Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265

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Original article

ACL reconstruction in over-50 year-olds: Comparative study between

prospective series of over-50 year-old and under-40 year-old patients
Jean-Claude Panisset a,∗ , Jean-François Gonzalez b , Christophe de Lavigne c , Quentin Ode d ,
David Dejour e , Matthieu Ehlinger f , Jean-Marie Fayard g , Sébastien Lustig d ,
the French Arthroscopic Societyh
a
Centre Ostéoarticulaire des Cèdres, 5, rue des Tropiques, Parc Sud Galaxie, 38130 Echirolles, France
b
CHU de Nice, Hôpital Pasteur, 30, voie Romaine, 06001 Nice, France
c
Clinique du Sport- Centre de Consultations, 2, rue Negrevergne, 33700 Merignac, France
d
CHU Lyon, Hôpital Croix Rousse, Centre Albert Trillat, 103, Grande rue de la Croix-Rousse, 69004 Lyon, France
e
Lyon-Ortho-Clinic - Clinique de la Sauvegarde, 29, avenue des Sources, 69009 Lyon, France
f
Service de Chirurgie Orthopédique et de Traumatologie, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, 1, avenue Molière, 67098
Strasbourg cedex, France
g
Centre Orthopédique Santy, 24, avenue Paul-Santy, 69008 Lyon, France
h
15, rue Ampère, 92500 Rueil-Malmaison, France

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: ACL reconstruction is increasingly proposed for over-50 year-olds, although surgery had a
Received 4 July 2019 poor reputation in this age-group, mainly due to postoperative stiffness. ACL reconstruction results were
Accepted 2 September 2019 compared between two prospective series of, respectively, over-50 year-old (group 1) and under-40 year-
old patients (group 2). The main study hypothesis was that ACL surgery provides the same functional
Keywords: results after 50 as before 40 years of age, and the secondary hypothesis was that the rate of complications
ACL does not differ.
50 year-old
Methods: A multicenter prospective non-randomized follow-up study included 228 over-50 year-old and
Return to sport
Quality of life
130 under-40 year-old patients in 10 public and private sector centers.
Prospective Epidemiological data were collected. Clinical laxity, differential laxity, KOOS, IKDC, Tegner and ACL-RSI
scores and radiologic aspect were assessed pre- and post-operatively. Early (< 3 months) and late (> 3
months) complications were collected. Functional scores were compared between groups at last follow-
up: 14.2 months (range, 3.5-30.5 months in group 1, and 20.5 months (range, 11.4-29.4 months) in group
2.
Results: Analysis of epidemiological data showed some inter-group differences: female predominance
in group 1 (59% versus 35%), longer trauma-to-surgery time in group 2 (23.6 versus 8.7 weeks), pre-
dominance of pivot-contact (team) sports in group 2 (49% versus 6%), and predominance of pivot sports
(skiing) in group 1. Tegner scores were lower in group 1 (5.2 versus 7.6). Meniscal lesions were more
frequent in group 1 (68% versus 36%), as were cartilage lesions (76% versus 10%). Initial laxity levels were
identical (6.5 mm in group 1 and 6.7 mm in group 2). Type of surgery was identical: 86% hamstring graft
in group 1 and 89% in group 2. There were more early complications (hematoma) in group 1; rates of late
complications were comparable. Laxity at last follow-up was 2.2 mm in both groups, and thus Lachman
and pivot-shift test results were identical in terms of firm end-feel and absence of pivot shift. Quality-
of-life assessment found higher KOOS scores in group 2, although ACL-RSI scores were identical. Global
IKDC scores were slightly better in group 2, due to osteoarthritis in the older patients.
Conclusion: ACL reconstruction after 50 years of age gave good results, correcting laxity as effectively as
in under-40 year-olds, with identical technique and identical rates of complications. Time to return to
sports and resumed level were comparable.
Level and type of study: III, prospective comparative non-randomized.
© 2019 Published by Elsevier Masson SAS.

