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Surgical treatment may be the answer for ACL tears in the aging athlete
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Introduction
“Don’t trust anyone over 30,” quipped the rebellious youth of the 1960s. The fact that those who said that are approaching 70 years of age demonstrates the relativity of youth. Today’s aging population manifests the benefits of societal advances in the areas of health, exercise physiology, athletic training, nutrition, and of course orthopedic sports medicine such that chronological age is but one measure of an individual’s fitness.
Additionally, advances in arthroscopic and related surgery have reduced the morbidity of surgical procedures. Anterior cruciate ligament (ACL) reconstruction represents a prime example of a surgery which is now routinely performed arthroscopically on an outpatient basis, with rapid return to activities of daily living and a positive long-term prognosis with regard to return to unrestricted activity.
Our research, conducted in Taos, New Mexico and published in Arthroscopy in 2008, indicates that, using an expected-value decision analysis model, operative treatment of ACL rupture in patients aged 40 years or older is preferred in comparison to nonoperative treatment. Individuals over 40 are extremely averse to accepting potential knee instability during pivoting, or a higher chance of reinjury or a modified return to activity, and thus favor ACL surgery despite the risk of surgical complications. In addition, age 40 or older is an arbitrary designation, and the population studied actually had a mean age of 53 years, ranging from 40 to 80 years of age.
Of course, as published, “Clinical experience dictates that treatment may differ for individual older patients facing the decision of operative versus nonoperative treatment for ACL tear based on more specific demographics of age, gender, and level of activity, as well as other potential unique variables such as regional location.” For example, a 40-year-old female molybdenum miner who participates in basketball and resides in the town of Questa in Taos County, New Mexico, may have different preferences than an 80-year-old, sedentary man living on a ground-floor apartment in a major urban center.
It thus gave me great pleasure to invite to participate in this Orthopedics Today Round Table discussion experienced ACL surgeons representative of diverse geographical locations and patient demographics to share their attitudes and experience with regard to treatment of ACL rupture in an aging population.
James H. Lubowitz, MD
Moderator
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James H. Lubowitz, MD
Donald H. Johnson, MD, FRCSC 
David A. McGuire, MD
Walter R. Shelton, MD
Patrick A. Smith, MDJames H. Lubowitz, MD: What is your definition of an “aging” athlete and what are your indications for surgical vs. nonsurgical treatment of ACL insufficiency in this population?
Donald H. Johnson, MD, FRCSC: I really don’t have a strong definition in terms of a chronological age for the aging athlete. The mature athlete is anyone who is beyond his or her competitive career. However, many masters athletes are competitive within their age group.
As I age, I have been pushing back the upper limit of the age at which I would perform ACL reconstruction. I really don’t have an upper limit, but look more at physical fitness, and level of activity. To pin me down to a specific number, 50 is the new 40. My oldest patient was 76 years old, and doing an ACL reconstruction in a 60-year-old is becoming routine.
I would proceed with an ACL reconstruction for any active older patient with a complete ACL tear presenting with instability symptoms and a positive pivot shift test.
However if the patient has one of these scenarios: a partial tear; a complete tear of only one bundle; or partial healing of the ACL that was torn in down-hill skiing, I will initially treat this patient conservatively if they don’t have positive pivot shift test (or at most a mild pivot glide). If they are not involved in a pivotal sport they may do fine without an operation and I will advocate the use of a brace for return to a sport such as skiing.
David A. McGuire, MD: All athletes are human: all humans age. Our goal as surgeons should be to restore any human being with an ACL injury to their best possible function. In the end, everyone wants their knee to perform for its intended purpose.
Exactly what we call athletes depends on your point of view. Dog mushers are athletes and soccer players are athletes. Their physical requirements may differ but in the end they both need their knees to function. So our goal in the aging athlete is to restore function to the maximum level possible for that individual patient. We have demonstrated that ACL reconstruction can be successful in the degenerative knee. Therefore, the ACL should be reconstructed in the patient who is experiencing symptoms whether or not he or she is aging or an athlete.
Walter R. Shelton, MD: The definition of the aging athlete has certainly changed since I first began practice. Today there are many more senior citizens participating in organized sports such a basketball, tennis and racquetball.
The age at which athletes depend on ACL-stable knees has dramatically gone up. For example, an 85-year-old retired internist who recently saw me for an aching knee who was still playing tennis. He depends on stable knees as much as a college tennis player.
This increased level of participation in sport by the older patient makes us rethink our approach to ACL insufficiency. Of course we must factor in many variables when treating these individuals such as general health, but we should consider surgical treatment when an older athlete faces an end to his or her sport when experiencing an ACL unstable knee. When expectations are realistic and the patient is motivated my results have been as good as ACLs performed in the younger athlete.
Patrick A. Smith, MD: My definition of an aging athlete would be an individual active in sports activities who is older than 35 years with really no top end relative to age. Furthermore, sports activities would encompass not just team sports but general fitness activities like jogging, cycling, swimming, weight training etc.
