Clinical and Functional Outcomes of Anterior

Cruciate Ligament Reconstruction With Autologous

Hamstring Tendon in Patients Aged 50 Years or Older
Chun-Jui Weng, M.D., Wen-Ling Yeh, M.D., Kuo-Yao Hsu, M.D., Chih-hao Chiu, M.D.,
Shih-Sheng Chang, M.D., Alvin Chao-Yu Chen, M.D., and Yi-Sheng Chan, M.D.

Purpose: To assess the clinical and functional outcomes, including the return to sports and the progression of arthritis, in
patients aged 50 years or older after anterior cruciate ligament (ACL) reconstruction. Methods: A retrospective series of
patients aged 50 years or older with ACL rupture who received ACL reconstruction surgery with autologous hamstring
tendon was examined. Preoperative and postoperative functional outcomes were evaluated with the International Knee
Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score. Associated injuries, post-
operative complications, and the rate of return to preinjury sports were documented. A paired t test and the minimal
clinically important difference (MCID) and patient acceptable symptom state (PASS) were used for statistical evaluation.
Results: A total of 67 patients with a mean age of 56.6 years were enrolled. The mean follow-up time was 30.2 months.
Clinical improvement in the IKDC score (from 41.4 preoperatively to 88.9 postoperatively), Lysholm score (from 49.8 to
86.1), and Tegner activity score (from 2.7 to 4.4) was noted. Regarding clinically relevant values of the MCID, all patients
(100%) showed a DLysholm score exceeding 8.9; 66 of 67 patients (98.5%) revealed a DIKDC score exceeding 16.7; and
47 of 67 patients (70.1%) showed a DTegner activity score of more than 1. For the PASS, none of the patients had an
IKDC score over 75.9 preoperatively whereas 60 patients (89.5%) had a score exceeding 75.9 postoperatively. Associated
lesions included meniscal injuries (73.1%) and osteochondral lesions (89.6%). Of the patients, 36 (53.7%) returned to
preinjury sports and 18 (22.9%) returned to sports with less intensity. No major complication, rerupture, or deterioration
of arthritis was noted. Conclusions: Patients aged 50 years or older receiving ACL reconstruction achieved significant
improvements in IKDC, Lysholm, and Tegner scores. All patients reached the MCID for the DLysholm score; 98.5%, for
the DIKDC score; and 70.1%, for the DTegner activity score. None of the patients reached the PASS for the preoperative
IKDC value, whereas 89.5% reached the PASS postoperatively. Among patients aged 50 years or older, 53.7% returned to
preinjury sports and 26.9% returned to sports with lower intensity. Level of Evidence: Level IV, therapeutic case series.

A lthough anterior cruciate ligament (ACL) recon-

struction surgery is frequently performed in active
young patients, conservative treatments are mostly
adopted in middle-aged and older patients.1,2 However,
middle-aged and older persons could also have high
functional demands on the knee joint while engaging in
sports activities. Studies have shown that conservative
From the Department of Orthopedic Surgery, Chang Gung Memorial
Hospital, Chang Gung University, Taoyuan, Taiwan.
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Full ICMJE author disclosure forms are
available for this article online, as supplementary material.
Received April 11, 2019; accepted August 23, 2019.
Address correspondence to Yi-Sheng Chan, M.D., Department of Orthopedic
Surgery, Chang Gung Memorial Hospital, No. 5, Fu-Hsin Street, Kweishan,
Taoyuan, Taiwan. E-mail: yschan512@gmail.com
Ó 2019 by the Arthroscopy Association of North America
0749-8063/19454/$36.00
https://doi.org/10.1016/j.arthro.2019.08.047
treatments could increase the risk of residual instability
and associated injuries of the knee.3,4 In addition, a
high rate of secondary damage after conservative
treatment was reported when patients returned to
moderate or high levels of activity and underwent
lifestyle modification.1,3,5,6
With improvements in anesthesiology, surgical tech-
niques, instrumentation, and rehabilitation programs,
the indications for ACL reconstruction surgery have
widened. Age is no longer a contraindication for
receiving ACL reconstruction surgery,4,7-14 and
arthroscopic ACL reconstruction has been suggested for
patients older than 40 years. Previous studies have
shown that the outcomes of ACL reconstruction in
patients older than 40 years were comparable to those
in young patients.4,10,15 Plancher et al.15 showed that
the functional outcomes of 72 patients aged 40 years or
older who underwent ACL reconstruction improved,
with the Lysholm score changing from 63 to 94 and the

