington Hospital, London, United Kingdom
Address for correspondence Sameh El-Sallakh, MD, Orthopaedic Department, Tanta University Hospital, Al-Geish Street, Tanta, Egypt (e-mail: [email protected]).
Abstract
Keywords
► anterior cruciate ligament ► reconstruction ► older than 35 years
Anterior cruciate ligament (ACL) reconstruction is an increasingly established method even in patients older than 35 years. Our hypothesis is that functional outcome after ACL reconstruction is comparable in patients younger and older than 35 years. A total of 28 patients (5 women and 23 men) with average age of 41.5 years (36–68) were retrospectively evaluated. The average follow-up period was 33 months. All of them were treated operatively with arthroscopic single-bundle four-strand hamstring tendon autograft. The functional outcome was determined by clinical scores (Tegner activity scale and Lysholm knee score). The median values for the Lysholm knee score were preoperatively 77 and postoperatively 96 points (range, 90–100) with significant improvement (p < 0.05) and that for the Tegner activity scale were preoperatively 4.6 points (range, 3–6), which is the same pre- and postoperatively with an overall return to baseline for all patients. No significant correlation between functional outcome and patients’ age was present and no reported significant complications. The good results and a high level of patient satisfaction show that ACL reconstruction is justified even in patients (older than 35 years) with symptomatic anterior knee instability. We commonly propose surgical treatment in symptomatic patients who express the need to restore their preinjury activity levels, regardless of their age.
Anterior cruciate ligament (ACL) reconstruction surgery aims to restore functional stability of the knee and to allow patients to return to their occupational and sporting activities. While in the young and active population, surgery is often the best therapeutic option after an ACL tear to restore knee kinematics, reducing the risks of subsequent injury and the progression of degenerative changes,1 ACL reconstruction in middleaged individuals is probably more controversial due to concerns about a higher complication rate and whether or not it is needed because of their activity level. However, many of these middle-aged individuals are still very active and find such injuries debilitating.
Conservative treatment was frequently advocated in the past for middle-aged people with an ACL tear, which consists of modifying activities, quadriceps muscle strengthening, proprioception exercises, and bracing.2–4 This is because some surgeons thought ACL reconstruction on older patients could lead to complications such as stiffness, arthrofibrosis, infections, wound healing problems, or thromboembolic disease, and there were concerns that underlying degenerative knee osteoarthritis could prevent a satisfactory outcome.5,6 Currently, ACL reconstruction is becoming more common in active middle-aged patients, and age does not represent
received July 7, 2012 accepted after revision January 1, 2014 published online February 7, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1368141. ISSN 1538-8506.
Downloaded by: Rutgers University. Copyrighted material.
J Knee Surg 2014;27:497–500.
Anterior Cruciate Ligament Reconstruction
El-Sallakh et al.
the major criteria in the decision-making process for the treatment of the ACL-deficient knee in middle-aged to older population.1,7,8 The aim of the study is to evaluate the patients older than 35 years who had ACL reconstruction using a four-stranded hamstring autograft. Our hypothesis is that functional outcome after ACL reconstruction in the middle-aged patients is comparable to the outcome of the younger group (younger than 35 years).
Methods This is a retrospective study of the patients who had arthroscopic ACL reconstruction from May 2006 to October 2011 (66 months). Inclusion criteria included the patients older than 35 years with high demand activities. We looked at the occupation, the activity level, and the individual patient desire for high demand sporting or recreational activities. Also we looked at the presence of associated knee injuries. The main complaint was recurrent giving-way episodes during daily activities, which affect their quality of life. Clinical findings included a positive Lachman test and pivot shift test. All of them had a magnetic resonance imaging (MRI) scan to screen for meniscal lesions, and rule out any significant osteoarthritis, osteochondral lesion, or concomitant multiple ligament injury. We excluded the cases with advanced osteoarthritis or concomitant multiple ligament injury. Patients were treated operatively with arthroscopic single-bundle four-strand hamstring tendon autograft. Absorbable transfixion pins were used to fix the graft in the femoral tunnel (Rigid fix system, DePuy Mitek, Norwood, MA) and an absorbable sheath and screw construct was used to fix the graft in the tibial tunnel (Intrafix screw, DePuy Mitek). The functional outcome was determined by clinical scores (Lysholm knee score and Tegner activity scale) pre- and postoperatively. The uninjured side was used as a control group regarding the functional results and degree of laxity.
