A Comparison of Results after Anterior Cruciate Ligament Reconstruction in over 40 and under 40 Years of Age: A Meta-Analysis

Diagnosis and treatment of anterior cruciate ligament injuries: Consensus of Chinese experts part II: Graft selection and clinical outcome evaluation

Background

In the recent decade, there has been substantial progress in the technologies and philosophies associated with diagnosing and treating anterior cruciate ligament (ACL) injuries in China. The therapeutic efficacy of ACL reconstruction in re-establishing the stability of the knee joint has garnered widespread acknowledgment. However, the path toward standardizing diagnostic and treatment protocols remains to be further developed and refined.

Objective

In this context, the Chinese Association of Orthopaedic Surgeons (CAOS) and the Chinese Society of Sports Medicine (CSSM) collaboratively developed an expert consensus on diagnosing and treating ACL injury, aiming to enhance medical quality through refining professional standards.

Methods

The consensus drafting team invited experts across the Greater China region, including the mainland, Hong Kong, Macau, and Taiwan, to formulate and review the consensus using a modified Delphi method as a standardization approach. As members of the CSSM Lower Limb Study Group and the CAOS Arthroscopy and Sports Medicine Study Group, invited experts concentrated on two pivotal issues: "Graft Selection" and "Clinical Outcome Evaluation" during the second part of the consensus development.

Results

This focused discussion ultimately led to a strong consensus on nine specific consensus terms.

Conclusion

The consensus clearly states that ACL reconstruction has no definitive "gold standard" graft choice. Autografts have advantages in healing capability but are limited in availability and have potential donor site morbidities; allografts reduce surgical trauma but incur additional costs, and there are concerns about slow healing, quality control issues, and a higher failure rate in young athletes; synthetic ligaments allow for early rehabilitation and fast return to sport, but the surgery is technically demanding and incurs additional costs. When choosing a graft, one should comprehensively consider the graft's characteristics, the doctor's technical ability, and the patient's needs. When evaluating clinical outcomes, it is essential to ensure an adequate sample size and follow-up rate, and the research should include patient subjective scoring, joint function and stability, complications, surgical failure, and the return to sport results. Medium and long-term follow-ups should not overlook the assessment of knee osteoarthritis.

Both Hamstring and Quadriceps Tendon Autografts Offer Similar Functional Outcomes After Arthroscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 50 Years or Older

PURPOSE

To compare the outcomes of hamstring tendon (HT) and quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction in patients aged 50 years or older in terms of patient-reported functional outcomes, graft failure rates, complications, return to sports activity, and sports preference.

METHODS

Between 2010 and 2022, prospectively collected data were obtained from an institutional database. Patients aged 50 years or older who underwent primary arthroscopic ACL reconstruction with either HT or QT autograft and had a minimum 2-year follow-up were included. Patients with concomitant meniscal, cartilage, and medial collateral ligament injuries were also included. Patients undergoing revision ACL reconstruction, those undergoing primary ACL reconstruction with a graft other than HT or QT autograft, and those with contralateral knee injuries or ipsilateral osteoarthritis (Ahlbäck stage ≥2) were excluded. Patients were evaluated in terms of the Lysholm knee score, Tegner activity level, and visual analog scale (VAS) score for pain before injury and at 2-year follow-up, as well as graft failure, QT rupture, and return to sport. The Mann-Whitney test was used to analyze unpaired samples, whereas the Friedman test was used to analyze variables over time. The χ2 statistic test was used to determine differences in categorical data between groups.

RESULTS

The number of patients in the QT and HT groups was 85 and 143, respectively. In the QT and HT groups, the mean age was 54.4 years (range, 50-65 years) and 56.4 years (range, 50-65 years), respectively, and 49% and 51% of patients were men, respectively. The 2 groups did not differ significantly in terms of age, sex, time from injury to surgery, and concomitant injuries. No significant differences in preinjury patient-reported outcome measures, consisting of the Lysholm score, Tegner activity level, and VAS pain score, were found between the 2 groups (P > .05). At the 2-year follow-up, the Lysholm knee score, Tegner activity level, and VAS pain score improved to preinjury levels and no significant differences in preinjury and 2-year follow-up functional scores were noted between the 2 groups (P > .05). Furthermore, at the 2-year follow-up, the Lysholm score and VAS pain score did not show significant differences (P = .390 and P = .131, respectively) between the QT and HT groups. Similarly, no differences in Tegner activity level were observed between the HT and QT groups at the 2-year follow-up. No significant differences in terms of the minimal clinically important difference were detected between the 2 groups for the Lysholm knee score (P = .410) and Tegner activity level (P = .420). The 2 groups did not differ in terms of patients' percentage of sports participation at baseline and at the 2-year follow-up (P > .05). A significant decrease (P = .01) in participation in skiing/snowboarding was reported in the HT group at the 2-year follow-up compared with baseline (116 patients [81%] vs 98 patients [69%]). No case of graft failure or QT rupture was reported in either group.

CONCLUSIONS

Arthroscopic ACL reconstruction using HT or QT autografts in athletically active patients aged 50 years or older provides satisfactory patient-reported functional outcomes and allows recovery of the preinjury level of activity.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Impact of age on clinical outcomes in anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is a common procedure for symptomatic ACL injuries. Age is often factored into clinical decision making and can influence the choice of conservative management over surgical intervention. The aim of this study was to investigate the effect of chronological age on the clinical outcome following ACLR.

METHOD

Six validated patient-reported outcome measures (PROM) were used to collect pre-operative and post-operative scores from patients with ACL rupture undergoing ACLR. Data were stratified pertaining to the patient's age at the time of surgery to compare the Younger Group (under 40 years) with the Older Group (over 40 years).

