A Comparison of Results after Anterior Cruciate ...

Review Article Knee Surg Relat Res 2018;30(2):95-106 https://doi.org/10.5792/ksrr.17.065 pISSN 2234-0726 · eISSN 2234-2451

Knee Surgery & Related Research

A Comparison of Results after Anterior Cruciate Ligament Reconstruction in over 40 and under 40 Years of Age: A Meta-Analysis Kun-Tae Kim, MD1, Hyun-Jung Kim, PhD2, Hyang-Im Lee, MD3, Young-Jin Park, MD1, Dong-Geun Kang, MD4, Jun-Ill Yoo, MD1, Dong-Kyu Moon, MD1, Sung-Hee Cho, MD1, and Sun-Chul Hwang, MD, PhD1 1

Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju; 2Institute for Evidence-based Medicine, Department of Preventive Medicine, Korea University College of Medicine, Seoul; 3Department of Pathology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Changwon; 4Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Changwon, Korea

Purpose: Anterior cruciate ligament (ACL) injury is one of the most common injuries that occur in the knee, and ACL reconstruction (ACLR) is commonly performed for preventing aggravation of degenerative changes and restoring of knee stability in young, athletic patients. This metaanalysis has a purpose of evaluating the clinical and arthrometrical outcomes of ACLR in a group of middle age patients (40 years and older) and comparing with patients under 40 years of age. Methods: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and SCOPUS electronic databases were searched for relevant articles comparing the outcomes of ACLR between younger and older than 40 years of age until December 2016. Data searching, extraction, analysis, and quality assessment were performed based on the Cochrane Collaboration guidelines. Clinical outcomes were evaluated and compared between groups. The results were presented as mean difference for continuous outcomes with 95% confidence intervals whereas risk ratio for binary outcomes. Results: Seven studies were included in the meta-analysis. Based on International Knee Documentation Committee classification, side-to-side difference, Tegner activity score, Lysholm knee score, there were no significant clinical and mechanical differences between the groups. Conclusions: This meta-analysis confirmed that after ACLR, middle age (>40 years) and young age (40 years). However, it is well known that especially active patents of any age are increasingly unwilling to change their sports activities and request restora tion of intact overall knee function. Recent data have shown that the results of ACL reconstruction in patients over the age of 40 years, with or without concomitant degenerative changes, are comparable to those in younger patients4). Good results of ACL reconstruction in patients over 40 years have been widely docu mented as much as those in younger patients. Although several authors reported no statistically significant difference in clinical results between the two different age groups5), few systematically reviewed the literature for comparison on the efficacy of ACL reconstruction between over 40 and under 40 years of age. The purpose of this study is to compare the outcomes of ACL reconstruction between middle age patients (>40 years) and younger patients (40: normal or minimal change (small osteophytes without joint line narrowing)

Brandsson et al.7)

Arthroscopic ACL reconstruction

>40: postoperative bleeding, meniscal injury

>40: OA development


>40: graft failure, arthrofibrosis, infection (8.7%)

No definite signs of OA

Wierer et al.4)


NP


6)


NP


10)


>40: joint stiffness


8)

Gee et al.

Barber et al. Barber et al.

ACL: anterior cruciate ligament, NP: not provide, OA: osteoarthritis.

Knee Surg Relat Res, Vol. 30, No. 2, Jun. 2018

2. Quality and Publication Bias of the Included Studies All 7 studies1,4,6-10) were included for meta-analysis, and the risk of selection bias between the two groups was low. Assessable confounding factors did not exist for evaluation of demographic data. Follow-up period was recorded: the longer the period, the lower the risk of bias. All 7 studies included in this meta-analysis had a low risk of selection bias and compared demographic data of subjects undergoing ACL reconstructions in over 40 and un der 40 years of age, with none assessing possible confounding factors. Follow-up was defined as the interval between surgery and outcome evaluation. A longer interval was associated with a higher risk of bias, because clinical score may change over time because of correction loss.