∗ Corresponding author.
E-mail addresses: dr.panisset@wanadoo.fr, dr.panisset@gmail.com (J.-C. Panisset).

https://doi.org/10.1016/j.otsr.2019.09.009
1877-0568/© 2019 Published by Elsevier Masson SAS.
S260 J.-C. Panisset et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265

1. Introduction Table 1
Epidemiology.

Anterior cruciate ligament (ACL) tear is a common traumatic Group 1 Group 2

pathology, especially in sports players. In France, some 35,000 ACL Mean age 54.8(50-71.6) 26.7 (13.7-40)
reconstructions are performed each year [1]. Patients are manly Sex ratio 59% female 35% female
young and athletic. With increasing life-expectancy and general Trauma-to-surgery 23.6 weeks 8.7 weeks p < 0.001
health, pivot sports are becoming more common in over-50 year- time
Sports level 8% competition 55% competition p < 0.001
olds, and rates of ACL pathology and surgery have greatly increased
Type of sport 51% skiing 39% skiing p < 0.001
in this age-group. ACL surgery in over-50 year-olds now accounts Tegner score 5.2 7.6 p < 0.001
for 10% of the activity of French surgeons specialized in this pathol- Meniscal lesions 68% 38% p < 0.001
ogy. Several series of ACL reconstruction in over-50 year-olds have Cartilage lesions 76% 10% p < 0.001
Preoperative laxity 6.5 mm (range,−2 6.7 mm (range, p < 0.597
been reported [2–10], with good functional results in selected
to 17.5) −1.5 to 20.5)
patients. Some reports have even focused on over-55 year-olds 6 Lachman soft 95% 100% p < 0.009
[11] and over-50 year-olds [12,13]. A meta-analysis of all series Pivot shift clunk or 67% 81% p < 0.001
of over-50 year-olds recently claimed that age was no longer a explosive
criterion contraindicating ACL reconstruction [14]. Type of surgery 89% hamstring 89% hamstring p < 0.229

Twenty years ago, surgery used not to be recommended in these

cases, for fear of postoperative complications such as stiffness,
residual pain and progression toward osteoarthritis. Non-operative
treatment was preferred [15], but this entailed reducing sports level
or changing sports.
It therefore seemed useful to compare two series of patients
undergoing ACL reconstruction: over-50 and under-40 year-olds.
Three authors previously performed such studies [3,6,7], but unfor-
tunately either without reporting clinical follow-up or else with
small samples. We therefore conducted a multicenter prospective
non-randomized clinical follow-up study comparing ACL recon-
struction in over-50 and under-40 year-olds (groups 1 and 2,
respectively) in the same study period.
The main study hypothesis was that ACL reconstruction gives
the same functional results in terms of laxity, quality of life and
return to sport in over-50 and under-40 year-olds. The secondary
hypothesis was that complications rates do not differ.
2. Patients and methods
2.1. Type of study
This was a standard-care observational study, with review board
approval (RCB 2016-A01140-51) and authorization by the French
data protection commission (CNIL).
The prospective multicenter study was conducted in 10 ACL
surgery centers, mainly in eastern France plus one in Bordeaux.
2.2. Statistics
Statistical analysis was performed by an independent company.
Normal distribution was assessed on Shapiro–Wilk test. Inter-
group differences in non-normally distributed quantitative data
were assessed on Wilcoxon rank sum test (Mann–Whitney U test)
and Kruskal–Wallis test. Matched (pre- to post-operative) groups
were compared on t test. Inter-group correlations were assessed
on Pearson correlation coefficients. Inter-group differences in non-
normally distributed qualitative data were assessed on Fisher exact
and Chi2 tests. Multivariate linear regression was used to assess
associations between 5 results and > 15 independent variables.
Statistical analysis used R software, version 3.3.2 (R Founda-
tion for Statistical Computing, Vienna, Austria). The significance
threshold was set at p < 0.05.
2.3. Methods
frontal laxity. Radiographic assessment was based on AP and lateral
unipedal weight-bearing views and axial patellar view.
Laxity was measured in anterior drawer close to extension, in
absolute values and as differential with respect to the contralat-
eral side, using Telos (stress radiography), GNRB, or KT1000 devices
[16].
All patients had intermediate consultations between the initial
and final consultations, all scores being assessed in each.
Postoperative complications were collated.
Patients were graded on the objective IKDC classification at ini-
tial and final consultation [17].
They were scored on the Tegner activity scale [18], and on
KOOS [19] and ACL-RSI [20]. Date of resumption of sport was noted
to calculate maximum time to return to initial sport, defined by
resumption of competitive sport or the patient’s declaration that
he or she was playing “like before”.
Intraoperative data on meniscal and cartilage status were metic-
ulously recorded.
2.4. Patients
Each center included all over-50 year-old patients (group 1)
requiring ACL reconstruction over the period January 1st, 2016 to
June 30th, 2017 (Tables 1, 2 and 3). Minimum follow-up was 1 year.
Inclusion criteria comprised: ACL tear, whether isolated or associ-
ated with meniscal lesion, regardless of trauma-to-surgery interval,
with ACL reconstruction, whether isolated or associated to extra-
articular reconstruction, without associated bone surgery. Iterative
reconstruction was an exclusion criterion.
Over the same period, on the same criteria, a continuous series
of under-40 year-old patients (group 2) was included as control.
Group 1 comprised 228 patients, and group 2 130 patients.
3. Results
Mean follow-up was 14.2 months (range, 3.5-30.5 months) in
group 1 and 20.5 months (range, 11.4-29.4 months) in group 2
(Table 4).
3.1. Complications: Complications were distinguished as early
(< 3 months) or late (> 3 months). Iterative tear was counted as a
late complication.

