Anterior cruciate ligament (ACL) reconstruction is performed to restore knee function and stability for patients with instability after ACL injury. In young patients who participate in cutting and pivoting activities, arthroscopic ACL reconstruction is the gold standard treatment to restore knee stability and reduce the risk of subsequent meniscus and cartilage injury.
1- Gabler C.M.
- Jacobs C.A.
- Howard J.S.
- Mattacola C.G.
- Johnson D.L.
Comparison of graft failure rate between autografts placed via an anatomic anterior cruciate ligament reconstruction technique: A systematic review, meta-analysis, and meta-regression.
,2Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture.
The majority of ACL reconstruction cases in the United States are performed in patients aged 10 to 29 years.
3- Leathers M.P.
- Merz A.
- Wong J.
- Scott T.
- Wang J.C.
- Hame S.L.
Trends and demographics in anterior cruciate ligament reconstruction in the United States.
,4- Herzog M.M.
- Marshall S.W.
- Lund J.L.
- Pate V.
- Mack C.D.
- Spang J.T.
Trends in incidence of ACL reconstruction and concomitant procedures among commercially insured individuals in the United States, 2002-2014.
In older patients, however, the use of surgical management for ACL deficiency has been controversial in the past due to concerns about the possibility of infection, reoperation, and increased joint stiffness postoperatively.
5- Buss D.D.
- Min R.
- Skyhar M.
- Galinat B.
- Warren R.F.
- Wickiewicz T.L.
Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients.
Based on these concerns, patients aged 50 years or older old were traditionally referred to physical therapy and encouraged to modify physical activity before ACL reconstruction was considered. Older patients are increasingly active and involved in high-risk pivoting sports such as skiing, leading to an aversion to accepting potential knee instability and prompting the desire to undergo reconstruction despite the possible risk of complications.
6- Seng K.
- Appleby D.
- Lubowitz J.H.
Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients aged 40 years or older: An expected-value decision analysis.
,7- Desai N.
- Björnsson H.
- Samuelsson K.
- Karlsson J.
- Forssblad M.
Outcomes after ACL reconstruction with focus on older patients: Results from The Swedish National Anterior Cruciate Ligament Register.
Importantly, however, data concerning the risk of possible complications remain limited for this group of older patients considering ACL reconstruction.
Several studies have assessed the differences in clinical and functional outcomes after ACL reconstruction in older and younger adult populations.
8- Wierer G.
- Runer A.
- Hoser C.
- Herbst E.
- Gföller P.
- Fink C.
Acute ACL reconstruction in patients over 40 years of age.
, 9- Kim K.T.
- Kim H.J.
- Lee H.I.
- et al.
A comparison of results after anterior cruciate ligament reconstruction in over 40 and under 40 years of age: A meta-analysis.
, 10- Brandsson S.
- Kartus J.
- Larsson J.
- Eriksson B.I.
- Karlsson J.
A comparison of results in middle-aged and young patients after anterior cruciate ligament reconstruction.
, 11- Best M.J.
- Zikria B.A.
- Wilckens J.H.
Anterior cruciate ligament injuries in the older athlete.
, 12- Brown C.A.
- McAdams T.R.
- Harris A.H.
- Maffulli N.
- Safran M.R.
ACL reconstruction in patients aged 40 years and older: A systematic review and introduction of a new methodology score for ACL studies.
, 13- Mall N.A.
- Frank R.M.
- Saltzman B.M.
- Cole B.J.
- Bach Jr., B.R.
Results after anterior cruciate ligament reconstruction in patients older than 40 years: How do they compare with younger patients? A systematic review and comparison with younger populations.
A recent meta-analysis found no significant difference in clinical or arthrometric outcome measures after ACL reconstruction between patients older 40 years old and younger than 40 years old.
9- Kim K.T.
- Kim H.J.
- Lee H.I.
- et al.
A comparison of results after anterior cruciate ligament reconstruction in over 40 and under 40 years of age: A meta-analysis.
A systematic review by Costa et al.
14- Costa G.G.
- Grassi A.
- Perelli S.
- et al.
