ACL reconstruction in older people

[shekat]

I was just wondering...do you recommend patellar autograft or hamstring autograft for a 53 year old who needs acl reconstruction and does not want an allograft? Is there any research or data that significantly favors one donor site over the other for "older" people? Thanks. (Just got back from Houston, wish I could have scheduled with you, maybe next trip...) Oh, and CPM or no CPM?

[Orthoski]

Shekat - while many surgeons would lean towards allograft in cases like yours, my understanding is that this is something you'd like to avoid. Honestly, both hamstring and patella have their respective advantages and disadvantage and, when taken together, most surgeons would recommend going with the one that YOUR surgeon does most often. Surgeons generally develop a preference for one or the other in their practice, and the benefits of going with the one your surgeon is familiar with far supersedes any other issue.

In case you are interested in the actual data, below is the abstract from a recent analysis of all quality literature to this time comparing hamstring and patella autograft. Heal up!

Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005960. doi: 10.1002/14651858.CD005960.pub2.
Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults.
Mohtadi NG, Chan DS, Dainty KN, Whelan DB.
Source

Orthopaedic Surgery, University of Calgary, Sport Medicine Centre, 2500 University Drive NW, Calgary, Alberta, Canada, T2N 1N4.
Abstract
BACKGROUND:

Reconstruction of the anterior cruciate ligament (ACL) commonly involves patellar tendon (PT) or hamstring tendon(s) (HT) autografts. There is no consensus with respect to the choice between these two grafts in ACL surgery.
OBJECTIVES:

This review compared the outcomes of ACL reconstruction using PT versus HT autografts in ACL deficient patients.
SEARCH STRATEGY:

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (2008, Issue 2), MEDLINE (1966 to April 10 2008), EMBASE (1980 to April 10 2008), conference proceedings and reference lists. No language restrictions were applied.
SELECTION CRITERIA:

Randomized and quasi-randomized controlled trials comparing outcomes (minimum two year follow-up) following ACL reconstruction using either PT or HT autografts in skeletally mature adults, irrespective of the number of bundles, fixation method or incision technique.
DATA COLLECTION AND ANALYSIS:

After independent study selection, the four authors independently assessed trial quality and risk of bias, and extracted data using pre-developed forms. Trial authors were contacted for additional data and information. Risk ratios with 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals for continuous outcomes.
MAIN RESULTS:

Nineteen trials providing outcome data for 1597 young to middle-aged adults were included. Many trials were at high risk of bias reflecting inadequate methods of randomization, lack of blinding and incomplete assessment of outcome.Pooled data for primary outcomes, reported in a minority of trials, showed no statistically significant differences between the two graft choices for functional assessment (single leg hop test), return to activity, Tegner and Lysholm scores, and subjective measures of outcome. There were also no differences found between the two interventions for re-rupture or International Knee Documentation Committee scores. There were inadequate long-term results, such as to assess the development of osteoarthritis.All tests (instrumental, Lachman, pivot shift) for static stability consistently showed that PT reconstruction resulted in a more statically stable knee compared with HT reconstruction. Conversely, patients experienced more anterior knee problems, especially with kneeling, after PT reconstruction. PT reconstructions resulted in a statistically significant loss of extension range of motion and a trend towards loss of knee extension strength. HT reconstructions demonstrated a trend towards loss of flexion range of motion and a statistically significant loss of knee flexion strength. The clinical importance of the above range of motion losses is unclear.
AUTHORS' CONCLUSIONS:

There is insufficient evidence to draw conclusions on differences between the two grafts for long-term functional outcome. While PT reconstructions are more likely to result in statically stable knees, they are also associated with more anterior knee problems.

[Orthoski]

By the way, someone should change the title of this thread from "older people" to "people who have skied more vertical feet".

[Alpinord]

As someone with more vertical feet than most on this forum and a hamstring autograft 2 years ago, the 'new cabling' in my left new is sound. I'm thinking my right knee would also benefit.

My ortho was a former Steadman Clinic doctor (which may have been were Lindsey went after her crash). The way I got it was that the hamstring autograft had come to be about equal or has surpassed the patellar autografts in frequency. He did both and it almost came to a coin toss. I asked him what he'd do if was him. He thought for second and said hamstring. Also, apparently patellar autografts caused more knee pain while kneeling. No issues here in that department.

I was (carefully) biking (w/loose clipless pedals) and hiking within a month. The only issue now is I do not have full bending of the knee and have tweaked it a couple times when too much force bent it back hard.

[Chainsaw_Willie]

I'm 46 and none of the four docs I've seen in the last month have said anything at all about my age other than that one doc said he prefers allografts in older patients. Honestly, I don't see why being in your 40s or even older should make much difference. I'm in much better shape than most guys my age and am often mistaken for being ten years younger. I don't want to be treated like a sedentary desk jockey just because of my age. I'll be skiing or hiking or biking 3 of every 4 weekends and for a couple week long vacations every year plus running or biking several times a week until I simply can't any more - which should be another 30 - 40 years if everything goes right.