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2019: pp 1-5 1
2 C-J. WENG ET AL.
Hospital for Special Surgery score changing from 69 to
92. Improvements in functional scores and a reduction
in knee laxity were reported in 627 patients aged 40
years or older who received ACL reconstruction in a
review study performed by Brown et al.4 Furthermore,
Brandsson et al.10 found that patients older than 40
years were subjectively more pleased with the overall
outcomes after receiving ACL reconstruction than pa-
tients aged between 20 and 24 years. However, to our
knowledge, only a few studies have reported outcomes
of ACL reconstruction in patients older than 50
years.7,16
The purpose of this study was to assess the clinical and
functional outcomes, including the return to sports and
the progression of arthritis, in patients aged 50 years or
older after ACL reconstruction. We hypothesized that
patients aged 50 years or older with an active lifestyle
would show good to excellent clinical and functional
outcomes after ACL reconstruction.
Methods
A retrospective series of patients aged 50 years or
older with a clinical and imaging diagnosis of ACL
rupture who had received ACL reconstruction surgery
in our hospital from 2012 to 2015 was examined. To be
included in the study, patients had to satisfy the
following criteria: (1) age 50 years or older, (2) ACL
reconstruction surgery with a minimum of 2 years’
follow-up, and (3) uninjured contralateral leg. The
exclusion criteria included inflammatory disease, ACL
reconstruction before age 50 years with ACL rerupture
after age 50 years, multiligament injury, and a high
anesthesia risk owing to underlying disease. Our sur-
gical indications were persistent major instability during
daily activity or sports activity with failed conservative
treatment. The study protocol was approved by the
ethical committee at our hospital.
The surgical procedures were performed by 3 expe-
rienced orthopaedic doctors (W.L.Y., K.Y.H., Y.S.C.) in
the hospital. All patients received single-bundle ACL
reconstruction with autologous hamstring tendon from
the same leg. Two surgeons used a transtibial femoral
tunnel with button fixation (EndoButton; Smith &
Nephew), whereas one surgeon used an outside-in
technique and fixation with an interference screw
(HA Interference Screw; Smith & Nephew). Chondral
lesions were diagnosed arthroscopically and treated
with either debridement if they were low grade or
microfracture if they were high grade, according to the
Outerbridge classification. If a meniscal lesion coex-
isted, it was treated with either partial meniscectomy or
meniscal repair. A standard rehabilitation protocol was
used in all cases. Isometric quadriceps exercise was
executed from the first postoperative day. All patients
were asked to ambulate with crutches for 4 to 6 weeks
after surgery. Low levels of sports activities such as
jogging and swimming were allowed 6 months after
surgery. High levels of sports activities such as contact
sports or those involving pivoting movements were
allowed 9 months after surgery.
Clinical and functional outcomes were recorded
before surgery and at the last follow-up. Preoperative
clinical evaluation consisted of the Lachman test,
anterior drawer test, pivot-shift test, and McMurray
test. Preoperative imaging included radiographs and
magnetic resonance imaging. The stage of osteoarthritis
was classified by the Ahlbäck classification17 through
radiographs taken preoperatively and at last outpatient
clinic department follow-up. Determination of the stage
of osteoarthritis was performed by a radiology doctor.
Functional outcomes were evaluated with the Lysholm
score, Tegner activity level, and International Knee
Documentation Committee (IKDC) subjective score by
an independent orthopaedic doctor who interviewed
patients before surgery and at final outpatient clinic
department follow-up after surgery. Clinical relevance
and significance were evaluated through the minimal
clinically important difference (MCID) and patient
acceptable symptom state (PASS) for the IKDC score,
Lysholm score, and Tegner activity score. Table 1 lists
the defined values.18
For statistical analysis, the Kolmogorov-Smirnov test
was performed for the preoperative and postoperative
differences; it showed a value greater than 0.05, which
indicates a normal distribution of preoperative and
postoperative differences. Therefore, we used a paired-
samples t test for statistical analysis. The level of statis-
tical significance was set at P < .05.