Age over 50 years is not a contraindication for anterior cruciate ligament reconstruction.
similarly found that patients older than and younger than 50 years old experience comparable improvements in patient satisfaction and knee stability, although older patients reported a reduced rate of returning to sport after surgery. As the age range of patients choosing to undergo reconstruction continues to broaden, there remains uncertainty concerning the incidence of postoperative complications among older patients. In addition, the magnitude of increase in the use of ACL reconstruction in the active aging population over recent years remains unclear.
The purpose of this study was to assess the use of ACL reconstruction in older adults and to compare postoperative complication and revision surgery rates between patients older than and younger than 50 years old. We hypothesized that the performance of ACL reconstruction in older adults is increasing over time, and that rates of complications, especially venous thromboembolism (VTE) and stiffness, are significantly greater in older adults.
Discussion
We observed that patients 50 years old and older were more likely to experience at least 1 postoperative complication within 90 days after ACL reconstruction relative to patients younger than 50 years old. Our initial hypothesis was partially confirmed because older patients had an increased risk of VTE, DVT, and PE after ACL reconstruction and increased risk of early conversion to TKA, although older patients were less likely to have subsequent knee surgery or experience knee pain, stiffness, or infection after surgery. There was also a decrease in the performance of ACL reconstruction in patients 50 years old and over from 2010 to 2017 (P = .044), contrary to our initial hypothesis. The findings of this study can allow for informed discussions between surgeons and patients older than 50 years regarding the potential for risk after ACL reconstruction, especially as medical risks are observed more frequently in this group of patients.
Nonsurgical management of ACL injuries in older athletes has been advocated in the past due to concerns that ACL reconstruction in older patients would lead to increased knee stiffness, arthrofibrosis, infections, poor wound healing, and thromboembolic disease compared with younger patients.
17- Legnani C.
- Terzaghi C.
- Borgo E.
- Ventura A.
Management of anterior cruciate ligament rupture in patients aged 40 years and older.
This has been refuted by studies reporting similar outcomes among younger and older patients after ACL reconstruction.
11- Best M.J.
- Zikria B.A.
- Wilckens J.H.
Anterior cruciate ligament injuries in the older athlete.
, 12- Brown C.A.
- McAdams T.R.
- Harris A.H.
- Maffulli N.
- Safran M.R.
ACL reconstruction in patients aged 40 years and older: A systematic review and introduction of a new methodology score for ACL studies.
, 13- Mall N.A.
- Frank R.M.
- Saltzman B.M.
- Cole B.J.
- Bach Jr., B.R.
Results after anterior cruciate ligament reconstruction in patients older than 40 years: How do they compare with younger patients? A systematic review and comparison with younger populations.
Patient-reported outcomes after nonoperative management of ACL rupture in older adults are also mixed. Ciccotti et al.
18- Ciccotti M.G.
- Lombardo S.J.
- Nonweiler B.
- Pink M.
Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. Results after long-term follow-up.
reported an 83% satisfaction rate among patients 40 to 60 years old treated with nonoperative management, but 37% of patients experienced reinjury and all patients were required to modify their activities and lifestyle. Gföller et al.
19- Gföller P.
- Abermann E.
- Runer A.
- et al.
Non-operative treatment of ACL injury is associated with opposing subjective and objective outcomes over 20 years of follow-up.
similarly found that subjective patient satisfaction improved over time after nonoperative management, but radiologic outcomes scores stayed constant or deteriorated and knee laxity testing showed increased instability over time. Physical activity levels also decreased significantly compared with preinjury levels.
19- Gföller P.
- Abermann E.
- Runer A.
- et al.
Non-operative treatment of ACL injury is associated with opposing subjective and objective outcomes over 20 years of follow-up.
Given that nonoperative treatment is associated with chronic degenerative changes, progressive instability, and high risk of reinjury, this approach may be unacceptable for many older patients with ACL deficiency who desire to return to previous activity levels.
The overall complication rate of ACL reconstruction surgery was significantly greater in older patients relative to younger patients in this cohort. Importantly, multiple previous reports have described the clinical effectiveness of ACL reconstruction in these older patients. Barber et al.
20- Barber F.A.
- Elrod B.F.
- McGuire D.A.
- Paulos L.E.