Relative to surgical or nonsurgical management for an ACL tear in an aging athlete, this decision is multifactorial with patient input very important.
Factors to consider:
- the extent of subjective instability;
- the particular sport or activity in which the patient is compromised and how much rotational knee stress is involved;
- the degree of objective laxity in terms of the pivot shift;
- the presence of an associated meniscus tear;
- the presence of significant degenerative changes;
- patient expectations relative to time commitment/sacrifices with treatment options especially surgery; and
- patient acceptance of allograft tissue for reconstruction option.
In general, if a patient complains of giving way with his or her physical activity-or experiences giving way with activities of daily living, has a positive pivot shift on exam with minimal to mild degenerative joint disease (DJD) on radiographs, and is committed to postoperative rehabilitation, I would recommend ACL reconstruction especially if they also have a significant meniscus tear.
If the patient is willing to modify activities to protect the knee and does not have an associated symptomatic meniscus tear, I would treat him or her with a home-based exercise program for quadriceps/hamstring strengthening with the option of an ACL functional brace to wear for any stressful activity, and monitoring for any future giving way.
Lubowitz: When you perform ACL reconstructive surgery on aging athletes, what is your technique, fixation and graft choice and rehabilitation protocol?
Johnson: My procedure of choice is a double, tripled or even quadrupled autogenous semitendinosus graft fixed on the femoral side with a Retrobutton (Arthrex), and on the tibial side with a cortico-cancellous screw. If this is an all-inside procedure I back up the Retroscrew (Arthrex) by tying the leader sutures over a periosteal button to improve the pullout strength. This is essentially the same procedure that I do for the younger recreational athlete.
On occasion I would do a tibialis allograft for the older athlete who needs to maintain his full knee flexion strength, such as a track sprinter. I would still do a bone-patellar tendon-bone (BTB) for the young competitive pivotal athlete who needs his full hamstring flexion strength.
I do not change the rehab protocol for the older athlete.
McGuire: I use allografts, BTB (Figure 1) or Achilles tendon, with femoral and tibial tunnel concentric axes located with an endoscopic femoral aimer and the Tundra System tibial guide (Smith & Nephew) respectively. With an ACL insufficiency accompanied by posterolateral corner injury induced rotational instability, the proximal end of the Achilles (preferred in these cases) is used for a lateral side augmentation (Figure 1).
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Image: McGuire DA |
I prefer bioabsorbable, headless cannulated interference screws (HCIS) for fixation. The BTB graft is sized to fit 12-mm and 11-mm femoral tunnels, but can be any size from 7 mm to 12 mm. Each end is secured with 7-mm × 25-mm HCIS. An Achilles graft is sized 12 mm for the bone or 9 mm for the tendinous end and is secured with 9-mm × 25-mm HCIS in a 10-mm femoral tunnel. The Achilles tibial tunnel and its bone plug is sized and secured the same as a BTBs at 12 mm.
If patient bone is osteoporotic, upsizing the screw — using a 9 mm × 25 mm vs. a 7 mm × 25 mm — may be required. If the patient has DJD, synovitis may be extensive, the patellofemoral joint may be arthritic, and loose bodies or adhesion formations are typical. In these patients you should distribute normal ACL rehabilitation cycle over a longer interval for at least 1 year. Passive range of motion (ROM) exercises must be used, such as heel sits and chair slides. Cryotherapy use may be required intermittently for the first year. Short intervals of physical therapy (PT) with plenty of rest are better than long intervals of PT to the point of pain.
Shelton: When I perform ACL reconstruction on patients older than the age of 55, I almost always use BTB allograft. I explain the risks and benefit of allograft use and let the patient make the final decision, but most desire the decrease in morbidity experienced with allografts.
I use an endoscopic technique with single-bundle reconstruction. The bone plugs are secured with absorbable interference screws. The surgery is done as an outpatient and I employ femoral/sciatic blocks. I keep the knee quiet with ice and elevation for 48 to 72 hours, and then start aggressive rehabilitation supervised by a physical therapist.
No braces are used and the patient is encouraged to bear as much weight as they can with two crutches for the first 3 weeks. The second 3 weeks are weight-bearing as tolerated with one crutch under the contralateral arm. At 6 weeks they are off crutches, by 3 months they can run on a track and at 6 months they are allowed back to sport if they have a full ROM, they are stable and they have 75% of their muscle strength back.
This rehab protocol does not differ from my younger patients and actually I have found the older individuals to be more compliant.
Smith: Relative to definitive ACL reconstruction, my preference in the aging-athlete population is an all-inside approach with use of a doubled soft tissue (anterior or posterior tibialis) allograft. The all-inside technique is minimally invasive, based on creating blind sockets, not tunnels, in both the femur and tibia. The femoral socket is created through the anteromedial portal with multiple femoral fixation options including interference screw, cross pin, or suspension RetroButton or combination of screw and RetroButton.