Results
The mean age at surgery was 56.6 years (range, 50-67
years), and the mean follow-up time was 30.2 months
(range, 25-58 months). Other demographic character-
istics are listed in Table 2. The mechanism of injury was
either a sports injury or a sprain or falling injury during
daily activity. All patients received nonsurgical treat-
ment initially when the diagnosis of an ACL rupture
was made. The mean time from injury to index ACL
reconstruction was 16.1 weeks (range, 9-23 weeks). All
patients had a persistent feeling of instability after
receiving conservative treatment, among whom 41
exhibited instability during daily activity and 26 had an
Table 1. Defined Values of MCID and PASS
MCID PASS
Lysholm score 8.9 NA
IKDC score 16.7 75.9
Tegner score 1 NA
IKDC, International Knee Documentation Committee; MCID, min-
imal clinically important difference; NA, not available; PASS, patient
acceptable symptom state.
 ACLR IN PATIENTS AGED 50 YEARS OR OLDER
Table 2. Demographic Characteristics of Patients
Data
No. of patients 67
Sex: male/female, n 34/33
Side of surgery: left/right, n 29/38
Mean age (range), yr 56.6 (50-67)
Mean follow-up time (range), mo 30.2 (25-58)
Mean time from injury to index surgery (range), wk 16.1 (9-23)
Preoperative Ahlbäck classification, n (%)
Grade 0 8 (11.9)
Grade 1 22 (32.8)
Grade 2 29 (43.4)
Grade 3 8 (11.9)
Grade 4 0
unstable sensation during sports. According to the
Ahlbäck classification, the preoperative radiographic
osteoarthritis grade was 0 in 8 patients, 1 in 22 patients,
2 in 29 patients, 3 in 8 patients, and 4 in 0 patients.
Intraoperative findings of associated meniscal lesions
were noted in 49 patients (73.1%), and associated
cartilage lesions were found in 60 patients (89.6%).
Detailed intraoperative findings of associated injuries
are listed in Table 3.
Significant improvements in functional outcomes
were detected after surgery in the Lysholm score,
Tegner activity level, and IKDC subjective score
(Table 4). The mean IKDC scores preoperatively and
postoperatively were 41.4 (range, 23-60.9) and 88.9
(range, 71.3-100), respectively. The mean Lysholm
scores were 49.8 (range, 30-65) preoperatively and
86.1 (range, 60-100) postoperatively. For the Tegner
activity level, the mean score was 2.7 (range, 0-6)
preoperatively and 4.4 (range, 3-7) postoperatively.
Regarding clinically relevant values of the MCID, all
patients (100%) showed a DLysholm score exceeding
8.9; 66 of 67 patients (98.5%) revealed a DIKDC score
exceeding 16.7; and 47 of 67 patients (70.1%) showed
a DTegner activity score of more than 1. For the PASS,
none of the patients had an IKDC score of more than
75.9 preoperatively whereas 60 of 67 (89.5%) had a
score exceeding 75.9 postoperatively.
At the last follow-up, 36 patients (53.7%) returned to
sports with the same intensity as before injury and 18
patients (26.9%) returned to sports with less intensity.
None of the patients had symptoms of instability or
major complications. No rerupture or radiographic
deterioration of osteoarthritis was reported during the
follow-up period. Superficial infection over the graft
donor site occurred in 3 patients (4.4%), and only 1
received debridement surgery.
Discussion
Patients aged 50 years or older who underwent ACL
reconstruction showed significant improvements in the
IKDC score, Lysholm score, and Tegner activity level
without residual instability and major complications or
3
deterioration of knee arthritis for at least 2 years. These
findings support our hypothesis that patients aged 50
years or older who exercise regularly would show good
to excellent clinical and functional outcomes after
receiving ACL reconstruction.
Similar results were reported in previous studies.
Blyth et al.16 showed good symptomatic relief, resto-
ration of function, and return to sports in 30 patients
older than 50 years who exercise regularly after
receiving ACL reconstruction. Using 4-strand hamstring
tendon autograft for ACL reconstruction in 18 patients
aged 50 years or older, Trojani et al.19 showed that all
patients were satisfied with the good results without
postoperative instability. In a 9-year follow-up study of
12 patients aged 55 years or older with minimal oste-
oarthritis, Arbuthnot et al.20 suggested that ACL
reconstruction with autograft could allow knee stability
to be regained. They reported 1 graft failure at 11 years
after reconstruction and 1 total knee replacement at 5
years after reconstruction but noted good improve-
ments in the Lysholm score from 33 to 79 in the other
patients. Figueroa et al.9 found that 88% of 50 patients
older than 50 years returned to preinjury sports, and
96% of them were satisfied with their results after
receiving ACL reconstruction. A study by Toanen et al.7
even recruited patients older than 60 years who
received ACL reconstruction. In their series, 10 of 12
patients (83%) reported recovery of sports activities
and 6 (50%) returned to the previous sports level.