RESULTS

A total of 45 patients were included in this study. Pre-operatively the Younger Group (n = 32) had significantly better Lysholm (p = 0.016), Tegner (p = 0.001), Knee Injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living (ADL) sub-score (p = 0.003) and International Knee Documentation Committee (IKDC) score (p = 0.014) as compared to the Older Group (n = 13). Post-operatively, there was no significant difference (p > 0.05) between the two groups as all the PROM scores were comparable except for the Tegner score (p = 0.02), where younger patients had higher activity levels. Significant inverse correlations were only found between age and Tegner score (rho = - 0.58, p < 0.001) and KOOS Sport and Recreation sub-score (rho = - 0.33, p = 0.038).

CONCLUSION

ACLR is a clinically successful treatment strategy for patients of all ages. Thus, age should not be used in isolation to determine patient suitability.

Anterior Cruciate Ligament Reconstruction in Patients Over 40 Years Old Shows Low Failure Rates: A Systematic Review

Purpose

To review the literature reporting on complications and failure rates after primary anterior cruciate ligament reconstruction (ACLR) in patients ≥40 years.

Methods

This was a secondary analysis from a prior systematic review of the MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases on studies evaluating clinical outcomes in ACLR patients ≥40 years. Studies were included based on the following criteria: English-language studies reporting on postoperative complications and/or ACLR failure rates in patients ≥40 years. Case reports, technical notes, studies with duplicate reporting of patient cohorts, or studies using publicly available registry data were excluded. ACLR failure definitions, failure rates, graft rupture rates, revision ACLR and non-ACLR revision rates, and complication rates were recorded.

Results

Twenty-one studies were included following full-text review. Autografts were used in 89.0% of cases. Definitions for ACLR failure varied, ranging from (1) revision ACLR, (2) graft rupture, (3) clinical examination of increased knee laxity, and (4) postoperative arthrofibrosis requiring an additional surgery. The median ACLR failure rate was 5.0% (range, 0%-12.1%) among the 9 studies reporting this outcome, with only 4 of the studies providing explicit definitions of failure. The median ACLR revision surgery, graft rupture, and non-ACLR revision surgery rates were 0% (range, 0%-7.7%), 2.7% (range, 0%-9.1%), and 7.2% (range 0%-34.4%), respectively. Commonly reported complications included pain (range, 0%-14.0%), stiffness (range, 0%-12.7%), hematoma (range, 2.5%-8.8%), neurovascular (range, 0%-41.7%), and undefined (range, 0%-13.8%).

Conclusions

ACLR in patients over 40 years old shows low failure rates.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

Factors associated with perioperative deep vein thrombosis in arthroscopic anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is reportedly associated with a higher incidence of deep vein thrombosis (DVT) incidence than other arthroscopic surgical procedures. The aim of this study is to retrospectively investigate the incidence and type of DVT and evaluate the relationship between DVT and risk factors among all patients who underwent ACLR under uniform conditions consisting of mechanical prophylaxis, no medical prophylaxis, and preoperative and postoperative lower extremity venous ultrasonography.

METHODS

Of the 114 patients who underwent arthroscopic primary ACLR at our hospital who did not have a compound ligament injury or revision surgery, 112 patients were included. Two patients were not examined. DVT evaluation consisted of whole-leg ultrasonography at 1 week after surgery. We evaluated age, sex, body mass index, comorbidities, operative time, tourniquet time, presence of concurrent surgery (meniscus repair/resection or osteochondral column grafting), and non-weight-bearing status at 1 week after surgery as risk factors for DVT.

RESULTS

DVT was found in 33 (29.5%) of 112 patients. Of these, 22 (19.6%) had distal DVT and 11 (9.8%) had proximal DVT. Non-weight-bearing status at 1 week after surgery was a statistically significant risk factor for proximal DVT (P = .034).

CONCLUSIONS

Non-weight-bearing status is an independent risk factor for DVT, suggesting that early weight bearing may reduce the occurrence of DVT.

Quadriceps autograft is a viable graft choice for arthroscopic ACL reconstruction in patients over 50 years of age

PURPOSE

The purpose of this study was to evaluate the patient-reported outcomes, graft failure, quadriceps rupture and sports preference after arthroscopic ACL reconstruction in patients older than 50 years who underwent arthroscopic ACL reconstruction with a quadriceps tendon (QT) autograft.

METHODS

Between 2010 and 2020, prospectively collected data were obtained from an institutional database. Patients older than 50 years with primary arthroscopic ACL reconstruction and a minimum of 2 years of follow-up were included. Patients undergoing a revision ACL reconstruction or undergoing a primary ACL reconstruction using a graft other than a QT autograft, and patients with a contralateral knee injury or osteoarthritis (Ahlbäck stage 2 or higher) were excluded. A minimally invasive technique was used for QT autograft harvesting. Patients were evaluated for pre-injury and 2-year follow-up Lysholm knee score, Tegner activity level, Visual Analog Scale (VAS) for pain, graft failure, quadriceps tendon rupture, and return to sport.

RESULTS

A total of 57 patients were included in the study. The mean age of the cohort was 54.9 ± 5.2 (range 50-75). Of the 57 reconstructions, 16 (28%) were isolated ACL reconstructions, while 41 (72%) were complex reconstructions (concomitant meniscus, cartilage and/or collateral ligament injuries). At the 2-year follow-up Lysholm knee score, Tegner activity level and VAS for pain improved to pre-injury level and no significant difference was noted between pre-injury and 2-year follow-up functional scores (n.s.). No case of graft failure or quadriceps tendon rupture was reported. No significant difference was noted in the pre-injury and postoperative sports preference (n.s.) and all patients return to their desired sports activity.

