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Anterior Cruciate Ligament Reconstruction Outcomes as a Function of Age
Introduction
Anterior cruciate ligament (ACL) reconstruction is a relatively common procedure in young adults, with the majority of surgery being undertaken in patients aged between 16 and 35 years. The mean age of patients in outcome studies of ACL reconstruction is typically in the mid-20s. Overall, this reflects the activity and sporting profile of this age group. However, there is evidence of an increasing incidence of ACL reconstruction outside this age bracket, both younger and older. This chapter explores the influence of age on outcomes of ACL reconstruction, with particular reference to outcomes in younger and older patients, relative to the typical cohort described in the literature.
Clinical Outcomes
Studies that have explored outcome as a function of age vary in the cutoff ages used, with older patients being described variously as those older than 35, 40, and 50. The definition of young also varies considerably, from skeletally immature through to less than 20 years old. An early review by Sloane et al. identified four studies that had investigated whether age influenced the outcome of ACL reconstruction. However, with such a small number of studies and only one common outcome between them, few conclusions could be drawn. There have been a number of further publications since this review, and Table 121.1 summarizes some of the studies that have specifically looked at age as a variable that might influence outcome.
TABLE 121.1
Studies Investigating the Influence of Patient Age on the Outcome of Anterior Cruciate Ligament Reconstruction
| Study | Patients | Age Groups | Follow-Up | Measures | Results |
|---|---|---|---|---|---|
| Barber et al. (1996) | 203 ACLR PT autograft ( n = 118) or allograft ( n = 85) |
Younger group <40 Average age = 27 (range 16–39; n = 170) Older group >40 Average age = 44 (range 40–52; n = 33) |
21 (12–36) months | Tegner, Lysholm, Laxity (KT-1000), Clinical Laxity (Lachman, pivot shift), ROM | No difference between age groups |
| Barber et al. (2010) | 32 ACLR All PT allograft |
Younger group Median age = 31 (range 18–39; n = 21) Older group >40 Average age = 46 (range 40–55; n = 11) |
Minimum 24 months | Cincinnati, Lysholm, Tegner, IKDC activity score, ROM, Lachman, pivot shift, laxity (KT-1000) | No differences between groups for physical examination outcomes Cincinnati, Lysholm, Tegner, and IKDC activity scores improve significantly for both groups |
| Brandsson et al. (2000) | 67 ACLR | Younger group Median age = 23 (range 21–24; n = 37) Older group >40 Average age = 43 (range 40–51; n = 30) |
Younger group Median 38 (24–60) months Older group Median 31 (22–60) months |
Lysholm, Tegner, IKDC, Knee walking, Laxity (KT-1000), ROM, one leg hop test | Significantly higher Tegner activity score in young group Significantly higher subjective scores in older group (more pleased with overall result) |
| Conteduca et al. (2013) | 88 ACLR HS autograft |
<30 ( n = 27) 30–40 ( n = 25) >40 ( n = 36) |
Average 5-year follow-up | Lysholm, Tegner, IKDC subjective and objective, Lachman, Laxity (KT-1000) | No difference between age groups for any measure except KT-1000 laxity, which showed less side-to-side differences in the older >40 patient group |
| Deakon and Zarnett (1996) | 80 ACLR PT autograft |
Younger group Mean age = 25 (range 15–37; n = 40) Older group >40 Average age = 45 (range 40–63; n = 20) |
Mean 26 (12–67) months | Lachman, Laxity (KT-1000) | No difference between age groups |
| Desai et al. (2014) | 22,699 ACLR from Swedish Registry (2149 5-year follow-up) |
0–19 20–29 30–39 ≥40 |
5 years | Knee injury and Osteoarthritis Outcome Score | Preoperative KOOS scores worse in older age group At 5 years KOOS scores improve most in older group and are not different from younger age groups |
| Gee et al. (2013) | 94 ACLR | Younger group ≤ 25 Average age = 21 ( n = 48) Older group >40 Average age 45 ( n = 46) |
Younger group Mean 5.1 years Older group Mean 5.4 years |
Lysholm | No difference between age groups |
| Kinugasa et al. (2011) | 102 ACLR Double-bundle HS autograft |
<29 (mean age 22; n = 55) 30–49 (mean age 37; n = 36) >50 (mean age = 59; n = 11) |