Statistics We used paired t-test with significance p ¼ 0.5 between preoperative and postoperative Lysholm and Tegner clinical scores.
Results Twenty-nine patients met the criteria for inclusion in this study; however, one patient was lost to follow-up. Thus, our cohort included 28 patients (23 male and 5 female). The mean age was 41.2 years old (range, 36–58). The mean follow-up was 33 months (8–74 months). ►Table 1 shows an analytical breakdown of the patient age groups. Fourteen of our patients had meniscus tears, which were treated with partial meniscectomy. Twelve of them underwent partial meniscectomy before ACL reconstruction and, due to persistent instability symptoms, underwent ACL reconstruction following recovery. Two patients underwent partial meniscectomy at the time of their ACL reconstruction. The Journal of Knee Surgery
Vol. 27
No. 6/2014
Table 1 Analytical breakdown of patient age groups Age range
No. of patients
35–39
12
40–44
13
45–49
2
50–54
0
55–60
1
There was a slight improvement in the functional outcome in the patients who had partial meniscectomies in comparison to the patients who did not have partial meniscectomies, but it was not significant (p ¼ 0.12). There were no changes in the stability of the both group. Also there were no significant differences between the 13 patients who had minor osteoarthritic changes (Outerbridge classification grades I and II)9 and the 15 nonosteoarthritic cases (p < 0.05). There were no reported significant complications as a result of the operation in any of our patients. ►Table 2 shows the pre- and postoperative Lysholm and Tegner activity scores for all patients. The results show that there was a statistically significant improvement in Lysholm scores as a result of the surgical intervention (p < 0.05). Regarding the Tegner score, the results show an overall return to baseline for all patients with clinical improvement, which was not statistically significant. One patient (no. 25) was unsatisfied with the procedure, despite an increase in both Lysholm and Tegner activity scores, improvement in the knee laxity, and he was able to do more light work (level 3). His main complaint was that he was unable to return to his full level of manual activities that involved lifting heavy objects. Of note, patient no. 26 was a full-time, self-employed window fitter who due to his injury was on disability benefits and hence had a preoperative Tegner activity score of 0. After surgery, his Tegner activity score improved and he is able to work and do moderately heavy labor (level 4).
Discussion Conservative treatment was frequently advocated in the past for middle-aged patients with an ACL tear, which consists of modifying activities, quadriceps muscle strengthening, proprioception exercises, and bracing.2–4 A retrospective study by Ciccotti et al2 on 30 middle-aged patients who underwent “aggressive” nonoperative management for such injuries found that the mean Lysholm score was 82 points. Eight of the 11 patients who had combined ligamentous injuries had a score of less than 84 points, which was causing a degree of disruption to their daily activities. Overall 25 (83%) of these patients, who had had guided rehabilitation and had modified activity, had a satisfactory outcome without an operation. However, those patients who wished to resume competitive sports activity that required pivoting were dissatisfied with the final outcome. Strehl and Eggli10 followed up 38 patients between the age of 16 and 55 years who were deemed suitable for conservative
Downloaded by: Rutgers University. Copyrighted material.
498
Anterior Cruciate Ligament Reconstruction
El-Sallakh et al.