CONCLUSION

Arthroscopic ACL reconstruction by using QT autograft in highly active older patients provides satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity. QT autograft is a good graft option in patients older than 50 years.

LEVEL OF EVIDENCE

Level IV.

Operative Management for Anterior Cruciate Ligament Injury in Patients Over 40 Years Old Yields Increased Clinical Outcome: A Systematic Review

PURPOSE

To evaluate outcomes of anterior cruciate ligament (ACL) rupture in patients ≥40 years treated nonoperatively or with ACL reconstruction (ACLR).

METHODS

A review of MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases from inception to June 1, 2021, was performed to identify randomized controlled trials, prospective or retrospective cohorts, case controls, or case series that met the following criteria: English-language studies reporting at least one subjective and/or objective outcome measure in ACL rupture patients ≥40 years treated nonoperatively or by ACLR. No limits were placed on graft type, time-to-surgery/follow-up, or concomitant procedures. Variability in patient-reported outcome scores, including subjective IKDC score, Lysholm score, Tegner activity score, and Knee Injury and Osteoarthritis Outcome Score, was assessed to evaluate the utility of applying previously established clinically meaningful thresholds to pooled outcome data.

RESULTS

12,605 citations were identified using screening criteria. Sixty studies satisfied criteria following full-text review. As previous systematic reviews reported on earlier literature evaluating ACLR outcomes in patients ≥40 years, studies in this review were limited to include only those published in the last 10 years (40 studies). An additional 16 studies were excluded based on aims of the review not identified during initial screen. Although preoperative to postoperative population-based improvements in Lysholm score, Tegner score, and IKDC score surpassed minimal clinically important differences (MCID) in at least 50% of studies, the variability present in the pooled data may limit its application. No studies evaluated nonoperative outcomes.

CONCLUSIONS

Evidence supports operative management in patients ≥40 years, as studies generally demonstrated preoperative to postoperative improvements in clinical outcomes based on population-level changes. However, application of patient-level clinically relevant thresholds to pooled outcome data should be undertaken with caution as reporting of population-based outcome scores may not accurately reflect changes in individual patients.

LEVEL OF EVIDENCE

Systematic review, IV.

Preoperative factors associated with failure to reach the patient acceptable symptom state after anterior cruciate ligament reconstruction in patients aged 40 and older

PURPOSE

To perform a predictive analysis to identify preoperative patient factors associated with failure to achieve a newly defined patient acceptable symptom state (PASS) for the International Knee Documentation Committee (IKDC) Score after anterior cruciate ligament reconstruction (ACLR) in patients aged ≥ 40 years with a minimum of 2-year follow-up.

METHODS

This was a secondary analysis of a retrospective review of all patients aged 40 years or older receiving a primary allograft ACLR at a single institution between the years of 2005 and 2016, with 2-year minimum follow-up. Using an updated PASS threshold of 66.7 for the International Knee Documentation Committee (IKDC) score previously established for this patient cohort, a univariate and multivariate analysis was performed to identify preoperative patient characteristics predictive of failure to achieve PASS.

RESULTS

A total of 197 patients with a mean follow-up of 6.2 ± 2.1 years (range 2.7 - 11.2) were included in the analysis (48.5 ± 5.6 years, 51.8% female, Body Mass Index (BMI) 25.9 ± 4.4). PASS was achieved by 162 patients (82.2%). Patients who failed to achieve PASS more often had lateral compartment cartilage defects (P = 0.001) and lateral meniscus tears (P = 0.004), higher BMIs (P = 0.004), and Workers' Compensation status (P = 0.043) on univariable analysis. Factors predictive of failure to achieve PASS on multivariable analysis included BMI and lateral compartment cartilage defect (OR 1.12 [1.03-1.23], P = 0.013; OR 5.1 [1.87-13.9], P = 0.001).

CONCLUSION

Among patients ≥ 40 years who receive a primary allograft ACLR, patients who fail to achieve PASS more often had lateral compartment cartilage defects and higher BMIs.

LEVEL OF EVIDENCE

Level IV.

Delay of Timing of Anterior Cruciate Ligament Reconstruction Is Associated With Lower Risk of Arthrofibrosis Requiring Intervention

PURPOSE

To conduct 2 separate stratum-specific likelihood ratio analyses in patients younger than 40 year of age (<40 years) and those aged 40 and older (40+ years) at time of anterior cruciate ligament (ACL) reconstruction to define data-driven strata between ACL tear and primary isolated ACL reconstruction in which the risk of arthrofibrosis, using manipulation under anesthesia and arthroscopic lysis of adhesions as surrogates, is significantly different.

METHODS

A retrospective cohort analysis was conducted using the PearlDiver Database. Patients who underwent ACL reconstruction were identified using the Current Procedure Terminology code 29888. Patients were stratified to those aged younger than 40 (<40) and those 40 and older (40+) at time of ACL reconstruction. The incidence of 2-year arthrofibrosis was calculated for weekly intervals from initial ACL injury to reconstruction. Stratum specific likelihood ratio analysis was conducted to determine data-driven intervals from initial ACL tear to reconstruction that optimize differences in 2-year arthrofibrosis. Following the identification of these intervals for both those <40 and 40+, multivariable analysis was conducted.

RESULTS

For those <40, stratum-specific likelihood ratio analysis identified only 2 data-driven timing strata: 0-5 and 6-26 weeks. For those 40+, stratum-specific likelihood ratio analysis also only identified 2 data-driven strata: 0-9 and 10-26 weeks. A delay in ACL reconstruction from initial injury by at least 6 weeks in patients younger than 40 and at least 10 weeks in patients older than 40 years is associated with a 65% and 35% reduction of 2-year manipulation under anesthesia and arthroscopic lysis of adhesions, respectively.