Clinical, instrumental and radiologic follow-up was identical in 3.1.1. Early complications
both series. Early complications featured a higher rate of hematoma in group
Clinical data were collected in a data-base: age, body-mass 1: 15%, including 1 patient requiring drainage (p < 0.001) (Table 5).
index (BMI), pain, effusion, motion, Lachman test, pivot-shift, and There were no cases of infection in either series.
 J.-C. Panisset et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265 S261

Table 2
Surgical data.

≥50 years n = 228 ≤40 years n = 130

n (%) n (%) n (%) n (%) p valuea

Anterolateral reconstruction 0.229

Yes 37 (16%) 13 (10%)
No 191 (84%) 117 (90%)
Intra-articular graft 0.509
Hamstring 197 (86%) 116 (89%)
Quadriceps/patellar tendon 31 (14%) 14 (11%)
Fixation Femoral Tibial Femoral Tibial Femoral Tibial
Cortical (Endobutton) 124 (54%) 38 (17%) 106 (82%) 28 (22%) <0.001 0.014
Pressfit 17 (7%) 14 (11%)
Screw 76 (33%) 179 (79%) 10 (8%) 102 (78%)
DTC 11 (5%) 11 (5%)
Meniscal lesion <0.001
None 74 (32%) 81 (62%)
Isolated medial 83 (36%) 24 (18%)
Isolated lateral 25 (11%) 20 (15%)
Bicompartmental 46 (20%) 5 (4%)
Meniscal treatment Medial Lateral Medial Lateral Medial Lateral
None 99 (43%) 157 (69%) 101 (78%) 105 (81%) <0.001 0.017
Left in place 17 (7%) 29 (13%) 5 (4%) 5 (4%)
Resected 77 (34%) 24 (11%) 13 (10%) 15 (12%)
Sutured 25 (11%) 16 (7%) 10 (8%) 5 (4%)
Prior resection sequela 10 (4%) 2 (1%) 1 (1%)
Cartilage lesion <0.001
None 55 (24%) 117 (90%)
Isolated medial 30 (13%) 9 (7%)
Isolated lateral 4 (2%) 51 (22%)b 1 (1%) 11 (8%)b
Patellar 17 (7%) 1 (1%)
Multicompartmental 122 (54%) 2 (2%)
a
Chi-squared test.
b
Unicompartmental.

3.1.2. Late complications 3.5. Return to sport and quality of life

There was a 14% rate of late complications in group 1, and 11%
in group 2, this difference being non-significant (p = 0.247); surgi- The findings were as follows:
cal revision rates were 9% in group 1 and 8% in group 2 (Table 5).
Late complications mainly comprised secondary meniscal lesions,
• KOOS score (Table 4): there was a significant difference in global
stiffness in extension and flexion, or iterative tear, which was more
score in favor of group 2: 90.1 versus 85.8. This came mainly from
frequent in under-40 year-olds (4% versus 1%), although the differ-
higher scores in group 2 on 3 items: daily living, pain and sport.
ence was non-significant (p = 0.247).
• ACL-RSI score: there was no significant inter-group difference:
70.8 and 69.1, with slight improvement from pre- to post-
3.2. Laxity operative in both groups (p < 0.001)
• Tegner score (Table 4) decreased significantly in both groups: by
Laxity improved significantly in both groups, with residual lax- 7.1 in group 1 and 4.9 in group 2, (p < 0.001); the decrease, how-
ity of 2.2 mm (-6/13) in group 1 and 2.2 mm (-3.8/10) in group 2; ever, was comparable in both groups: -0.3 in group 1 and -0.5 in
most Lachman tests found firm end-feel and absence of pivot shift. group 2 (p < 0.155).
The 2 groups were comparable for postoperative laxity (NS).

