The use of hamstrings in anterior cruciate ligament reconstruction in patients over 40 years

Anterior cruciate ligament reconstruction is an increasingly established method even in patients over 40 years old. Recent studies with regard to this procedure used BTB transplants. We did a retrospective follow-up examination on over-40-year-old patients with anterior cruciate ligament reconstruction using hamstring transplants and compared them to a younger control group. Our hypothesis is that functional outcome after ACL-reconstruction is comparable in patients under and over 40 years of age.

Retrospective follow-up examinations in 28 patients, 11 women and 17 men. The average age at the time of operation was 43.5 years (range 40-61). The average follow-up period was 30.4 months. Half of the patients had a femoral fixation in TransFix technique (Arthrex, Naples, USA), while the other 14 patients had a femoral bioscrew fixation (Arthrex, Naples, USA). Objectivity was ensured by measurements of anterior tibial translation with the rolimeter (Aircast). The functional outcome was determined by clinical scores (Tegner activity scale, Lysholm knee score, OAK score and IKDC score). The degree of arthrosis was defined on the basis of tunnelview radiographs and compared to the non-operated site. Functional results and degree of laxity was compared to a sex matched control group (mean age 28.0).

The median values for the Lysholm knee score were 91.5 points (range 69-100), for the OAK score 93.5 points (range 67-100) and for the IKDC score 83.35 points (range 62.1-100). For the Tegner activity scale values of 4.5 points (range 3-8) were obtained. In the IKDC knee examination form we found normal and nearly normal values in 86% and in the OAK examination score good and very good results in 82%. Ninety-three percent had an AP side-to-side difference of <5 mm in the operated knee. Subjectively, 75% reported that they had no feeling of instability, even when practising sport. No significant correlation between functional outcome and patients' age was present. Furthermore there were no significant differences between the investigated and the younger control group. The most advanced signs of arthrosis were found in the medial compartment of the operated side (degree A: 36%; degree B: 46%; degree C: 14%; degree D: 4%).

The predominantly good results and a high level of patient satisfaction show that anterior cruciate ligament reconstruction is justified even in over-40-year-old patients with persistend subjective symptomatic anterior knee instability. The indication for reconstruction should be based on individual factors such as level of activity or subjective feeling of instability rather than on a dogmatic age limit. Advanced arthrotic changes compared to the healthy side, might be due to a too long period of preoperative decision making.