499
Table 2 Pre- and postoperative Lysholm and Tegner activity scores for all patients Age at surgery
Pre-/postoperative Lysholm pre
Lysholm post
Tegner pre
Tegner post
1
39
89
100
6
5
2
44
84
100
6
6
3
37
75
90
5
5
4
42
75
90
5
5
5
36
89
100
6
6
6
46
73
100
6
6
7
38
73
100
6
6
8
43
75
90
5
5
9
42
63
100
5
5
10
43
73
93
5
4
11
58
69
90
4
3
12
37
73
95
5
5
13
43
75
95
5
5
14
43
81
100
5
5
15
39
81
100
5
5
16
36
84
100
6
5
17
39
84
95
5
5
18
36
84
100
5
5
19
40
89
100
4
4
20
44
89
94
4
4
21
41
84
95
4
4
22
37
73
100
5
5
23
47
79
95
4
4
24
38
79
94
3
3
25
44
75
90
2
3
26
43
56
95
0
4
27
42
63
94
4
4
28
38
73
93
5
4
Mean
41.3
77.14286
96
4.64
4.64
Maximum
58
89
100
6
6
Minimum
36
56
90
0
3
p 0.05 (significant)
treatment of ACL rupture. Twelve patients had a very good outcome. Twenty-three patients continued to experience knee instability symptoms and eventually underwent ligament reconstruction. Of the 12 who responded well to conservative treatment, only 2 patients were able to return to high demand sporting activities. Another study by Fitzgerald et al11 showed that with appropriately screened individuals, conservative treatment is adequate to allow patients to return to a satisfactory level of activity. Seng at al12 revealed an interesting outcome when using an expected value decision analysis tool to determine the optimal treatment of ACL rupture in patients aged 40 years or older. With a mean age of 53 years (range, 40–80 years), they
Downloaded by: Rutgers University. Copyrighted material.
Patients
p < 0.05 (not significant)
noted that increasing the probability of surgical complications decreased the expected value of operative treatment but not below the expected value of nonoperative treatment. Thus, they highlighted an observation that individuals aged 40 years or older may be more averse to accepting potential knee instability during pivoting and thus prefer ACL surgery despite the risk of surgical complications. A recent systematic review by Legnani et al1 aimed at reviewing the current body of evidence surrounding the treatment of middle-aged patients who sustain ACL ruptures; there appears to be a growing body of evidence supporting surgical treatment options for higher demand patients. The authors concluded that the chronological age should not be The Journal of Knee Surgery
Vol. 27
No. 6/2014
Anterior Cruciate Ligament Reconstruction
El-Sallakh et al.
the primary factor when considering ACL reconstruction. These patients tend to be more motivated to adhere to rehabilitation regimens and therefore activity level and functional demand should be the principal determining factors. Our study and experience advocates the use of surgical reconstruction of ACL in appropriately selected individual patients. We believe that each patient should be reviewed individually and counseled about their posttreatment expectations, irrespective of whether they opt of conservative or surgical treatment. There was a significant improvement in the Lysholm scores for our patient cohort from 77 to 96. Although there was no increase in the Tegner activity scores overall, our study shows a return to baseline preinjury activity levels. There were no reported significant complications as a result of the operation in any of our patients. Only one patient was unsatisfied with the procedure, despite an increase in both his Lysholm and Tegner activity scores. His main complaint was inability to return to his full level of manual activities that involve lifting heavy objects. Our results were comparable to other studies7,8,13,14 with operative treatment documenting favorable outcomes in this patient population with regard to knee stability and patient satisfaction. Among these four studies reporting on the difference in the outcomes between middle-aged and young patients, no significant difference between both groups and no increased risk of complication (stiffness, arthrofibrosis, and infections) were noted in the middle-aged patients compared with the control group. In our study, we used MRI first to confirm the diagnosis and find out the associated injuries including osteoarthritic changes and we used the Outerbridge classification for grading osteoarthritis according to the arthroscopic findings. It has been proven that the existence of significant underlying osteoarthritis and concomitant cartilage lesions (more common among middle-aged patients) can affect the outcomes of ACL reconstruction.5,6 In our study, the patients with significant osteoarthritis changes were excluded and did not have ACL reconstruction. The patients who had minor osteoarthritic changes did not have a significant difference (in outcomes) in comparison to nonosteoarthritic cases. These are compatible with previous studies.15 Poor results are, however, correlated with more advanced degenerative changes.5,15
commonly propose surgical treatment in symptomatic patients who express the need to restore their preinjury activity levels, regardless of their age. Further studies are required to aid surgeons in determining the correct therapeutic approach for the ACL-deficient knee in the more mature population.