Return to initial sport was slightly earlier in group 1: 266.8 ver-

3.3. Cartilage lesions and osteoarthritis
Rates of medial compartment osteoarthritis were the same pre-
operatively and at follow-up: 27% in group 1 versus 1% in group
2; progression was non-significant, but the inter-group difference
was significant (p < 0.001) (Table 6). In the lateral compartment, the
rates were 5% in group 1 versus 1% in group 2. In the patellofemoral
compartment, the rate was 10% preoperatively and 11% at follow-
up in group 1; progression was low in over-50 year-olds and absent
in under-40 year-olds.
3.4. IKDC score
There was a significant inter-group difference in IKDC score,
with 96% IKDC A and B in group 2 versus 79% in group 1 (p < 0.001)
(Table 6). This higher rate of grades C and D in over-50 year-olds
correlated with the higher ate of osteoarthritis.
sus 302.7 days.
4. Discussion
The present study showed that ACL reconstruction in over-50
year-olds and under-40 year-olds gave equivalent results in terms
of anterior laxity. There were no significant inter-group differences
in postoperative laximetry (p = 0.9) or laximetric gain (p = 0.54). The
treatment thus appeared effective. Return to sport was likewise
similar between groups, with no difference in gain in Tegner score
(0.3 versus 0.5; p = 0.155), and likewise no difference in ACL-RSI
score (70.8 versus 69.1; p = 0.427), confirming that the two groups
were in the same state of mind regarding return to sport. KOOS
score, on the other hand, was lower in group 1 (p < 0.001), especially
as regards daily living, pain and sport, in slight contradiction to the
main study hypothesis [21].
Table 3

S262
Pre- and post-operatiive categoric variables.

≥ 50 years n = 228 ≤ 40 years n = 130 ≥ 50 years n = 228 ≤ 40 years n = 130

n (%) n (%) p valuea p valueb n (%) n (%) p valuea p valueb

Effusion < 0.001 < 0.001 0.002 0.034
None 110 (48%) 116 (89%) 202 (89%) 127 (98%)
Trace 77 (34%) 13 (10%) 17 (7%) 3 (2%)
Medium 31 (14%) 1 (1%) 4 (2%)
Severe 10 (4%)
Not known 5 (2%)
Extension deficit 0.114 0.150 0.039 0.018
< 3◦ 187 (82%) 114 (88%) 205 (90%) 128 (98%)
3◦ –5◦ 32 (14%) 16 (12%) 17 (7%) 2 (2%)
6◦ –10◦ 5 (2%) 1 (0%)

J.-C. Panisset et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265
> 10◦ 4 (2%)
Not known 5 (2%)
Flexion deficit < 0.001 < 0.001 0.007 0.002
0◦ –5◦ 161 (71%) 92 (71%) 201 (88%) 128 (98%)
6◦ –15◦ 36 (16%) 35 (27%) 19 (8%) 1 (1%)
16◦ –25◦ 14 (6%) 3 (2%) 2 (1%) 1 (1%)
> 25◦ 17 (7%) 1 (0%)
Not known 5 (2%)
Lachman test < 0.001 0.009 < 0.001 0.656
Firm 11 (5%) 219 (96%) 129 (99%)
Soft 217 (95%) 130 (100%) 4 (2%) 1 (1%)
Not known 5 (2%)
Jerk test < 0.001 0.001 < 0.001 0.022
Identical to contralateral knee 16 (7%) 207 (91%) 129 (99%)
Slight 51 (22%) 25 (19%) 10 (4%)
Clunk 135 (59%) 93 (72%) 2 (1%) 1 (1%)
Explosive 18 (8%) 12 (9%) 2 (1%)
Non-measurable 8 (4%)
Not known 7 (3%)
Medial osteoarthritis < 0.001 < 0.001 < 0.001 < 0.001
None 178 (78%) 128 (98%) 166 (73%) 129 (99%)
Mild: small osteophytes, slight sclerosis 37 (16%) 2 (2%) 43 (19%) 1 (1%)
Moderate: < 50% impingement or 2-4 mm space 13 (6%) 12 (5%)
Severe: >50% impingement or < 2 mm space
Not known 7 (3%)
Arthrose latérale 0.202 0.101 0.023 0.005
Aucune 216 (95%) 129 (99%) 206 (90%) 130 (100%)
Mild: small osteophytes, slight sclerosis 9 (4%) 1 (1%) 11 (5%)
Moderate: < 50% impingement or 2-4 mm space 3 (1%) 3 (1%)
Severe: >50% impingement or < 2 mm space
Not known 8 (4%)
Arthrose femoropatellaire < 0.001 < 0.001 < 0.001 0.001
Aucune 206 (90%) 130 (100%) 204 (89%) 130 (100%)
Mild: small osteophytes, slight sclerosis 18 (8%) 16 (7%)
Moderate: < 50% impingement or 2-4 mm space 4 (2%) 2 (1%)
Severe: >50% impingement or < 2 mm space
Not known 6 (3%)
IKDC score < 0.001 < 0.001 < 0.001 0.002
A 84 (37%) 64 (49%)
B 11 (5%) 22 (17%) 96 (42%) 61 (47%)
C 109 (48%) 85 (65%) 29 (13%) 4 (3%)
D 102 (45%) 23 (18%) 8 (4%) 1 (1%)
Not known 6 (3%) 11 (5%)
Dichotomized IKDC score < 0.001 < 0.001 < 0.001 < 0.001
A&B 11 (5%) 22 (17%) 180 (79%) 125 (96%)
C&D 211 (93%) 108 (83%) 37 (16%) 5 (4%)
Not known 6 (3%) 11 (5%)
a
Overall Chi2 test.
b
Pairwise comparison: ≥ 50 vs. ≤ 40 years.
 J.-C. Panisset et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265 S263

