Lupine Publishers : A Systematic Review of Anterior Cruciate Ligament Reconstructions with Hamstring Autograft in Patients Over 50 Years of Age

  Lupine Publishers |  Orthopedics and Sports Medicine

Abstract

Background: While ACL injuries in older patients have historically been treated non-surgically, several recent studies have demonstrated excellent clinical outcomes with ACL reconstruction in patients over 50 years of age. Despite these outcomes, the ideal graft choice in this age group has yet to be defined.

Objective: The purpose of this study was to systematically review the literature and analyze the clinical outcomes, failure rates and complication rates in patients over the age of 50 who have undergone ACL reconstruction using a hamstring autograft.

Methods: A systematic review of the literature was performed according to the PRISMA guidelines and included English studies from January 2000 to 2020. Studies that reported on outcomes of patients over 50 years of age undergoing ACL reconstruction with a hamstring autograft were included. Studies with other graft types, patients under 50 and expert opinions were excluded. Data consisted of patient demographics, physical exam findings, functional outcome scores, failure rates and complications.

Results: 6 studies met the inclusion criteria and included 167 patients with a mean age of 54.8 (50-71). Mean follow up was 41.4 (12-72) months. All studies demonstrated a significant improvement in functional outcomes at final follow up, including IKDC, Lysholm, and Tegner scores. Very few complications and no clinical failures or revisions were reported in this cohort.

Conclusions: The results of this systematic review support hamstring autograft as a viable graft option for ACLR in patients over 50 with excellent functional outcomes, high patient satisfaction, low failure rates and minimal donor site morbidity.

Keywords: ACL: Anterior Cruciate Ligament; Reconstruction; Hamstring Autograft; Advanced Age

Introduction

Anterior cruciate ligament (ACL) rupture is one of the most common injuries seen in orthopedic sports medicine with over 129,000 occurring every year [1]. Until relatively recently, operative treatment has focused mostly on younger active athletes while older individuals were treated conservatively. Ciccotti et al. have reported an 83% satisfaction rate at final follow-up for older patients with an ACL tear treated conservatively [2]. Despite the high patient satisfaction rate, the authors noted persistent instability on exam in 97% of the patients and a reinjury rate of close to 40%, calling into question the benefit of conservative treatment in this age group. With an ever-increasing number of active individuals and increasing life expectancy, more and more patients are participating in high risk activities for ACL injury well into the later years of life. As a result, there has been an increasing number of studies evaluating the clinical outcomes of ACL reconstruction in older patients [3-16]. While 40 years of age has traditionally been the cut off for older patients, several published case reports have documented satisfactory clinical outcomes in patients in their 70s and 80s [11-15]. Because of this growing evidence, many have advocated for ACL reconstruction (ACLR) regardless of the age of the patient in the absence of advanced degenerative changes in the knee. Despite the positive outcomes of ACL reconstruction in older patients, the ideal graft choice in patients over the age of 50 remains controversial. While allograft is commonly utilized, several studies have advocated for the use of hamstring autograft in this population demonstrating excellent clinical outcomes and minimal donor site morbidity. The purpose of this study was to systematically review the literature and analyze the clinical outcomes in patients over the age of 50 who have undergone ACL reconstruction using a hamstring autograft. The secondary purpose was to characterize the overall failure and complication rate.

Methods

A systematic review of the literature was performed per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Search Strategy and Criteria

A literature search was conducted in the PubMed, Ovid, EMBASE, and Medline databases for studies in the English language between January 2000 and March 2020. Keywords used to identify relevant articles included “anterior cruciate ligament” OR “ACL” AND “50” OR “aged” OR “aging” OR “older patient”. Filters activated included: clinical trial, comparative study, controlled clinical trial, meta-analysis, multicenter study, observational study, randomized controlled trial, review, systematic reviews, validation studies, humans, and English. The focus was to study the various outcomes reported after ACLR among patients who are 50 years or older and had a hamstring autograft. Studies included prospective cohort studies, retrospective studies, and case series. A cohort of patients over the age of 50 years undergoing ACL reconstruction with a hamstring autograft was the primary inclusion criteria. Studies that did not have all patients treated with hamstring autograft, expert opinions, nonclinical studies, clinical studies that did not include a cohort over 50 years of age, clinical studies that were primarily centered on arthroplasty and studies in which the primary pathology did not involve the ACL were excluded from the analysis.

Extraction of Data and Synthesis

The primary outcomes were clinical and functional results such as Lysholm score and International Knee Documentation Committee (IKDC) score. These scores were extracted independently (M.M and G.Y) and presented as the mean with range of values listed in parentheses. Both pre-operative and post-operative scores were evaluated when available. To evaluate patient’s activity level, the Tegner activity score was used where 0 represented disability because of knee problems, and 10 represented the highest score corresponding to national and international elite competitive sports. Failure rate was also extracted which corresponded to a need for surgical revision due to recurrent ACL tear. The Lachman test and pivot-shift test were also assessed. An exam of 0-1 was listed as negative and 2-3 were listed as positive for both tests. Patient satisfaction information was also evaluated when listed.

 

Statistical Analysis

The meta-analyses were carried out using STATA software version 14 (Stata Corp, College Station, TX) and R software version 3.6.3. Heterogeneity was quantified by I2 statistic. A random-effect model was used when significant heterogeneity was detected among studies (p < 0.10, I2 ≥ 50%). The Egger’s linear regression test and funnel plots were used to examine the possibility of publication bias due to small-study effects (Figure 1 and 2). Differences in change of mean and standard deviation were calculated using:

Conclusion

The results of this systematic review support hamstring autograft as a viable graft option for ACLR in patients over 50 with excellent functional outcomes, high patient satisfaction, low failure rates and minimal donor site morbidity. 

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