References 1 Legnani C, Terzaghi C, Borgo E, Ventura A. Management of anterior
2
3
4
5
6
7
8
9
10
11
12
Conclusion We conclude that although middle-aged patients may not be high level sporting individuals, many of them are still very active and require knee stability to carry out their everyday jobs, as highlighted by some of the patients. There are patients who also enjoy sporting activities such as running, playing football, or skiing that require a stable knee pivot, and thus should also be considered for reconstruction. The good results and a high level of patient satisfaction show that ACL reconstruction is justified even in patients (older than 35 years) with symptomatic anterior knee instability. We
The Journal of Knee Surgery
Vol. 27
No. 6/2014
13
14
15
cruciate ligament rupture in patients aged 40 years and older. J Orthop Traumatol 2011;12(4):177–184 Ciccotti MG, Lombardo SJ, Nonweiler B, Pink M. Non-operative treatment of ruptures of the anterior cruciate ligament in middleaged patients. Results after long-term follow-up. J Bone Joint Surg Am 1994;76(9):1315–1321 Buss DD, Min R, Skyhar M, Galinat B, Warren RF, Wickiewicz TL. Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients. Am J Sports Med 1995;23(2): 160–165 Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA. The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74(1):140–151 Shelbourne KD, Wilckens JH. Intraarticular anterior cruciate ligament reconstruction in the symptomatic arthritic knee. Am J Sports Med 1993;21(5):685–688, discussion 688–689 Noyes FR, Barber-Westin SD. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage. Am J Sports Med 1997;25(5):626–634 Osti L, Papalia R, Del Buono A, Leonardi F, Denaro V, Maffulli N. Surgery for ACL deficiency in patients over 50. Knee Surg Sports Traumatol Arthrosc 2011;19(3):412–417 Marquass B, Hepp P, Engel T, Düsing T, Lill H, Josten C. The use of hamstrings in anterior cruciate ligament reconstruction in patients over 40 years. Arch Orthop Trauma Surg 2007;127(9): 835–843 Cameron ML, Briggs KK, Steadman JR. Reproducibility and reliability of the Outerbridge classification for grading chondral lesions of the knee arthroscopically. Am J Sports Med 2003; 31(1):83–86 Strehl A, Eggli S. The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma 2007;62(5): 1159–1162 Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 2000;8(2):76–82 Seng K, Appleby D, Lubowitz JH. Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients aged 40 years or older: an expected-value decision analysis. Arthroscopy 2008;24(8):914–920 Barber FA, Elrod BF, McGuire DA, Paulos LE. Is an anterior cruciate ligament reconstruction outcome age dependent? Arthroscopy 1996;12(6):720–725 Brandsson S, Kartus J, Larsson J, Eriksson BI, Karlsson J. A comparison of results in middle-aged and young patients after anterior cruciate ligament reconstruction. Arthroscopy 2000; 16(2):178–182 Brown CA, McAdams TR, Harris AHS, Maffulli N, Safran MR. ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies. Am J Sports Med 2013;41(9):2181–2190
Downloaded by: Rutgers University. Copyrighted material.
500
497
Anterior Cruciate Ligament Reconstruction in Patients Older Than 35 Years Sameh El-Sallakh, MD1,2
Philip Pastides, MRCS3
Panos Thomas, FRCS3
1 Department of Trauma and Orthopaedic Surgery, Tanta University
Hospital, Tanta, Egypt 2 Department of Trauma and Orthopaedic Surgery, Alwakra Hospital, Hamad Medical Corporation, Doha, Qatar 3 Department of Trauma and Orthopaedic Surgery, Whittington Hospital, London, United Kingdom
Address for correspondence Sameh El-Sallakh, MD, Orthopaedic Department, Tanta University Hospital, Al-Geish Street, Tanta, Egypt (e-mail: [email protected]).
