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Surgery may be the best option for ACL rupture patients older than 40 years

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WASHINGTON — An award-winning study presented at the 27th Annual Meeting of the Arthroscopy Association of North America, here, suggests that surgery is the optimal treatment for ACL rupture in individuals older than 40 years, and is still preferred over conservative care even when the probability of surgical complications increase.

To determine the optimal treatment for ACL rupture in people older than 40 years, James H. Lubowitz, MD, and colleagues, used an expected values decision analysis with sensitivity analysis, a tool that quantitates clinical choices. The investigators assessed 100 random individuals older than 40 years for gender, age and activity level.

Using the Visual Analog Scale, the investigators asked the participants to rate their preferences regarding the possible results of operative and nonoperative treatment. They also created a diagrammed tree of potential treatment outcomes and assessed the probability of these outcomes using a literature review. Finally, they performed a statistical fold-back analysis and sensitivity analysis.

The study group included patients who did not have an ACL rupture and excluded those with a prior knee injury or surgery. The final cohort consisted of 59 individuals with an average age of 53 years.

The investigators discovered an expected value of 7.99 for operative treatment and a value of 1.86 for nonoperative treatment. When the investigators increased the probability of surgical complications, the expected value decreased but was still greater than that of nonoperative care.

"Decision analysis demonstrates that surgery is the optimal treatment for ACL rupture in patients over 40 years of age," Lubowitz said during his presentation of the Richard O'Connor Award-winning study. "[Individuals] over the age of 40 are extremely averse to accepting potential knee instability during pivoting. Doing well nonoperatively, patients might still have buckling, and they did not prefer this. Thus, they [prefer] ACL surgical treatment despite the risk of the surgical complications."

For more information:

• Lubowitz J H, Seng K, Appleby D, et al. Operative vs. non-operative treatment of anterior cruciate ligament rupture in patients greater than 40 years of age. An expected values decision analysis. Paper SS34. Presented at the 27th Annual Meeting of the Arthroscopy Association of North America. April 24-27, 2008. Washington.