The technology that makes all-inside surgery possible is use of the RetroCutter (Arthrex) (Figure 2) to create the tibial socket from the joint side with aperture fixation on the tibial side with use of the RetroScrew (Figure 3). This approach, in my experience, results in the least postoperative pain and patients typically get back full motion in 3 to 4 weeks and most importantly, usually return to their normal everyday activities with minimal limitation in just a couple weeks.
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The technology that makes all-inside surgery possible is use of the RetroCutter (Arthrex) (Figure 2) to create the tibial socket from the joint side with aperture fixation on the tibial side with use of the RetroScrew (Arthrex) (Figure 3). Images: Smith PA |
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If a patient is not comfortable with allograft tissue, I utilize autogenous hamstring grafts harvested with a minimally invasive small popliteal incision.
One point I would make is that I have been fairly aggressive with meniscal suturing in this older population especially for the unstable posterior horn medial meniscus tear as these patients typically have early chondral changes. I have been pleasantly surprised relative to the clinical healing of these sutured tears once the knee joint is definitively stabilized. Recently, I have been adding autologous conditioned plasma (ACP, Arthrex) platelet extract therapy both to allograft preparation and for meniscal suturing to facilitate healing.
In terms of rehabilitation, my program is the same as for younger patients relative to a standard accelerated approach with early ROM along with emphasis on quadriceps exercises for full extension right away and immediate weight-bearing. Return to sport involving any cutting or twisting/pivoting activity especially with use of an allograft is generally 6 months.
Lubowitz: In the future, how do you imagine these answers could change?
Johnson: In the future we may be doing more acute suture repairs of the proximal tears augmented with biologic super clot, such as platelet rich plasma. Long-term in the chronic situation we may be augmenting the repairs with a synthetic collagen stent that has the appropriate growth factors implanted to optimize the healing environment.
McGuire: ACL lesions are often accompanied by concomitant injury. I’d hope as future patients present with knee problems, all of their pathology would be addressed at the same time. Currently, staging procedures, misdiagnosing clinically, or missing pathology intraoperatively (thus not attending to it) has no value for the patient short-, medium-, or long-term. It just creates more problems for the patient and the surgeon that gets to see them afterwards.
In the future, I hope orthopedic surgeons will continue to improve their ability to attend to the nuances of the multiply injured knee so revision ACL cases will lessen. Of course this includes teaching all patients that the laws of physics and biochemistry apply equally to them. Graft remodeling takes time, PT should be relatively pain free, and the more time spent strengthening quadriceps and participating in low-load PT without pain is the way to go.
Long-term I think that we will continue to redefine athletic age limitations and our capacity to help older patients with ACL knee injuries. I believe in the medium-term, distinctions of athlete vs. nonathlete will tend to blur as we seek to define patients less by their athletic endeavors and more by individual situations. Short-term I hope that my answers here make a difference and improve the outcomes for all ACL patients.
Shelton: In the future I can foresee the age at which we would consider an ACL reconstruction to go even higher. I think more patients will continue to participate in sport at an older age than did the previous generation. Certainly newer and better techniques with less morbidity will be developed and these new surgeries will benefit the older athlete. I think that one day we will be able to repair the damaged ACL rather than reconstruct it and in doing so preserve a more normal knee.
Smith: Regarding future directions, I think biologics such as platelet and other growth factor extracts will play an important role to facilitate graft fixation/healing/incorporation, and help treat early chondral joint damage in this population of older athletes with ACL involvement. This, in turn, may result in even more aggressive rehabilitation and quicker return to physical activities for these patients with overall less “surgical disability.”
For more information:
- Donald H. Johnson, MD, FRCSC, can be reached at Sports medicine Clinic, Carleton University , 1125 Colonel By Drive, Ottawa, ON K-1S 5B6; 613-520-3510; e-mail: Johnson_don@rogers.com.
- James H. Lubowitz, MD, can be reached at Taos Orthopaedic Institute, 1219-A Gusdorf Road, Ste. A, Taos, NM 87571; 505-758-0009; e-mail: jlubowitz@kitcarson.net. He is a consultant for Arthrex and Smith & Nephew; receives royalties from Arthrex; and receives research or education grant funding from Arthrex, Breg and Smith & Nephew.
- David A. McGuire, MD, can be reached at 4100 Lake Otis Parkway, Anchorage, AK 99508; 907-562-4142; e-mail: mcguired@alaska.net. Orthopedics Today was unable to determine whether he had any financial disclosures related to this article.
- Walter R. Shelton, MD, can be reached at 1325 E Fortification St., Jackson, MS 39202-2442; 601-354-4488; e-mail: wsheltonmd@msmoc.com. He is a paid consultant for Linvatec.
- Patrick A. Smith, MD, can be reached at 1 South Keene St., Columbia, MO 65201; 573-876-8633; e-mail: psmtihmudoc@aol.com. He is a consultant for Arthrex.