Summary
In patients aged 50 and over, ACL reconstruction using quadriceps tendon autografts results in pre-injury functional outcomes and no deterioration of osteoarthritic grade.
Abstract
Purpose
The purpose of the study was to assess the patient-reported functional outcomes (PROMs), knee stability, quadriceps rupture, graft failure rates, and sports participation after anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft in patients aged 50 years or older. The hypothesis was that ACLR with QT autograft in highly active older patients would provide satisfactory PROMs and no worsening of osteoarthritic grade. It was also hypothesized that after ACLR patients will be able to return to pre-injury sports participation and activity levels.
Methods
Twenty-nine patients fulfil the inclusion criteria. The inclusion criteria were primary ACLR using QT autograft, age ≥ 50 years. The exclusion criteria were revision ACLR, utilisation of graft tissue other than QT autograft, contralateral knee injuries, osteoarthritis (Kellgren Lawrence ≥ 2), and conditions that might interfere with the standard postoperative rehabilitation protocol. A minimally invasive technique was used for QT autograft harvesting. Patients were evaluated at pre-injury, 2-year, and 5-year follow-ups for Lysholm knee score, Tegner activity level, and VAS (visual analogue scale) for pain; knee stability (Lachman and pivot shift test); quadriceps tendon rupture; graft failure; and sports participation. Lachman test and pivot shift test were recorded pre-operatively under anaesthesia and post-operatively at a 2-year and 5-year follow-up.
Results
Out of 29 patients, 15 (52%) were female and 14 (48%) were male. The mean age at the time of surgery was 54 ± 5.4 (range 50-67). In 26 (90%) patients, QT autograft without bone block and in 3 (10%) patients, QT autograft with a bone block was used. Of the 29 surgeries, 9 (31%) were isolated ACLR, while 20 (69%) were complex reconstructions defined as the presence of associated injuries and concomitant procedures on the meniscus, cartilage, and/or collateral ligament. Lateral and medial meniscal injuries were reported, respectively, in 6 (21%) and 9 (31%) patients. Six patients (21%) had chondral injuries that were treated by chondroplasty. Two patients reported MCL injuries, all treated conservatively. PROMs (Lysholm knee score, Tegner activity level, VAS) and knee stability improved to pre-injury level, and no significant difference was found between pre-injury and 5-year follow-up for Lysholm, Tegner, and VAS scores (p > 0.05). No incident of quadriceps tendon rupture, graft failure, or patellar fracture was reported. At a 5-year follow-up, patients achieved pre-injury level sports participation (p > 0.05). No significant worsening of osteoarthritic grade between baseline and final follow-up (p > 0.05). The ICC value for the reliability of OA was 0.89, indicating an excellent agreement.
Conclusion
ACL reconstruction with quadriceps tendon autografts provides preinjury-level functional outcome and no worsening of arthritic grade in patients aged 50 years or older. The use of QT autograft in these highly active elderly patients is a safe and feasible procedure.
Level of evidence
Level 3
What is known about the subject: Conservative management of ACL injuries in the elderly active population may result in persistent instability, and this can predispose strongly to meniscal damage and cartilage degeneration. With the availability of better instrumentation and a better understanding of ACLR with advances in surgical techniques, ACLR has been performed even in patients older than 60 years of age with good results, with the restoration of anterior knee stability and resumption of pre-injury activity.
What this study adds to existing knowledge: Arthroscopic ACLR by using QT autograft in highly active older patients provides satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity. QT autograft is a viable graft option in patients older than 50 years.