Table 4
Pre- and post-treatment continuous variables.

≥ 50 years n = 228 ≤ 40 years n = 130

Mean ± SD (range) p valuea Mean± SD (range) p valuea p valueb

Hospital stay (days) 1.1 ± 1.3 (0.0-15.0) 1.16 ± 0.4 (1.0–3.0) 0.657
Follow-up (months) 14.2 ± 3.8 (3.5-30.5) 20.5 ± 5.4 (11.4-29.4) < 0.001
Differential laxity (mm)
Preoperative 6.5 ± 3.4 (−2.0-17.5) 6.7 ± 3.9 (−1.5-20.5) 0.597
Post-treatment 2.2 ± 2.4 (−6.0-13.0) < 0.001 2.2 ± 2.1 (−3.8–10.0) < 0.001 0.900
Improvement −4.2 ± 3.9 (−23.5–6.0) −4.5 ± 4.1 (–16.7–4.8) 0.540
Tegner score (1–10)
Preoperative 5.2 ± 1.5 (2.0–9.0) 7.6 ± 1.5 (4.0–9.0) < 0.001
Postoperative 4.9 ± 1.6 (1.0–9.0) < 0.042 7.1 ± 1.8 (4.0–9.0) 0.012 < 0.001
Improvement −0.3 ± 1.2 (−4.0–4.0) −0.5 ± 1.3 (−5.0–3.0) 0.155
KOOS Symptoms (0–100)
Preoperative 62.5 ± 19.8 (0.0–100.0)
Postoperative 84.9 ± 13.5 (38.0–100.0) < 0.001 85.9 ± 12.1 (32.1–100) 0.485
Improvement 22.2 ± 22.6 (−39.3–79.0)
KOOS Pain (0–100)
Preoperative 61.3 ± 19.9 (6.0–100.0)
Postoperative 87.7 ± 12.3 (38.9–100.0) < 0.001 91.3 ± 11.8 (1.7–100) 0.006
Improvement 26.4 ± 22.6 (−33.3–94.0)
KOOS Daily living(0–100)
Preoperative 66.9 ± 21.5 (0.0–100.0)
Post−treatment 91.2 ± 10.0 (44.4–100.0) < 0.001 97.5 ± 5.2 (63.2–100) < 0.001
Improvement 24.4 ± 23.7 (−29.4–100.0)
KOOS Sport (0–100)
Preoperative 34.3 ± 19.7 (0.0–100.0)
Postoperative 74.6 ± 18.0 (10.0–100.0) < 0.001 83.5 ± 15.2 (25–100) < 0.001
Improvement 40.2 ± 25.7 (−50.0–100.0)
KOOS Quality of life (0–100)
Preoperative 34.5 ± 21.0 (0.0–92.0)
Postoperative 76.5 ± 18.4 (0.0–100.0) < 0.001 75.3 ± 18.0 (6.3–100) 0.575
Improvement 41.9 ± 25.6 (−31.8–100.0)
KOOS Global (0–100)
Preoperative 58.0 ± 17.5 (3.6–100.0)
Postoperative 85.8 ± 11.1 (41.8–100.0) < 0.001 90.5 ± 8.2 (51.8–100) < 0.001
Clear improvement 27.8 ± 20.0 (−24.9–95.2)
ACL-RSI (/100%)
Preoperative 25.0 ± 20.2 (0.0–82.0)
Postoperative 70.8 ± 19.7 (0.0–100.0) < 0.001 69.1 ± 20.5 (4.2–100) 0.427
Improvement 45.8 ± 28.9 (−19.8–100.0)
Return to: (days)
Sport 266.8 ± 107.4 (26.0–651.0) 302.7 ± 102.1 (157–777) 0.004
Work 106.9 ± 108.7 (7.0–518.0) 60.7 ± 75.4 (0–415) < 0.001
a
Paired T-test, pre- vs. post-operative
b
Mann–Whitney test: ≤ 40 vs. ≥ 50 years.