CONCLUSIONS

Our analysis showed a delay in ACLR of at least 6 weeks in patients younger than 40 years to be associated with a 65% reduction in the risk of surgical intervention for arthrofibrosis and a delay of at least 10 weeks in patients 40 years and older to be associated with only a 35% reduction in the risk of surgical intervention for arthrofibrosis. The authors propose this difference in reduction to be multifactorial and potentially associated with mechanism of injury, activity level, and preoperative factors such as amount of physical therapy, rather than solely timing.

LEVEL OF EVIDENCE

III, retrospective comparative prognostic study.

Patients older than 55 years regain sporting and recreational activities after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

(1) To compare sporting and recreational activity levels before and at a minimum 6 year follow-up, and (2) to assess the clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction in patients older than 55 years.

METHODS

A retrospective evaluation of prospectively collected data of 150 patients with a mean age of 64 ± 4.5 (57-74) years was evaluated 8.6 ± 1.4 (6-11) years after primary ACL reconstruction using hamstring autograft. All patients were assessed using the International Knee Documentation Committee scoring system (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity level, and visual analog scale (VAS) for pain. The level of recreational activities was assessed using a sport-specific questionnaire. All patients were categorized according to Isolated and Combined ACL injury groups.

RESULTS

The data of 125 patients were analyzed at the last follow-up. While 25 patients were lost to follow-up, 117 of 125 patients were active before their injury in at least one sports discipline compared to 121 of 125 patients after ACL reconstruction. One hundred and two (82%) patients had returned to their recreational activities at the final follow-up. The mean IKDC subjective score increased from 49.5 ± 23.2 (11.5-100) to 76.2 ± 14.8 (33.3-100) (p < 0.0001). The mean KOOS sport increased significantly from 36 ± 36.2 (0-100) to 74.1 ± 25.5 (0-100) (p < 0.0001). The mean VAS score improved from 6.0 ± 2.6 (0-10) to 1.0 ± 1.4 (0-6) (p < 0.0001). There was no significant difference in the median Tegner activity level (preoperative 5 (2-8) vs. follow-up 5 (2-8) (n.s). There was no significant difference in the number of sports disciplines and duration when comparing pre-injury and mid-term follow-up activity after ACL reconstruction. High-impact activities experienced a significant decline, while a significant increase in participation in low-impact activities was recorded.

CONCLUSION

The majority of patients with symptomatic instability regained their pre-injury recreational activity level with excellent clinical and functional outcomes after arthroscopic ACL reconstruction. Nevertheless, a change from high-to low-impact activities has been observed.

LEVEL OF EVIDENCE

Level IV.

The reliability of lower limb 3D gait analysis variables during a change of direction to 90- and 135-degree manoeuvres in recreational soccer players

BACKGROUND

Several biomechanical outcomes are being used to monitor the risk of injuries; therefore, their reliability and measurement errors need to be known.

OBJECTIVE

To measure the reliability and measurement error in lower limb 3D gait analysis outcomes during a 90∘ and 135∘ change of direction (COD) manoeuvre.

METHODS

A test re-test reliability study for ten healthy recreational players was conducted at seven-day intervals. Kinematics (Hip flexion, adduction, internal rotation angles and knee flexion abduction angles) and kinetics (Knee abduction moment and vertical ground reaction force) data during cutting 90∘ and 135∘ were collected using 3D gait analysis and force platform. Five trials for each task and leg were collected. Standard error of measurement (SEM) and the intraclass correlation coefficient (ICC) were calculated from the randomised leg.

RESULT

The ICC values of the kinematics, kinetics, and vertical ground reaction force (VGRF) outcomes (90∘ and 135∘) ranged from 0.85 to 0.95, showing good to excellent reliability. The SEM for joint angles was less than 1.69∘. The VGRV showed a higher ICC value than the other outcomes.

CONCLUSION

The current study results support the use of kinematics, kinetics, and VGRF outcomes for the assessment of knee ACL risk in clinic or research. However, the hip internal rotation angle should be treated with caution since the standard measurement error exceeded 10% compared to the mean value. The measurement errors provided in the current study are valuable for future studies.

The Majority of Patients Aged 40 and Older Having Allograft Anterior Cruciate Ligament Reconstruction Achieve a Patient Acceptable Symptomatic State

PURPOSE

To evaluate patient satisfaction, retear rates, and patient-reported outcomes (PROs) in patients aged 40 and older undergoing allograft anterior cruciate ligament reconstruction (ACLR). The secondary goal was to compare these parameters between groups of patients with intact versus failed grafts, and to evaluate these in relation to a historically reported International Knee Documentation Committee (IKDC) patient-acceptable symptoms state (PASS) score.

METHODS

Records of patients aged 40 and older who underwent ACLR between 2005 and 2016 at a single institution with a minimum 2-year follow-up were retrospectively reviewed. Patient-reported satisfaction, outcome scores, and failure rates were analyzed. The rate of achieving a previously defined IKDC PASS score based on younger cohorts was reported, and an updated PASS threshold for older patients was calculated.

RESULTS

201 patients were included with a mean age of 48.6 years (range: 40-68) and mean follow-up of 6.2 years (range: 2.8-11.2). 182 (90.5%) patients reported satisfaction following surgery. 16 (8.0%) patients experienced failure of their ACLR, 10 of which underwent revision ACLR. The median IKDC score in the intact ACLR group was 86.2, compared to 66.7 in the failure group (P < .001). In total, 134 (72.4%) patients in the intact group achieved the historical PASS score of 75.9 on IKDC compared to only 4 (25%) in the failure group (χ² = 15.396, P < .001). An updated IKDC PASS threshold for older cohorts was calculated to be 66.7.