Toanen et al. reported comparable results to ours, with
a more elderly patient group.
The reported rate of ACL rerupture in patients older
than 50 years undergoing ACL reconstruction was
between 3%16,17 and 8.6%.8,18 However, ACL graft
rerupture was not found during the 2-year follow-up
period in our study. Clinical concerns about per-
forming ACL reconstruction surgery in older patients
include the quality of autologous graft and the po-
tential poor healing at the tendon-bone junction.
Kinugasa et al.21 performed second-look arthroscopy
within 2 years of ACL reconstruction in 3 age groups
(29 years, 30-49 years, and 50 years) and found
that the clinical outcomes were comparable among all
Table 3. Intraoperative Findings of Associated Injuries
Lesion n (%)
Cartilage lesion 60 (89.6)
Grade 1 19 (28.4)
Grade 2 26 (38.8)
Grade 3 13 (19.4)
Grade 4 2 (3.0)
Meniscal lesion 49 (73.1)
Medial 28 (41.8)
Lateral 11 (16.4)
Both 10 (14.9)
4 C-J. WENG ET AL.
Table 4. Functional Outcomes
Score Preoperative Postoperative
IKDC 41.4 (23 to 60.9) 88.9 (71.3 to 100)
Lysholm 49.8 (30 to 65) 86.1 (60 to 100)
Tegner 2.7 (0 to 6) 4.4 (3 to 7)
CI, confidence interval; IKDC, International Knee Documentation Committee; SD, standard deviation.
groups. Nevertheless, poorer synovial coverage of the
ACL graft was noted in patients aged 50 years or
older.
Although ACL reconstruction was considered inap-
propriate in patients with degenerative arthritis, the
degree of arthritis seemed to be independent of post-
operative functional outcomes in our study. We found
that 8 patients had Ahlbäck grade 3 osteoarthritis and
none had Ahlbäck grade 4 osteoarthritis. In addition,
arthroscopic findings showed 13 patients with Outer-
bridge grade 3 osteoarthritis and 2 patients with grade 4
osteoarthritis. These findings may suggest that degen-
erative arthritis should not be excluded from the in-
dications for ACL reconstruction surgery if the patient’s
chief complaint is instability rather than pain. The ac-
tivity level and participation in sports activity before
injury are more important than the degree of osteoar-
thritis when deciding whether ACL reconstruction
surgery is suitable for patients aged 50 years or older.
With the population aging and an increase in the
number of older adults participating in sports activities,
chronological age should not be the single determining
factor for ACL reconstruction surgery. In the manage-
ment of patients with ACL rupture, the physiological
age, lifestyle, and activity level before injury should all
be evaluated to identify the applicability of ACL
reconstruction surgery in such patients.
Limitations
There are limitations in this study. This was a retro-
spective study with heterogeneous surgical techniques
and a lower level of evidence. Besides, no control group
was included in our study. A comparison between
young and older patients may be necessary to further
clarify the effects of age on the clinical and functional
outcomes after ACL reconstruction. Moreover, 22.4%
of our patients had grade 3 or 4 cartilage injuries, and
we may need to clarify the relation between outcomes
of ACL reconstruction surgery and cartilage injuries
with higher patient numbers in the future. A longer
follow-up period is needed to see if any ACL graft
rerupture or deterioration of arthritis occurred.
Conclusions
Patients aged 50 years or older receiving ACL recon-
struction achieved significant improvements in IKDC,
Lysholm, and Tegner scores. All patients reached the
MCID for the DLysholm score; 98.5%, for the DIKDC
95% CI SD P Value
e94.9 to e0.9 10.1 <.0001
e72.3 to e0.4 12.3 <.0001
e2.4 to e0.06 0.22 <.0001
score; and 70.1%, for the DTegner activity score. None
of the patients reached the PASS for the preoperative
IKDC value, whereas 89.5% reached the PASS post-
operatively. Among patients aged 50 years or older,
53.7% returned to preinjury sports and 26.9% returned
to sports with lower intensity.
Acknowledgment
The authors thank the Center for Big Data Analytics
and Statistics from Chang Gung Memorial Hospital for
the statistical analysis.
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