Is an anterior cruciate ligament reconstruction outcome age dependent?.
found no difference in patient satisfaction between patients older than 40 years (average 44 years) and younger than 40 (average 27 years), with 89% and 91% patient satisfaction respectively. A recent meta-analysis including four retrospective cohort studies and a total of 287 patients (129 older than 50 years, 158 younger than 50 years) found no difference in the improvement of International Knee Documentation Committee scores or Lysholm scores between patients older than and younger than 50 years old.
21- Tan C.W.
- Hsu W.H.
- Yu P.A.
- et al.
Anterior cruciate ligament reconstruction in patients older than 50 years: A systematic review and meta-analysis.
There was also no difference in Tegner activity scores or the incidence of knee AP laxity as measured on KT-1000 or KT-2000 arthrometer at final follow-up.
21- Tan C.W.
- Hsu W.H.
- Yu P.A.
- et al.
Anterior cruciate ligament reconstruction in patients older than 50 years: A systematic review and meta-analysis.
All studies included in the meta-analysis reported significant improvement in clinical outcomes across both patient age groups.
21- Tan C.W.
- Hsu W.H.
- Yu P.A.
- et al.
Anterior cruciate ligament reconstruction in patients older than 50 years: A systematic review and meta-analysis.
These findings indicate that ACL reconstruction in patients older than 50 years old results in similar knee stability and function scores compared to younger patients. However, this prior meta-analysis was unable to assess for differences in complication rates due to their low incidence after ACL reconstruction and the limited number of patients included in the analysis. Compared with the study by Tan et al.,
21- Tan C.W.
- Hsu W.H.
- Yu P.A.
- et al.
Anterior cruciate ligament reconstruction in patients older than 50 years: A systematic review and meta-analysis.
the current study highlights this difference in complication rates, with the most notable difference being the rate of DVT/PE in older patients.
In our large cohort, we observed that patients 50 years old and older have a greater risk of DVT and PE compared with younger patients. These findings build off of those by Gaskill et al.,
22- Gaskill T.
- Pullen M.
- Bryant B.
- Sicignano N.
- Evans A.M.
- DeMaio M.
The prevalence of symptomatic deep venous thrombosis and pulmonary embolism after anterior cruciate ligament reconstruction.
who found that patients older than 35 years had increased odds of VTE after ACL reconstruction. VTE is a rare but serious complication after ACL reconstruction, with a recent systematic review reporting incidences of asymptomatic DVT, symptomatic DVT, and PE of 8.4%, 2.3%, and 0.2%, respectively.
23- Erickson B.J.
- Saltzman B.M.
- Campbell K.A.
- Fillingham Y.A.
- et al.
Rates of deep venous thrombosis and pulmonary embolus after anterior cruciate ligament reconstruction: A systematic review.
While we were unable to determine whether VTE was symptomatic or asymptomatic due to database limitations, the increased risk of thromboembolic disease in patients 50 years old and older reported in this study suggests that anticoagulation prophylaxis may be considered for older patients undergoing ACL reconstruction. Currently, there is no standardized recommendation for the use of VTE prophylaxis during ACL reconstruction. A recent survey study found that 50.7% of orthopedic surgeons routinely use chemical VTE prophylaxis, with 95% reporting using aspirin although no standardized dosing protocol was identified.
24- Keller R.A.
- Moutzouros V.
- Dines J.S.
- Bush-Joseph C.A.
- Limpisvasti O.
Deep venous thrombosis prophylaxis in anterior cruciate ligament reconstructive surgery: What is the current state of practice?.
Given the rate of DVT/PE, surgeons may consider thromboembolic prophylaxis following ACL reconstruction for older patients. Future studies should assess for the prevalence of thrombotic prophylaxis for knee arthroscopy and the association between prophylaxis and clinically significant VTE in this population.
We also observed that the incidence of knee stiffness was actually lower for patients 50 years old and older relative to younger patients in our cohort. The incidence of knee stiffness overall was also lower in our cohort (4.4%) than in previous studies. Robertson et al.
25- Robertson G.A.
- Coleman S.G.
- Keating J.F.