CONCLUSION

Patients aged 40 and older who underwent allograft ACLR had an 8.0% failure rate at a mean follow-up of 6 years. Graft failure in patients aged 40 and older was associated with worse PROs. The majority of patients achieved the historically reported IKDC PASS threshold. Additionally, an updated age-appropriate IKDC PASS score of 66.7 was calculated to aid in future ACLR studies assessing older patients.

STUDY DESIGN

Level IV.

Editorial Commentary: Age-Appropriate Expectations Are Critical When Analyzing Knee Anterior Cruciate Ligament Reconstruction Outcomes: Age Is More Than Just a Number

In patients undergoing anterior cruciate ligament (ACL) reconstruction, age affects treatment and postoperative recovery decisions, as well as failure rates and outcomes. However, how age affects postoperative patient-reported outcomes and the appropriateness of using the International Knee Documentation Committee patient acceptable symptoms state score in the >40-year-old patient population has received little attention. This study assesses commonly used patient-reported outcomes in older patients undergoing ACL reconstruction and aims to redefine a more suitable patient acceptable symptoms state score for this patient population. As our understanding of both the importance of ACL reconstruction on knee biomechanics and joint stability, as well as the increased rate of ACL reconstruction in older patients grows, having age-appropriate outcomes expectations is critical to both counseling patients and developing future research aims. Future application of outcomes scores in clinical practice and in the research, arena must take into account patient age and function after ACL reconstruction.

Patients Aged 50 Years and Older Have Greater Complication Rates After Anterior Cruciate Ligament Reconstruction: A Large Database Study

Purpose

To assess the use of anterior cruciate ligament (ACL) reconstruction in older adults and to compare postoperative complication and revision surgery rates between patients older than and younger than 50 years old.

Methods

Retrospective data were obtained using the PearlDiver database for patients who underwent arthroscopic ACL reconstruction from January 2010 to December 2017. Trends in the annual performance of ACL reconstruction were determined using nonparametric test of trends of ranks. Patients in each age group were matched based on sex and the Charlson Comorbidity Index. The incidence of postoperative complications within 90 days and subsequent knee surgery within 2 years of ACL reconstruction was collected. Postoperative complication rates were compared between matched age groups using the χ² test.

Results

A total of 20,993 patients aged 50 years and older and 154,817 patients younger than 50 years underwent ACL reconstruction between 2010 and 2017. The use of ACL reconstruction in patients aged 50 years or older decreased over time (P = .044). Patients aged 50 years or older were more likely to experience at least 1 postoperative complication within 90 days compared to patients younger than 50 years (2.5% vs 2.1%, P = .007). Older patients were 1.3 times as likely to experience deep vein thrombosis (P = .002) and 1.8 times as likely to experience pulmonary embolism (P < .001). Younger patients were more likely to undergo subsequent ACL reconstruction and experience knee pain, stiffness, and wound infection postoperatively (P < .001, P < .001, P = .041). 1.6% of patients aged 50 years or older underwent total knee arthroplasty within 2 years.

Conclusions

ACL reconstruction in patients aged 50 years or older is associated with greater complication rates but lower rates of subsequent knee surgery relative to patients younger than 50 years of age. Younger patients were more prone to surgical complications whereas older patients experienced more medical complications. The increased incidence of VTE in this population suggests that thrombotic prophylaxis may be considered.

Level of Evidence

Level III, retrospective comparative observational trial.

Second-look arthroscopy after double-bundle posterior cruciate ligament reconstruction: Effect of patient age

Purpose

Second-look arthroscopy is invasive but still one of the most useful postoperative evaluation methods since graft morphology including graft tension, graft tear, and synovial coverage can be directly evaluated. However, only a few studies have evaluated transplanted posterior cruciate ligament (PCL) grafts. This study aimed to clarify the PCL graft morphology and chondral damages at second-look arthroscopy after double-bundle PCL reconstruction (PCLR) and to investigate the effects of patient age on these arthroscopic findings.

Methods

This study retrospectively included 26 patients who underwent second-look arthroscopy at the time of hardware removal 14 months after double-bundle PCLR for isolated PCL injury from January 2007 to December 2020. The patients were divided into two groups: group A, 39 years or younger (n = 14); and group B, 40 years or older (n = 12). At second-look arthroscopy, the grafts were evaluated based on tension (taut, graft tension as tense as a normal PCL; lax, graft tension looser than a normal PCL, unclassified, completely torn graft), tear (one or more tendon strands torn), and synovial coverage (good, synovial coverage greater than 80% around the graft; fair, synovial coverage greater than 50%; and poor, synovial coverage less than 50%). The chondral damages were evaluated using the Outerbridge classification system. Radiographic posterior tibial translation with gravity sag view as well as clinical outcomes were also evaluated.

Results

Anterolateral (AL) graft tension was lax in 8% of the patients, whereas posteromedial (PM) graft tension was lax or unclassified in 24% (p = 0.043). Graft tear was observed only in the PM graft of 19% patients (p = 0.022). Synovial coverage of AL grafts was good or fair in all cases, whereas that of PM grafts was poor in 28% cases (p < 0.001). Regarding the effect of patient age, the synovial coverage of PM grafts was significantly poorer in group B (p = 0.033), but no statistical difference in graft tension or tear was found. The chondral damages were significantly advanced in group B (p ≤ 0.01), except for the trochlear groove and lateral femoral condyle. No patients had residual subjective posterior instability, knee swelling, or loss of extension exceeding 5° or flexion exceeding 10°. All patients had improved from grade II or III preoperatively to grade I or grade II in the posterior drawer test. The posterior tibial translation significantly improved from 10.0 ± 3.6 mm preoperatively to 3.6 ± 2.1 mm at second-look arthroscopy. No significant differences in the postoperative clinical outcomes were observed between the two groups.