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3. Outcomes of ACL Reconstruction in Age-Based Comparative Studies A total of 369 ACL reconstructions were performed (170 in young patients; 199 in middle age patients) in the entire studies included. Among the 199 middle age patients, ACL injury only patients were 64 and the remaining 135 patients had degenerative changes with a meniscus tear or chondral damage accompany ing the ACL injury. As for the surgical technique, anatomical single- or double-bundle endoscopic ACL reconstruction, ar throscopically-assisted two incision technique, and isolated ACL reconstruction with hamstring tendon graft were performed. Regarding the graft, autograft (hamstring, gracilis tendon, and bone-patellar tendon-bone graft) and allograft (Achilles tendon and tibialis anterior tendon) were used. The follow-up period

Table 3. Comparison of Clinical Outcomes between Groups in Included Studies Study Conteduca et al.1)

Viola and Vianello9)

Group (no.)

Lysholm knee score (SD)

Tegner score (SD)

40 (36)

93 (7.5)

IKDC (objective evaluation)

KT-1000 arthrometer (side-to-side difference)

A (12, 42.9%), B (14, 50%), C (2, 7.1%), D (0, 0%)

5 mm: 15%

A (13, 52%), B (10, 40%), C (2, 8%), D (0, 0%)

5 mm: 12%

4 (2–8)/5.2 (2–8)

A: 25 (69.5), B: 7 (19.5), C: 3 (8.3), D: 1 (2.7)

5 mm: 11%

>40 (11)

88.5 (73–100)

3.7 (3–5)/5.3 (4–6)

A (1), B (8), C (2), D (0)

30 lb/max5 mm: 0

40 years) and it is not absolutely age-dependent. The presence of OA, tendon stiffness, and concomitant injury should be consid ered in determining ACL reconstruction for middle age patients; however, in terms of greater possibility of more activities and better knee stability, surgical treatment may be helpful for middle age patients with ACL injury.

Conflict of Interest No potential conflict of interest relevant to this article was re ported.

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8. Gee AO, Kinsella S, Huffman GR, Sennett BJ, Tjoumakaris FP. Anterior cruciate ligament reconstruction in patients aged >40 years: a case-control study. Phys Sportsmed. 2013; 41:30-4. 9. Viola R, Vianello R. Intra-articular ACL reconstruction in the over-40-year-old patient. Knee Surg Sports Traumatol Arthrosc. 1999;7:25-8. 10. Barber FA, Elrod BF, McGuire DA, Paulos LE. Is an anterior cruciate ligament reconstruction outcome age dependent? Arthroscopy. 1996;12:720-5. 11. Desai N, Bjornsson H, Samuelsson K, Karlsson J, Forssblad M. Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cru ciate Ligament Register. Knee Surg Sports Traumatol Ar throsc. 2014;22:379-86. 12. Singh J, Sloan JA, Johanson NA. Challenges with health-re lated quality of life assessment in arthroplasty patients: prob lems and solutions. J Am Acad Orthop Surg. 2010;18:72-82. 13. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman

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104 Kim et al. A Comparison of Results after Anterior Cruciate Ligament Reconstruction according to Age Factor Appendix 1. Electronic Search Strategy on Each Database MEDLINE 1. “Anterior Cruciate Ligament”[TIAB] OR “Anterior Cruciate Ligaments”[TIAB] OR ACL[TIAB] 18052 2. “Anterior Cruciate Ligament”[Mesh] 11255 3. 1 OR 2 19693 4. Reconstructive[TIAB] OR reconstruction[TIAB] OR Surgical[TIAB] OR Surgery[TIAB] OR Surgeries[TIAB] OR grafts[TIAB] OR Grafting[TIAB] OR graft[TIAB] OR arthroscopy[TIAB] OR Arthroscopic[TIAB] OR Arthroscopies[TIAB] OR reconstructions[TIAB] OR arthrometer[TIAB] OR Arthrometry[TIAB] OR Operative[TIAB] OR Operation[TIAB] OR operations[TIAB] OR Transplantation[TIAB] OR Transplantations[TIAB] 2287524 5. “Reconstructive Surgical Procedures”[Mesh:NoExp] OR “Arthroscopy”[Mesh] OR “Arthrometry, Articular”[Mesh] OR “Ten don Transfer”[Mesh] OR “Minimally Invasive Surgical Procedures”[Mesh:NoExp] OR “Second-Look Surgery”[Mesh] OR “Transplantation”[Mesh] OR allograft[TIAB] OR allotransplantation[TIAB] OR autograft[TIAB] OR autotransplantation[TIAB] OR allografts[TIAB] OR allotransplantations[TIAB] OR autografts[TIAB] OR autotransplantations[TIAB] 539065 6. 4 OR 5 2462891 7. 3 AND 6 12467 8. “Anterior Cruciate Ligament Reconstruction”[Mesh] 2556 9. 7 OR 8 12648 10. “Age Factors”[Mesh] 444997 11. middle-aged[TIAB] OR age[TIAB] OR young[TIAB] OR Elders[TIAB] OR Elder[TIAB] OR Older[TIAB] OR younger[TIAB] OR aged[TIAB] OR elderly[TIAB] OR Adults[TIAB] OR Adult[TIAB] OR 40[TIAB] OR 50[TIAB] OR Forty[TIAB] 4529330 12. 10 OR 11 4683264 13. 9 AND 12 4186 14. 13 NOT “review”[Publication Type] OR “review literature as topic”[MeSH Terms] 3896 EMBASE 1. “Anterior Cruciate Ligament”:ab,ti OR “Anterior Cruciate Ligaments”:ab,ti OR ACL:ab,ti 21479 2. ‘anterior cruciate ligament’/exp 9691 3. 1 OR 2 23146 4. reconstructive:ab,ti OR reconstruction:ab,ti OR surgical:ab,ti OR surgery:ab,ti OR surgeries:ab,ti OR grafts:ab,ti OR grafting:ab,ti OR graft:ab,ti OR arthroscopy:ab,ti OR arthroscopic:ab,ti OR arthroscopies:ab,ti OR reconstructions:ab,ti OR arthrometer:ab,ti OR arthrometry:ab,ti OR operative:ab,ti OR operation:ab,ti OR operations:ab,ti OR transplantation:ab,ti OR transplantations:ab,ti OR allograft:ab,ti OR allotransplantation:ab,ti OR autograft:ab,ti OR autotransplantation:ab,ti OR allografts:ab,ti OR allotransplantations:ab,ti OR autografts:ab,ti OR autotransplantations:ab,ti 2919721 5. ‘plastic surgery’/de OR ‘tendon reconstruction’/exp OR ‘minimally invasive surgery’/exp OR ‘second look surgery’/exp OR ‘trans plantation’/de OR ‘allograft’/exp OR ‘allotransplantation’/exp OR ‘autograft’/exp OR ‘autotransplantation’/exp OR ‘arthroscopy’/ de OR ‘knee arthroscopy’/exp OR ‘arthrometry’/exp 338367 6. 4 OR 5 3009187 7. 3 AND 6 14345 8. ‘anterior cruciate ligament reconstruction’/exp 5662 9. 7 OR 8 15069 10. middle-aged:ab,ti OR age:ab,ti OR young:ab,ti OR Elders:ab,ti OR Elder:ab,ti OR Older:ab,ti OR younger:ab,ti OR aged:ab,ti OR elderly:ab,ti OR Adults:ab,ti OR Adult:ab,ti OR 40:ab,ti OR 50:ab,ti OR Forty:ab,ti 6106475 11. 9 AND 10 4964 12. 11 NOT ‘review’/it 4645 13. 12 NOT (‘animal experiment’/de OR ‘animal model’/de OR ‘animal tissue’/de OR ‘nonhuman’/de) 4297