Abstract
Keywords
► anterior cruciate ligament ► reconstruction ► older than 35 years
Anterior cruciate ligament (ACL) reconstruction is an increasingly established method even in patients older than 35 years. Our hypothesis is that functional outcome after ACL reconstruction is comparable in patients younger and older than 35 years. A total of 28 patients (5 women and 23 men) with average age of 41.5 years (36–68) were retrospectively evaluated. The average follow-up period was 33 months. All of them were treated operatively with arthroscopic single-bundle four-strand hamstring tendon autograft. The functional outcome was determined by clinical scores (Tegner activity scale and Lysholm knee score). The median values for the Lysholm knee score were preoperatively 77 and postoperatively 96 points (range, 90–100) with significant improvement (p < 0.05) and that for the Tegner activity scale were preoperatively 4.6 points (range, 3–6), which is the same pre- and postoperatively with an overall return to baseline for all patients. No significant correlation between functional outcome and patients’ age was present and no reported significant complications. The good results and a high level of patient satisfaction show that ACL reconstruction is justified even in patients (older than 35 years) with symptomatic anterior knee instability. We commonly propose surgical treatment in symptomatic patients who express the need to restore their preinjury activity levels, regardless of their age.
Anterior cruciate ligament (ACL) reconstruction surgery aims to restore functional stability of the knee and to allow patients to return to their occupational and sporting activities. While in the young and active population, surgery is often the best therapeutic option after an ACL tear to restore knee kinematics, reducing the risks of subsequent injury and the progression of degenerative changes,1 ACL reconstruction in middleaged individuals is probably more controversial due to concerns about a higher complication rate and whether or not it is needed because of their activity level. However, many of these middle-aged individuals are still very active and find such injuries debilitating.
Conservative treatment was frequently advocated in the past for middle-aged people with an ACL tear, which consists of modifying activities, quadriceps muscle strengthening, proprioception exercises, and bracing.2–4 This is because some surgeons thought ACL reconstruction on older patients could lead to complications such as stiffness, arthrofibrosis, infections, wound healing problems, or thromboembolic disease, and there were concerns that underlying degenerative knee osteoarthritis could prevent a satisfactory outcome.5,6 Currently, ACL reconstruction is becoming more common in active middle-aged patients, and age does not represent
received July 7, 2012 accepted after revision January 1, 2014 published online February 7, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1368141. ISSN 1538-8506.
Downloaded by: Rutgers University. Copyrighted material.
J Knee Surg 2014;27:497–500.
Anterior Cruciate Ligament Reconstruction
El-Sallakh et al.
the major criteria in the decision-making process for the treatment of the ACL-deficient knee in middle-aged to older population.1,7,8 The aim of the study is to evaluate the patients older than 35 years who had ACL reconstruction using a four-stranded hamstring autograft. Our hypothesis is that functional outcome after ACL reconstruction in the middle-aged patients is comparable to the outcome of the younger group (younger than 35 years).
Methods This is a retrospective study of the patients who had arthroscopic ACL reconstruction from May 2006 to October 2011 (66 months). Inclusion criteria included the patients older than 35 years with high demand activities. We looked at the occupation, the activity level, and the individual patient desire for high demand sporting or recreational activities. Also we looked at the presence of associated knee injuries. The main complaint was recurrent giving-way episodes during daily activities, which affect their quality of life. Clinical findings included a positive Lachman test and pivot shift test. All of them had a magnetic resonance imaging (MRI) scan to screen for meniscal lesions, and rule out any significant osteoarthritis, osteochondral lesion, or concomitant multiple ligament injury. We excluded the cases with advanced osteoarthritis or concomitant multiple ligament injury. Patients were treated operatively with arthroscopic single-bundle four-strand hamstring tendon autograft. Absorbable transfixion pins were used to fix the graft in the femoral tunnel (Rigid fix system, DePuy Mitek, Norwood, MA) and an absorbable sheath and screw construct was used to fix the graft in the tibial tunnel (Intrafix screw, DePuy Mitek). The functional outcome was determined by clinical scores (Lysholm knee score and Tegner activity scale) pre- and postoperatively. The uninjured side was used as a control group regarding the functional results and degree of laxity.
Statistics We used paired t-test with significance p ¼ 0.5 between preoperative and postoperative Lysholm and Tegner clinical scores.