Conclusion

The morphology of the PM grafts at second-look arthroscopy after double-bundle PCLR was poorer than that of the AL grafts. Patient age negatively affected the postoperative graft synovial coverage and chondral status but did not affect the clinical outcomes.

•

Second-look arthroscopy is a direct evaluation of the transplanted graft.

•

There are very few studies of second-look arthroscopy of transplanted PCL grafts.

•

Arthroscopic findings in the PM graft were inferior to those in the AL graft.

•

Poorer synovial coverage in the PM graft was observed in the patients ≥40 years.

Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears

PURPOSE

To assess failure rates and patient-reported outcomes measures following arthroscopic primary anterior cruciate ligament (ACL) repair of proximal tears in different age groups.

METHODS

Between 2008 and 2017, the first 113 consecutive patients treated with repair were retrospectively reviewed at minimum of 2 years. Patients were stratified into 3 age groups: ≤21, 22-35, and >35 years. Primary outcomes were ipsilateral reinjury or reoperation, and contralateral injury rates, and secondary outcomes consisted of Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, International Knee Documentation Committee subjective, pain, and satisfaction scores. Group differences were compared using χ² tests and Mann-Whitney U tests.

RESULTS

Follow-up was obtained in 113 patients (100%). Median age was 35 years (interquartile range [IQR] 23-43) and median follow-up was 2.2 years (IQR 2.0-2.8). Overall, ACL reinjury occurred in 13 patients (11.5%), reoperation in 7 patients (6.2%), complications in 2 patients (1.8%) and contralateral ACL injury in 4 patients (3.5%). Overall, median Lysholm was 95 (IQR 89-100) and International Knee Documentation Committee subjective 92 (IQR 84-99). Treatment failure was significantly greater in the youngest age group (37.0%) as compared with the middle and older groups (4.2% and 3.2%, both P < .005). No significant differences were seen in reoperation, complication, or contralateral injury rates between groups (all P > .2), nor in patient-reported outcomes measures between the groups (all P > .1).

CONCLUSIONS

The failure rate of primary repair of proximal ACL tears is high in patients aged 21 or younger (37.0%), and this should be taken into account when discussing repair in this patient group. In patients older than 21, repair may be an excellent treatment with low failure (3.5%) and complication rates (1.2%) and good subjective scores.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Low Rate of Return to Preinjury Tegner Activity Level Among Recreational Athletes: Results at 1 Year After Primary ACL Reconstruction

Background

There is limited information about the functional recovery and rate of return to preinjury levels of sports among recreational athletes after anterior cruciate ligament reconstruction (ACLR).

Purpose

To investigate the recovery of quadriceps or hamstring strength, assess functional performance, and determine the rate of return to preinjury sports levels among recreational athletes at 1 year after ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 91 recreational-level athletes who underwent anatomic single-bundle ACLR were enrolled. We evaluated the limb symmetry index (LSI) of the quadriceps and hamstring peak torque strength at 60°, in addition to hop test performance (single-leg, triple, crossover, and 6-m timed), patient-reported outcomes, and pre- versus postoperative Tegner activity levels. Outcomes were compared between younger (age <25 years) and older patients (age ≥25 years).

Results

There were 48 patients in the younger group and 43 patients in the older group. At 1-year follow-up, the overall LSIs for quadriceps strength and hamstring strength were 77% and 86%, respectively, and the LSIs of the hop tests were 79% for single-leg, 81% for triple, 84% for crossover, and 85% for 6-m timed hop. Overall, only 24% patients returned to their preinjury Tegner level, and only 8% of patients met the criteria for return to pivoting, cutting, and jumping sports. At 1-year follow-up, the younger group showed significantly more quadriceps strength than the older group (85% vs 64%; P = .0001), better single, triple, crossover, and 6-m timed hop test results (85% vs 69%, P = .003; 84% vs 75%, P = .046; 91% vs. 74%, P < .001; and 91% vs 76%, P = .003, respectively), higher Lysholm score (87 vs 74; P < 0.001) and International Knee Document Committee score (82 vs 66; P < .001), and a higher rate of return to preinjury Tegner level (35% vs 12%; P = .009).

Conclusion

Only 24% of patients returned to the preinjury Tegner level at 1 year after ACLR (35% younger group vs 12% older group; P = .009). This information might be helpful in setting realistic expectations for recreational athletes after surgery.

Clinical Outcomes and the Failure Rate of Revision Anterior Cruciate Ligament Reconstruction Were Comparable Between Patients Younger Than 40 Years and Patients Older Than 40 Years: A Minimum 2-Year Follow-Up Study

PURPOSE

To compare the clinical outcomes and failure rates of revision anterior cruciate ligament reconstruction (ACLR) between young and middle-aged surgery patients.

METHODS

Patients who underwent revision ACLRs between January 2008 and June 2017 with a minimum 2-year follow-up were retrospectively evaluated. Patients were divided into 2 groups according to age: ≥40 years (group A) and <40 years (group B). Detailed patient demographic data, preoperative radiographic data, and concurrent meniscal and chondral lesion were reviewed. Clinical scores, laxity tests results, and graft failures were compared between groups at the final follow-up.

RESULTS

Eighty-six patients (group A, n = 24, 46.6 ± 4.5 years; group B, n = 62, 26.2 ± 6.3 years) were included in this study. Demographic data showed that the time interval from primary to revision ACLR was longer in group A than in group B (96.2 ± 80.9 vs. 52.0 ± 42.1 months, P = .011). Group A had a higher prevalence of chondral defects of the trochlea (P = .016). No significant differences were identified in the prevalence and severity of meniscal lesions. At the final follow-up, all clinical scores were improved postoperatively but did not differ significantly between the groups. No significant differences were identified in side-to-side difference on Telos stress radiographs (group A, 6.3 ± 5.0 mm; group B, 5.6 ± 3.8 mm; P = .403) and graft failure rate (group A, 33.3%; group B, 30.6%; P = .358) at the final follow-up.