[Jim S]

Great thread.

I'm going to to be 50 next week. I now ski about 100 days per year.

My 12 month old right ACL allograft held up in AK last week (repair 4/12/12). I plan on skiing for at least 30 more years.

My 15 year old left ACL autograft with patella tendon is rock solid. I had intermittent patella tendonitis for about 2-3 years post op and pain with kneeling but it resolved. My MCL strain still inhibits some moves like yoga but no other activity that I partake in bothers it.



Yes, I read my own MRIs but I have a colleague double read mine for objectivity just in case I have a subconcious head game when I look at it.

[valli]

I'm 44 and I don't think of myself as "older" yet. Older means qualifying for the discount meal at the early bird special, right? Part of it may be that I compete in a sport where people often don't peak until their forties and compete into their fifties. All five of the surgeons I met with recommended replacing the ACL, but they did recommend allograft because of age.

[fabienzan]

I was 48 when I had my acl (patellar tendon autograft), 70% menisectomy, chondroplasty, and microfracture surgery. My doc placed me in a CPM machine from the first night and I had full range of motion and could walk without a limp in 4 weeks. I ran at 12 weeks and I skied (tele on sand dunes) at 4.5 months. Whenever somebody tells me I can't do something because of my age (now 53) or for any other reason I get this fire in my gut that I won't stop until I prove them wrong.

Just had two shoulder surgeries in the last year and now I am starting to get myself back in shape for next season. Not only that, I have a goal forming to run the Leadville 100 mile footrace next year. It's your life. Don't let somebody who doesn't know you put limits on what you can do.

Hi ,

I am 43 and I am having knee reconstruction with medial meniscus repair / trimmed . I am worried about OA. I am wondering how you are dealing with that and if you have had any issues with your knee so far. Which meniscus was trimmed for you ? Medial or lateral ?

Cheers
Fab

[fabienzan]

Hi Mark,

I am wondering if you could help with this. I have been diagnosed with an acl tear and an oblique longitudinal tear within the periphery of the posterior horn of the medial meniscus extending to the inferior articular surface. THis extends for a length of approximately 26 mm involving the body of the posterior horn.
I have also got an incomplete wrisberg tear of the lateral meniscus with vertical longitudinal signal within the posterior horn at the wrisberg insertion.(happy to send you the MRI photos if you can help)
I am 43 active, I like skiing , basketball ( I had this injury playing basketball) and cycling (to work mainly about 20 kms a day)

I am about 16 weeks post injury and I feel that I have left it too long already. My knee is stable but I am some pain on the bottom left side and front of my knee ( hard to walk downstairs).
I have seen 3 surgeons , my main issues has been to find one that does mainly ACL and a lot of them like you which I have found recently I met him last week and he scheduled me for a knee reconstruction and medial meniscus repair on the 14/10.
The problem is that I can't probably wait like that as this is impacting my life very dramatically, I can't walk properly and I am also currently looking for a new job which makes things impossible therefore at this stage I am reverting to going back to see the first surgeon that I met at the beginning of my research process (well know Trauma professor here in Melbourne, my main worry is that I don't know how many knee reconstruction he does. I am assuming that his credential and reputation around town should be enough for him to be more than competent to do a good job nevertheless my main worry is that I need him to try to suture my medial meniscus rather than resected it which I understand that is what most surgeon will do.
Can you advise me from the description about what you think are my chances of a surgeon suturing my medial meniscus tear rather than trimming part of it.
I believe this is CRITICAL for me and the future quick onset of OA that would follow as this is the weight bearing part of my knee.

Cheers

[fabienzan]

Did you only tear your ACL or also meniscus ? I have a torn acl and medial meniscus and I am more worry about the meniscus tear than the ACL

[AR_Explorer]

***

I am wondering if there are others in my situation with an ACL injury from decades ago and how they proceeded -

I tore my ACL 22 years ago, when I was 18. I adapted to the pain for the next 6 months with physiotherapy but did not undergo any surgeries (personal situation). Now, with two kids, I find myself having intermittent knee pain from torn meniscus and instability from the torn ACL. MRI confirmed both. Ortho was okay with either surgery or not, and left it up to me. I would like to maintain an active lifestyle and delay any arthritis. Has anyone with an ACL injury from young age gotten it reconstructed decades later? What was the recovery like? Are there any special caveats about such a surgery? Is it too late to avert early arthritis? Will the surgery now help delay it?

Thanks so much for all your help! Enjoy the day!

[Marshall Tucker]

I'm pretty new/early in all this but my doc (massive Atlanta Ortho practice) was pretty quick to say, as best i can make out, that surgery will result in a stronger knee and more activity for a longer time vs. no surgery. He prefers allograft post 50, but I'm going to push for hamstring autograft - based on what I'm reading....