Results Twenty-nine patients met the criteria for inclusion in this study; however, one patient was lost to follow-up. Thus, our cohort included 28 patients (23 male and 5 female). The mean age was 41.2 years old (range, 36–58). The mean follow-up was 33 months (8–74 months). ►Table 1 shows an analytical breakdown of the patient age groups. Fourteen of our patients had meniscus tears, which were treated with partial meniscectomy. Twelve of them underwent partial meniscectomy before ACL reconstruction and, due to persistent instability symptoms, underwent ACL reconstruction following recovery. Two patients underwent partial meniscectomy at the time of their ACL reconstruction. The Journal of Knee Surgery
Vol. 27
No. 6/2014
Table 1 Analytical breakdown of patient age groups Age range
No. of patients
35–39
12
40–44
13
45–49
2
50–54
0
55–60
1
There was a slight improvement in the functional outcome in the patients who had partial meniscectomies in comparison to the patients who did not have partial meniscectomies, but it was not significant (p ¼ 0.12). There were no changes in the stability of the both group. Also there were no significant differences between the 13 patients who had minor osteoarthritic changes (Outerbridge classification grades I and II)9 and the 15 nonosteoarthritic cases (p < 0.05). There were no reported significant complications as a result of the operation in any of our patients. ►Table 2 shows the pre- and postoperative Lysholm and Tegner activity scores for all patients. The results show that there was a statistically significant improvement in Lysholm scores as a result of the surgical intervention (p < 0.05). Regarding the Tegner score, the results show an overall return to baseline for all patients with clinical improvement, which was not statistically significant. One patient (no. 25) was unsatisfied with the procedure, despite an increase in both Lysholm and Tegner activity scores, improvement in the knee laxity, and he was able to do more light work (level 3). His main complaint was that he was unable to return to his full level of manual activities that involved lifting heavy objects. Of note, patient no. 26 was a full-time, self-employed window fitter who due to his injury was on disability benefits and hence had a preoperative Tegner activity score of 0. After surgery, his Tegner activity score improved and he is able to work and do moderately heavy labor (level 4).
Discussion Conservative treatment was frequently advocated in the past for middle-aged patients with an ACL tear, which consists of modifying activities, quadriceps muscle strengthening, proprioception exercises, and bracing.2–4 A retrospective study by Ciccotti et al2 on 30 middle-aged patients who underwent “aggressive” nonoperative management for such injuries found that the mean Lysholm score was 82 points. Eight of the 11 patients who had combined ligamentous injuries had a score of less than 84 points, which was causing a degree of disruption to their daily activities. Overall 25 (83%) of these patients, who had had guided rehabilitation and had modified activity, had a satisfactory outcome without an operation. However, those patients who wished to resume competitive sports activity that required pivoting were dissatisfied with the final outcome. Strehl and Eggli10 followed up 38 patients between the age of 16 and 55 years who were deemed suitable for conservative
Downloaded by: Rutgers University. Copyrighted material.
498
Anterior Cruciate Ligament Reconstruction
El-Sallakh et al.
499
Table 2 Pre- and postoperative Lysholm and Tegner activity scores for all patients Age at surgery
Pre-/postoperative Lysholm pre
Lysholm post
Tegner pre
Tegner post
1
39
89
100
6
5
2
44
84
100
6
6
3
37
75
90
5
5
4
42
75
90
5
5
5
36
89
100
6
6
6
46
73
100
6
6
7
38
73
100
6
6
8
43
75
90
5
5
9
42
63
100
5
5
10
43
73
93
5
4
11
58
69
90
4
3
12
37
73
95
5
5
13
43
75
95
5
5
14
43
81
100
5
5
15
39
81
100
5
5
16
36
84
100
6
5
17
39
84
95
5
5
18
36
84
100
5
5
19
40
89
100
4
4
20
44
89
94
4
4
21
41
84
95
4
4
22
37
73
100
5
5
23
47
79
95
4
4
24
38
79
94
3
3
25
44
75
90
2
3
26
43
56
95
0
4
27
42
63
94
4
4
28
38
73
93
5
4
Mean
41.3
77.14286
96
4.64
4.64
Maximum
58
89
100
6
6
Minimum
36
56
90
0
3
p 0.05 (significant)
treatment of ACL rupture. Twelve patients had a very good outcome. Twenty-three patients continued to experience knee instability symptoms and eventually underwent ligament reconstruction. Of the 12 who responded well to conservative treatment, only 2 patients were able to return to high demand sporting activities. Another study by Fitzgerald et al11 showed that with appropriately screened individuals, conservative treatment is adequate to allow patients to return to a satisfactory level of activity. Seng at al12 revealed an interesting outcome when using an expected value decision analysis tool to determine the optimal treatment of ACL rupture in patients aged 40 years or older. With a mean age of 53 years (range, 40–80 years), they
Downloaded by: Rutgers University. Copyrighted material.