CONCLUSIONS

The current study showed that the clinical outcomes of revision ACLRs in patients improved significantly in patients younger than 40 years and were comparable to those observed in patients older than 40 years at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

III.

Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis

BACKGROUND

Anterolateral augmentation procedures can be divided into traditional lateral extra-articular tenodesis (LET) and modern anterolateral ligament (ALL) reconstruction. Nevertheless, no studies have compared the clinical results between LET and ALL reconstruction, when combined with intra-articular ACL reconstruction. This study was therefore designed to compare the clinical results, including the anterior translation, rotational laxity, and patient-reported outcomes, in a group of patients who underwent ACL reconstruction combined with LET or ALL reconstruction.

METHODS

All studies systematically searched until March 2018 without any language restriction that reported the results of a lateral extra-articular stabilization procedure using either LET or ALL reconstruction methods combined with ACL reconstruction were evaluated. Two reviewers independently recorded data from each study, including the sample size, improvement in Lysholm score, and the number of patients with each grade of knee laxity using Lachman and pivot shift tests.

RESULTS

The pooled results of ten studies showed that the postoperative proportion of knees with grade 2 or 3 on the Lachman test was significantly higher following LET compared with ALL reconstruction in combination with ACL reconstruction (10.8%, 95% confidence interval [CI]: 6.6-17.1% vs. 1.5%, 95% CI 0.5-4.5%; p = 0.001). However, the pooled results of 12 studies showed that the proportion of knees that belonged to grade 2 or 3 on the pivot shift test, indicating poor rotational stability, was similar between these two techniques (4.9%, 95% CI 2.0-11.5% vs. 2.3%, 95% CI 1.1-4.5%; p = 0.101). The pooled improvements in Lysholm scores in these two groups were also similar (32.3, 95% CI 26.8-37.9 vs. 25.7, 95% CI 16.7-34.7, p = 0.218).

CONCLUSION

LET could lead to worse anterior instability than with ALL reconstruction when these two approaches were combined with single-bundle ACL reconstruction. However, rotational stability and patient-reported outcomes were similar between the techniques.

Do Older Skiers Have Worse Outcomes After Anterior Cruciate Ligament Reconstruction Compared With Non-Skiers or Younger Skiers?

Background:

There remains a paucity of literature comparing clinical outcomes after anterior cruciate ligament reconstruction (ACLR) between skiers and non-skiers, particularly in older patient populations.

Purpose:

To compare clinical outcomes after ACLR between skiers and non-skiers, with a subanalysis based on age.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A nested cohort of 128 patients from the Multicenter Orthopaedic Outcomes Network cohort who underwent primary ACLR completed a series of patient-reported outcomes pre- and postoperatively at 2 and 6 years including the Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and subjective International Knee Documentation Committee (IKDC) score. Data including patient sex, age at surgery, graft type, and sport participation were analyzed. Patients were stratified by participation in skiing (skiers vs non-skiers) and by age subgroup (≤29, 30-39, and ≥40 years). Student t tests and analysis of variance were used to compare mean improvement between pre- and postoperative outcomes.

Results:

A total of 44 skiers (female, 59.1%; age, 35.3 ± 11.6 years) and 84 non-skiers (female, 34.5%; age, 27.7 ± 11.3 years) were included. ACLR was performed using allograft in 36.7% (22 skiers, 25 non-skiers), autograft in 58.6% (19 skiers, 56 non-skiers), or hybrid autograft-allograft in 4.7% (3 skiers, 3 non-skiers). Although both non-skiers and skiers demonstrated improvements in outcomes from baseline to 2 and 6 years, non-skiers demonstrated significantly less overall improvement from 2 to 6 years postoperatively in KOOS Symptoms (P = .01), KOOS Pain (P = .002), and KOOS Activities of Daily Living (P = .03) subscales compared with skiers. There were 15 skiers who were 29 years or younger (34.1%), 14 skiers between 30 and 39 years (31.8%), and 15 skiers 40 years or older (34.1%). Skiers 40 years and older demonstrated significantly greater mean improvement in KOOS Symptoms (P = .02) and KOOS Quality of Life (QoL) (P = .01) subscales at 2 years and KOOS QoL (P = .01) at 6 years postoperatively compared with skiers 29 years or younger.

Conclusion:

Compared with non-skiers, skiers demonstrated significantly greater mean improvements in KOOS scores between 2 and 6 years after ACLR. In addition, skiers 40 years or older showed greater improvement in KOOS QoL compared with younger skiers. This information can be used to counsel skiers, especially those older than 40 years, as to their expected outcomes after ACLR.

Return to sports following arthroscopic primary repair of the anterior cruciate ligament in the adult population

BACKGROUND

To assess return to sport (RTS) rates and evaluate the timeline of rehabilitation milestones following arthroscopic primary anterior cruciate ligament (ACL) repair.

METHODS

A retrospective review of all patients treated with primary repair between 2008 and 2018 was conducted. All adult patients with preoperative Tegner of ≥6 and minimum follow-up of two years were included. Patients were seen in clinic or contacted to complete the postoperative Tegner, and report their time to return to work, time to running, and time to RTS. Additionally, they were asked to complete the ACL-Return to Sport After Injury (ACL-RSI). Outcomes were compared using Mann-Whitney U tests and chi-square tests.