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Cochrane 1. “Anterior Cruciate Ligament” or “Anterior Cruciate Ligaments” or ACL:ti,ab,kw 1821 2. MeSH descriptor: [Anterior Cruciate Ligament] explode all trees 835 3. 1 OR 2 1821 4. Reconstructive or reconstruction or Surgical or Surgery or Surgeries or grafts or Grafting or graft or arthroscopy or Arthroscopic or Arthroscopies or reconstructions or arthrometer or Arthrometry or Operative or Operation or operations or Transplantation or Transplantations:ti,ab,kw 155312 5. MeSH descriptor: [Reconstructive Surgical Procedures] this term only 759 6. MeSH descriptor: [Arthroscopy] explode all trees 1363 7. MeSH descriptor: [Arthrometry, Articular] explode all trees 83 8. MeSH descriptor: [Tendon Transfer] explode all trees 64 9. MeSH descriptor: [Minimally Invasive Surgical Procedures] this term only 1014 10. MeSH descriptor: [Second-Look Surgery] explode all trees 42 11. MeSH descriptor: [Transplantation] explode all trees 11712 12. allograft or allotransplantation or autograft or autotransplantation or allografts or allotransplantations or autografts or autotransplantations:ti,ab,kw 3603 13. 4-12/OR 155899 14. 3 AND 13 1459 15. MeSH descriptor: [Anterior Cruciate Ligament Reconstruction] explode all trees 288 16. 14 OR 15 1461 17. MeSH descriptor: [Age Factors] explode all trees 9585 18. middle-aged or age or young or Elders or Elder or Older or younger or aged or elderly or Adults or Adult or 40 or 50 or Forty:ti,ab,kw 638584 19. 17 or 18 638584 20. 16 and 19 963 21. 20/trials 921 SCOPUS 1. TITLE-ABS ( “Anterior Cruciate Ligament” OR “Anterior Cruciate Ligaments” OR acl ) 24011 2. Indexterms (“Anterior Cruciate Ligament”) 17584 3. 1 OR 2 27561 4. TITLE-ABS (Reconstructive OR reconstruction OR Surgical OR Surgery OR Surgeries OR grafts OR Grafting OR graft OR ar throscopy OR Arthroscopic OR Arthroscopies OR reconstructions OR arthrometer OR Arthrometry OR Operative OR Opera tion OR operations OR Transplantation OR Transplantations) 4166655 5. indexterms(“Reconstructive Surgical Procedures” OR “Arthroscopy” OR “Arthrometry, Articular” OR “Tendon Transfer” OR “Minimally Invasive Surgical Procedures” OR “Second-Look Surgery” OR “Transplantation”) 702415 6. TITLE-ABS(allograft OR allotransplantation OR autograft OR autotransplantation OR allografts OR allotransplantations OR autografts OR autotransplantations) 82411 7. 5 or 6 721644 8. 4 OR 7 4451750 9. 3 AND 8 16212 10. indexterms(“Anterior Cruciate Ligament Reconstruction”) 4624 11. 9 OR 10 16582 12. INDEXTERMS ( “Age Factors” ) 396038 13. TITLE-ABS ( middle-aged OR age OR young OR elders OR elder OR older OR younger OR aged OR elderly OR adults OR adult OR 40 OR 50 OR forty ) 8219158

106 Kim et al. A Comparison of Results after Anterior Cruciate Ligament Reconstruction according to Age Factor

14. 12 OR 13 8344656 15. 11 AND 14 5295 16. INDEXTERMS ( “review literature as topic” ) 4146 17. 15 and ( EXCLUDE ( DOCTYPE , “re” ) ) 4903 18. 17 and not 16 4903 Web of Science 1. TOPIC: (“Anterior Cruciate Ligament” OR “Anterior Cruciate Ligaments” OR ACL) OR TITLE: (“Anterior Cruciate Ligament” OR “Anterior Cruciate Ligaments” OR ACL) 19502 2. TOPIC: (Reconstructive OR reconstruction OR Surgical OR Surgery OR Surgeries OR grafts OR Grafting OR graft OR arthros copy OR Arthroscopic OR Arthroscopies OR reconstructions OR arthrometer OR Arthrometry OR Operative OR Operation OR operations OR Transplantation OR Transplantations) OR TITLE: (Reconstructive OR reconstruction OR Surgical OR Sur gery OR Surgeries OR grafts OR Grafting OR graft OR arthroscopy OR Arthroscopic OR Arthroscopies OR reconstructions OR arthrometer OR Arthrometry OR Operative OR Operation OR operations OR Transplantation OR Transplantations) 2552091 3. TOPIC: (allograft OR allotransplantation OR autograft OR autotransplantation OR allografts OR allotransplantations OR auto grafts OR autotransplantations) OR TITLE: (allograft OR allotransplantation OR autograft OR autotransplantation OR allografts OR allotransplantations OR autografts OR autotransplantations) 95625 4. 1 AND (2 OR 3) 11495 5. TOPIC: (middle-aged OR age OR young OR Elders OR Elder OR Older OR younger OR aged OR elderly OR Adults OR Adult OR 40 OR 50 OR Forty) OR TITLE: (middle-aged OR age OR young OR Elders OR Elder OR Older OR younger OR aged OR elderly OR Adults OR Adult OR 40 OR 50 OR Forty) 5825783 6. 4 AND 5 3901 7. 6 Refined by: [excluding] DOCUMENT TYPES: ( REVIEW ) 3713