Patients
p < 0.05 (not significant)
noted that increasing the probability of surgical complications decreased the expected value of operative treatment but not below the expected value of nonoperative treatment. Thus, they highlighted an observation that individuals aged 40 years or older may be more averse to accepting potential knee instability during pivoting and thus prefer ACL surgery despite the risk of surgical complications. A recent systematic review by Legnani et al1 aimed at reviewing the current body of evidence surrounding the treatment of middle-aged patients who sustain ACL ruptures; there appears to be a growing body of evidence supporting surgical treatment options for higher demand patients. The authors concluded that the chronological age should not be The Journal of Knee Surgery
Vol. 27
No. 6/2014
Anterior Cruciate Ligament Reconstruction
El-Sallakh et al.
the primary factor when considering ACL reconstruction. These patients tend to be more motivated to adhere to rehabilitation regimens and therefore activity level and functional demand should be the principal determining factors. Our study and experience advocates the use of surgical reconstruction of ACL in appropriately selected individual patients. We believe that each patient should be reviewed individually and counseled about their posttreatment expectations, irrespective of whether they opt of conservative or surgical treatment. There was a significant improvement in the Lysholm scores for our patient cohort from 77 to 96. Although there was no increase in the Tegner activity scores overall, our study shows a return to baseline preinjury activity levels. There were no reported significant complications as a result of the operation in any of our patients. Only one patient was unsatisfied with the procedure, despite an increase in both his Lysholm and Tegner activity scores. His main complaint was inability to return to his full level of manual activities that involve lifting heavy objects. Our results were comparable to other studies7,8,13,14 with operative treatment documenting favorable outcomes in this patient population with regard to knee stability and patient satisfaction. Among these four studies reporting on the difference in the outcomes between middle-aged and young patients, no significant difference between both groups and no increased risk of complication (stiffness, arthrofibrosis, and infections) were noted in the middle-aged patients compared with the control group. In our study, we used MRI first to confirm the diagnosis and find out the associated injuries including osteoarthritic changes and we used the Outerbridge classification for grading osteoarthritis according to the arthroscopic findings. It has been proven that the existence of significant underlying osteoarthritis and concomitant cartilage lesions (more common among middle-aged patients) can affect the outcomes of ACL reconstruction.5,6 In our study, the patients with significant osteoarthritis changes were excluded and did not have ACL reconstruction. The patients who had minor osteoarthritic changes did not have a significant difference (in outcomes) in comparison to nonosteoarthritic cases. These are compatible with previous studies.15 Poor results are, however, correlated with more advanced degenerative changes.5,15
commonly propose surgical treatment in symptomatic patients who express the need to restore their preinjury activity levels, regardless of their age. Further studies are required to aid surgeons in determining the correct therapeutic approach for the ACL-deficient knee in the more mature population.
References 1 Legnani C, Terzaghi C, Borgo E, Ventura A. Management of anterior
2
3
4
5
6
7
8
9
10
11
12
Conclusion We conclude that although middle-aged patients may not be high level sporting individuals, many of them are still very active and require knee stability to carry out their everyday jobs, as highlighted by some of the patients. There are patients who also enjoy sporting activities such as running, playing football, or skiing that require a stable knee pivot, and thus should also be considered for reconstruction. The good results and a high level of patient satisfaction show that ACL reconstruction is justified even in patients (older than 35 years) with symptomatic anterior knee instability. We
The Journal of Knee Surgery
Vol. 27
No. 6/2014
13
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