Anterior cruciate ligament reconstruction in the over-50s. A prospective comparative study between surgical and functional treatment.

INTRODUCTION: In patients aged over-50 years, although data are sparse, results of anterior cruciate ligament (ACL) surgery are good if selection is correctly performed. However, non-operative treatment is usually proposed for this age group, as patients generally prefer just to scale down their sports activities. Non-operative results are acceptable, but with a high risk of residual instability, secondary lesions and lifestyle alteration. The main aim of the present study was to compare results between surgical versus non-surgical treatment of ACL tear in over-50 year-olds. Secondary objectives comprised assessing prognostic factors for poor functional outcome, and comparing the 2 groups epidemiologically to identify clinical decision-making factors. The study hypothesis was that results are comparable between operative and non-operative treatment of ACL tear. MATERIAL AND METHOD: Three hundred twenty patients were followed up prospectively: 92 non-surgical (NS group) and 288 surgical (S group). Classical epidemiological data were collected. Clinical laxity, differential laximetry, KOOS, IKDC, Tegner and ACL-RSI scores and radiologic assessment were collected pre- and postoperatively, as were intraoperative data. Early and late complications were collected. RESULTS: All patients were followed up. Patients were principally female, and were older, less athletic, with more stable knee and less severe functional impact in the NS group. Functional scores improved in both groups, and especially in group S, where sports scores were also better. In the NS group, laximetry at follow-up correlated with preoperative marked pivot-shift (p=0.024). Severe differential laxity was predictive of poor IKDC score (p=0.06). In the S group, laximetry at follow-up correlated with preoperative explosive pivot-shift (p<0.001), lateral meniscal lesion (p=0.007), use of hamstring tendon (p=0.007), and non-operated early complications (p=0.004). Factors for poor global KOOS score in group S comprised female gender (p<0.001), high BMI (p<0.001) and skiing (p=0.038). Factors for poor Tegner scores comprised skiing or team sport (p<0.05), isolated moderate medial osteoarthritis (p=0.01), and non-operated early complications (p=0.022). Factors for poor IKDC score comprised female gender (p=0.064), and non-operated early complications (p=0.019). Complications did not differ between groups. DISCUSSION/CONCLUSION: Results were satisfactory in both groups, with significant improvement in functional scores, but were better in group S. For NS patients, pivot sport was barely feasible and sports activity scores decreased. In case of severe laxity at diagnosis, surgical treatment should be proposed. LEVEL OF EVIDENCE: III; non-randomized prospective comparative series.

Factors affecting outcome of ACL reconstruction in over-50-year-olds.

INTRODUCTION: With increasing life expectancy and ever-improving quality of life in industrialized countries, functional demand and sports levels are increasing in older subjects, who are thus exposed to central pivot lesions almost as much as younger ones. While non-operative treatment provides acceptable results, it entails significant reduction in sports level. The aim of the present study was to analyze medium-term clinical, functional and radiological results of anterior cruciate ligament (ACL) reconstruction in over-50-year-olds, in order to identify factors for failure. HYPOTHESIS: The study hypothesis was that surgical management provides good results if patient selection is rigorous. PATIENTS AND METHODS: A multicenter retrospective study included 398 patients undergoing ACL reconstruction between April 1, 2009 and December 6, 2016. Inclusion criteria comprised: age≥50 years, with proven ACL tear. Preoperatively, clinical work-up was supplemented by measurement of differential anterior laxity and radiologic assessment of cartilage status. Functional level was assessed on the objective IKDC score. Intraoperative data comprised type of graft and meniscal and cartilage status. The same parameters were assessed postoperatively. Functional results were assessed on objective IKDS, KOOS and ACL-RSI scores. RESULTS: The mean follow-up was 42.2 months. The mean improvement in differential anterior laxity was 4.2mm. Pivot-shift showed improvement, with 97% absent or glide (p<0.001). Objective IKDC score showed significant improvement (p<0.0001). 23% of patients had poor clinical results: IKDC C or D. Preoperative explosive pivot-shift (p<0.0001), medial tibiofemoral osteoarthritis (p<0.0001) and medial meniscus lesion (p<0.002) emerged as risk factors for poor functional outcome. CONCLUSION: ACL reconstruction in over-50-year-olds provided satisfactory clinical and functional results. Rigorous patient selection is mandatory, as radiologic signs of medial tibiofemoral osteoarthritis indicate a risk of poor outcome. Surgery may be proposed in patients with high functional and athletic demand, before medial meniscal lesions can set in. In case of explosive pivot shift, associated anterolateral reconstruction should be considered.

Influence of operative technique on anterior cruciate ligament reconstruction in patients older than 50 years.

BACKGROUND: A consequence of the steady growth in the worldwide population of elderly individuals who remain in good health and continue to engage in sports is an increase in the incidence of anterior cruciate ligament (ACL) rupture occurring after 50 years of age. ACL reconstruction was formerly reserved for young athletes but now seems to produce good outcomes in over 50s. The type of graft and graft fixation method were selected empirically until now, given the absence of investigations into potential relationships of these two parameters with the outcomes. The objective of this study was to assess associations linking the type of graft and the method of femoral graft fixation to outcomes in patients older than 50 years at ACL reconstruction. HYPOTHESIS: The operative technique is not associated with the clinical outcomes or differential laxity. MATERIAL AND METHODS: A multicentre retrospective cohort of 398 patients operated between 1 January 2011 and 31 December 2015 and a multicentre prospective cohort of 228 patients operated between 1 January 2016 and 30 June 2017 were conducted. Mean follow-up was 42.7 months in the retrospective cohort and 14.2 months in the prospective cohort. The primary evaluation criterion was the clinical outcome as assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Score (TAS). Differential laxity was the secondary evaluation criterion. The Wilcoxon rank sum test and Kruskal-Wallis test were used to compare groups, and p-values<0.05 were considered significant. RESULTS: In the retrospective and prospective cohorts, hamstring tendons were used in 269 (67.6%) and 197 (86.4%) patients and extensor apparatus tendons in 124 (31.2%) and 31 (13.6%) patients. Femoral fixation in the retrospective cohort was cortical in 81 (20.4%) cases, by press-fit in 112 (28.1%) cases, and by interference screw in 205 (51.5%) cases; corresponding figures in the prospective cohort were 135 (59.2%), 17 (7.5%), and 76 (33.3%). The multivariate analysis of the retrospective data identified no significant associations of graft type or femoral fixation type with the KOOS, TAS, or differential laxity values. In the prospective cohort, hamstring grafts were associated with 0.6mm of additional laxity (p=0.007); compared to cortical fixation, press-fit fixation of patellar tendon grafts was associated with 0.3mm of additional laxity (p=0.029) and a 0.5-point lower TAS value (p=0.033), with no difference in KOOS values. None of these differences were clinically significant. DISCUSSION: The various ACL reconstruction techniques used in patients older than 50 years produce similar outcomes. The technique can be chosen based on surgeon preference without regard for patient age. LEVEL OF EVIDENCE: IV.