Mean 14 (8–22) months | IKDC subjective, Lysholm, Tegner, ROM, physical exam (Lachman, pivot shift, effusion, ROM) |
Tegner activity scores significantly lower in >50-year group compared with <29-year-old group |
| Marquass et al. (2007) | 56 ACLR HS autograft |
Younger group Average age = 28 (range 16–39; n = 28) Older group >40 Average age 44 (range 40–61; n = 28) |
Younger group 17.3 (12–29) months Older group 30 (14–57) months |
Lysholm, OAK-Score, Tegner, Laxity (Rolimeter) | No difference between age groups |
| Osti et al. (2011) | 40 ACLR | <30 ( n = 20) >50 ( n = 20) |
Younger group 33 (24–44) months Older group 32 (24–49) months |
Laxity (KT-1000), Lachman, pivot shift, IKDC (subjective and objective), Lysholm | No difference between age groups |
| Viola and Vianello (1999) | 22 ACLR PT autograft |
Younger group Average age = 20 (range 17–24; n = 11) Older group >40 Average age 44 (range 40–47; n = 11) |
Younger group Mean 12.9 months Older group Mean 13.7 months |
IKDC form, Lysholm, Tegner Laxity (KT-1000), pivot shift, Lachman |
No difference between age groups |
ACLR, Anterior cruciate ligament reconstruction; PT , patellar tendon; HS, hamstring; IKDC, International Knee Documentation Committee; KOOS, Knee Injury and Osteoarthritis Outcome Score; ROM, range of motion.
In broad terms, it appears that activity- and impairment-based outcomes and scores do not vary much with age. The studies consistently show that all patients tend to improve with surgery for both objective clinical testing and subjective measures, regardless of age. In terms of satisfaction, Brandsson et al. reported that their group of older patients (>40 years) were more pleased with the overall results of surgery compared with younger patients (<25 years).
Older age has not infrequently been used as a relative contraindication to ACL reconstruction. However, the studies that have looked at patients older than 50 have consistently shown good outcomes. Furthermore, a systematic review by Brown et al. concluded that satisfactory outcomes can be achieved for patients aged 40 years and over. It was, however, noted that longer-term data are lacking. Nonetheless, it appears that older age should not necessarily influence the decision to proceed to ACL reconstruction. The activity profile of the individual combined with the laxity of the knee would seem to provide a more logical basis for decision making. Indeed, depriving older patients of reconstructive surgery may well expose them to the potential for further injury or limit their lifestyle.
In Barber et al. chondral damage of the femoral and tibial surfaces was observed more often in the 40 and older age group (76%) than the younger than 40 group (56%). Brandsson et al. similarly showed a higher percentage of older patients with cartilage injury or degenerative changes at surgery compared with younger patients (37% versus 3%, respectively). In patients older than 50 years, Blyth et al. found that poorer outcomes on Cincinnati, International Knee Documentation Committee (IKDC), and Tegner scores were associated with more advanced articular cartilage degeneration as noted at the time of surgery. Other authors have made similar observations.
Desai et al. used data from the Swedish ACL registry to show that older patients wait significantly longer for ACL surgery and have more cartilage injuries preoperatively compared with younger patients. Blyth et al. and Marquass et al. also attributed the greater degenerative changes in older patients to a longer time between injury and ACL reconstruction as a result of a more drawn-out decision-making process. The same may apply to the status of the medial meniscus. In Trojani et al., patients who had undergone a medial meniscal resection prior to ACL reconstruction had more pain and less residual laxity at follow-up than those with an intact meniscus.
Graft Choice
The choice of graft can be influenced by the age of the patient. Most obviously, patellar tendon (PT) grafts are generally avoided in the skeletally immature because of concerns about a bone bridge causing premature growth plate arrest. However, in patients nearing skeletal maturity this may not be of as great concern.
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