RESULTS

Sixty patients treated with repair were included, of which 85% returned to any sports, 70% returned to knee-strenuous sports, and 60% returned to preinjury level. Patients returned to work in seven days (IQR five to 14 days), running in 90 days (IQR 57-120 days), and sports in 180 days (IQR 116-270 days). Overall, ACL-RSI score was 80.0 (IQR 53.0-95.0). Higher return to preinjury rates was found in patients with older age and lower fear of reinjury (all p < .05).

CONCLUSION

Following primary ACL repair, 70% of adult patients returned to knee-strenuous sports and 60% to preinjury levels by 180 days postoperatively. Positive predictors for return to preinjury levels included older age and low fear of reinjury.

LEVEL OF EVIDENCE

Retrospective Case-Series, level IV.

Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years: A Systematic Review and Meta-analysis

Background:

There is no consensus regarding the best treatment approach for middle-aged patients with anterior cruciate ligament (ACL) injuries. Chronic ACL-deficient knees are often associated with instability as well as secondary meniscal and cartilage lesions. ACL reconstruction (ACLR) has achieved satisfactory outcomes in younger patients; however, the effectiveness and safety of ACLR in middle-aged patients remain uncertain.

Purpose:

To compare the patient-reported functional scores, arthrometric outcomes, and complications of primary ACLR between older (≥50 years) and younger (<50 years) patients.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

We conducted a systematic review of cohort studies that compared the clinical outcomes of ACLR between patients aged ≥50 years and those aged <50 years. The Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases were searched for relevant studies. The Methodological Index for Non-randomized Studies (MINORS) criteria was used to assess the risk of bias and conducted a random-effects meta-analysis to combine the data, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the overall quality of the body of retrieved evidence. The primary outcome was knee functional outcomes, and secondary outcomes were arthrometric outcomes of ACLR and complications.

Results:

This study included 4 retrospective cohort studies with a total of 287 participants (129 in the older group and 158 in the younger group). All included studies reported significant improvements in clinical outcomes in both groups after ACLR. No significant differences were noted in the improvement of International Knee Documentation Committee (IKDC) scores (mean difference [MD], 0.20 [95% CI, −2.65 to 3.05]; P = .89) and Lysholm scores (MD, −1.98 [95% CI, −6.93 to 2.98]; P = .43) between the 2 groups. No significant differences were observed in anteroposterior stability or risk of complications between the groups.

Conclusion:

ACLR may be performed in middle-aged patients (≥50 years) without concern for inferior clinical and arthrometric results compared with younger patients (<50 years).

Patients older than 50 years had similar results of knee strength and anteroposterior stability after ACL reconstruction compared to younger patients

PURPOSE

To evaluate knee strength, ligament stability, and functional outcomes in patients older than 50 years who underwent anterior cruciate ligament (ACL) reconstruction, and to compare these results with those obtained from a younger patient group (< 40 years).

METHODS

Forty patients older than 50 years and 50 patients younger than 40 years who underwent ACL reconstruction were retrospectively studied. Isokinetic extensor and flexor muscle strength were evaluated. The peak torque was determined at speeds of 60°/s and 180°/s. The highest peak torque at each velocity was compared with that on the uninjured side. Patients were also evaluated for knee anteroposterior (AP) laxity and functional outcomes, which were measured by the Lysholm and International Knee Documentation Committee (IKDC) scores. All tests were evaluated at baseline and 1 year postoperatively.

RESULTS

The groups were comparable at the baseline. Both groups had significant improvements in all parameters, including isokinetic muscle strength, AP laxity, and functional scores, at 1 year postoperatively (all p < 0.05). Compared with younger patients, older patients had similar results for extensor and flexor strength, AP laxity, and Lysholm score (n.s.). However, younger patients had better IKDC scores than did older patients [median 81.1; 95% confidence interval (CI) 95% CI 78.9-88.7 vs. median 75.6; 95% CI 70.1-79.3, p = 0.007].

CONCLUSIONS

Though with lower IKDC scores, older patients with ACL reconstruction had comparable results of knee strength and ligament laxity to younger patients. ACL reconstruction is recommended for treating patients older than 50 years with ACL insufficiency, especially for those with high functional demand.

LEVEL OF EVIDENCE

Retrospective cohort study, III.

Supervised physiotherapy leads to a better return to physical activity after anterior cruciate ligament reconstruction

BACKGROUND

The main goal of rehabilitation after anterior cruciate ligament reconstruction (ACLR) is to return to functional and sports activity at a preinjury level. The aim of this study was to assess the influence of supervised (SU) versus non-supervised (NS) rehabilitation protocols after ACLR on the return to sports activity and quality of life of amateur athletes.

METHODS

The study included a total of 50 patients after ACLR, with 25 in the SU group and 25 in the NS group. No significant differences were observed between the two groups with regard to age, sex, or BMI. Two different ACLR techniques were used: hamstring graft and bone patellar tendon bone. The patients were examined preoperatively and 12 months postoperatively. Outcomes were evaluated utilizing the Kujala Scale, Tegner Scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), the Functional Movement Screen (FMS), and range of motion. Patients from the SU group participated in rehabilitation sessions with a physiotherapist with an average of 48 meetings. Those in the NS attended six meetings with the physiotherapist.

RESULTS

At final follow-up, patients from both groups demonstrated a higher level of functional and sports activity and had a better quality of life 12 months after ACLR. Patients from the supervised group returned to a significantly higher level of sports activity (Tegner Scale: SU=6, NS=5, P=0.003) and reported significantly better quality of life 12 months after ACLR (KOOS QOL: SU=90, NS=74; P<0.001).

CONCLUSIONS

Supervised, controlled physiotherapy results in higher activity levels and better quality of life in amateur athletes 12 months after ACLR.