Knee stiffness following anterior cruciate ligament reconstruction: The incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction.
reported an incidence of knee stiffness of 12% at 6 months and 5% at 12 months postreconstruction, with incomplete physiotherapy and previous knee surgery being the strongest predictors of knee stiffness. There was no difference in age (
P = .70) between patients who experienced stiffness and those who did not.
25- Robertson G.A.
- Coleman S.G.
- Keating J.F.
Knee stiffness following anterior cruciate ligament reconstruction: The incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction.
The decreased rate of knee stiffness in older patients cannot be fully explained with the data available, although could be due to graft choice, rehabilitation protocols, timing of surgery and administrative coding limitations, among other factors. Importantly, in this large cohort it does not appear that older patients have an increased risk of knee stiffness after ACL reconstruction.
Concerning the rate of subsequent knee surgery, we observed that younger patients were more likely to undergo additional knee arthroscopy including ipsilateral or contralateral ACL reconstruction within 2 years of the index ACL reconstruction. Part of this difference may be due to younger patients being more likely to undergo meniscal repair than meniscectomy, although we are unable to determine this conclusively given the study design and limitations. Contrastingly, patients 50 years old and older were more likely to undergo TKA within two years after ACL reconstruction compared to patients younger than 50 years old. These findings align with prior literature which identified older patient age at ACL reconstruction as a predictor of developing knee osteoarthritis.
26- Shelbourne K.D.
- Benner R.W.
- Gray T.
Results of anterior cruciate ligament reconstruction with patellar tendon autografts: Objective factors associated with the development of osteoarthritis at 20 to 33 years after surgery.
Overall, however, older patients were less likely to undergo subsequent surgery including arthroscopic surgery or TKA within 2 years compared with younger patients. Future studies should assess the mechanism by which ACL reconstruction influences TKA rates among older patients. The increased risk of TKA for older patients after ACL reconstruction compared with patients without ACL reconstruction can inform preoperative planning and assist surgeons in counseling patients about potential treatments.
Limitations
There are limitations to this study. Data analysis was limited to variables that were available in the database, as we did not have direct access to patient charts. Patient information including race and ethnicity, income, symptom severity, and duration of symptoms was unavailable. Patient-reported outcome measures and imaging reports are also not included in the database. Additionally, we were unable to assess the time from injury to ACL repair or cartilage status at the time of ACL repair. Notably, because laterality modifiers were not readily available for CPT codes, the laterality of primary and subsequent knee surgeries cannot be determined. Therefore, it is not clear whether the reported subsequent knee surgeries were a primary procedure on the contralateral leg, or a primary or revision procedure on the ipsilateral leg. Our study spans the introduction of ICD-10 codes, so the recording of postoperative complications was dependent upon the coding system used in a given year. Inconsistencies in how postoperative complications were recorded may have influenced our findings, as is the case with all retrospective and observational database studies. The use of autograft or allograft tissue, as well as primary or revision reconstruction surgery, cannot be discerned from CPT codes alone, so no recommendations can be drawn regarding graft type or approach to revision surgeries with these data. Despite these limitations, we believe that the findings from this large cohort of patients provides valuable insight into the incidence of postoperative complications in older patients after ACL reconstruction. Future studies can build off of these findings to explore the impact of additional variables on postoperative outcomes for older and younger patients after ACL reconstruction.
Article info
Publication history
Published online: October 08, 2021
Accepted:
August 30,
2021
Received:
February 24,
2021
Footnotes
The authors report the following potential conflicts of interest or sources of funding: B.M. reports board membership with Stryker, Conmed, and Tornier; grants from Aseculap, Samumed, Zimmer, and Conmed; and royalties from Conmed, outside the submitted work. A.L.Z. reports consultant for Stryker and Depuy Mitek, outside the submitted work. B.F. reports stocks in Bioniks and Kaliber.ai. D.A.L. reports grants from the Arthroscopy Association of North America (Arthroscopy Research Grant), American Orthopaedic Society for Sports Medicine (Young Investigator Award), Arthritis Foundation (research funding); patent pending for suture anchor device; Consultant for Vericel, Inc.; and educational support from Arthrex/Evolution Surgical and Stryker, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Copyright
© 2021 The Authors. Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.