Regarding the secondary hypothesis, early complications were Table 5

Postoperative categoric variables.
more frequent in group 1 (p < 0.001), notably due to hematoma; 1
patient required revision surgery. On the other hand, there was no ≥ 50 years ≤ 40 years
inter-group difference in late complications rates: 14% versus 11%; n = 228 n = 130
p = 0.247. n(%) n(%) p valuea
The present group 1, with 228 patients, was the largest series
Early complications < 0.001
of ACL reconstruction in over-50 year-olds, outside registries. The Total 34(15%) 0(0%)
largest previous series were the retrospective series of Ventura et al. Reoperated 1(0%)
[9] and the prospective series of Figueroa et al. [5], each with 50 Hematoma 1(0%)
patients. Not reoperated 33(14%) 0(0%)
Pain on VAS ≥ 6 (severe) 14(6%)
The present series confirmed the literature data, with improve- Hematoma 19(8%)
ments in IKDC, KOOS, Tegner and ACL-RSI scores [2–10]. Late complications 0.247
Likewise, laxity was controlled, with 2.2 mm residual differen- Total 33(14%) 14(11%)
tial laxity, comparable to previous reports: Blyth et al. [2] reported Reoperated 20(9%) 11(8%)
Unstable meniscal lesion 3(1%) 5(4%)
a 2.7 mm differential in a prospective series of 31 patients, Trojani
Stiffness in extension 4(2%) 1(1%)
et al. [8] reported 3.1 mm in a retrospective series of 18 patients, Stiffness in flexion 5(2%)
and Toanen et al. [13] reported 1.9 mm in a retrospective series of General knee pain 6(3%)
12 over-60 year-olds. Traumatic retear 2(1%) 5(4%)
The rate of return to sport was satisfactory, with a mean postop- Not reoperated 13(6%) 3(2%)
Persistent swelling 1(0%) 2(2%)
erative Tegner score of 4.9 points, showing a slight improvement of
CRPS 3(1%)
0.3 points, similar to previous reports of 4.3-5.6 points [2–6,9]. As Femoral ALR site pain 2(1%)
in the present series, Iorio et al. [6] compared postoperative Teg- Tibial ALR site pain 1(0%)
ner scores and gain between over-50 and under-40 year-olds, with Failure with residual laxity
Patellar syndrome 6(3%) 1(1%)
scores of respectively 5.4 and 5.8 and improvement of 0.4 points,
close to the present result. ALR: anterolateral reconstruction.
a
Overall Chi2 test.
S264 J.-C. Panisset et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265

Table 6
Osteoarthritis: pre- and post-operative categoric variables.

≥ 50 years ≤ 40 years ≥ 50 years ≤ 40 years

n = 228 n = 130 n = 228 n = 130
a b
n(%) n(%) p value p value n(%) n(%) p valuea p valueb

Medial osteoarthritis < 0.001 < 0.001 < 0.001 < 0.001
None 178(78%) 128(98%) 166(73%) 129(99%)
Mild: small osteophytes, slight sclerosis 37(16%) 2(2%) 43(19%) 1(1%)
Moderate: < 50% impingement or 2-4 mm space 13(6%) 12(5%)
Severe: >50% impingement or < 2 mm space
Not known 7(3%)
Lateral osteoarthritis 0.202 0.101 0.023 0.005
None 216(95%) 129(99%) 206(90%) 130(100%)
Mild: small osteophytes, slight sclerosis 9(4%) 1(1%) 11(5%)
Moderate: < 50% impingement or 2-4 mm space 3(1%) 3(1%)
Severe: >50% impingement or < 2 mm space
Not known 8(4%)
Patellofemoral osteoarthritis < 0.001 < 0.001 < 0.001 0.001
None 206(90%) 130(100%) 204(89%) 130(100%)
Mild: small osteophytes, slight sclerosis 18(8%) 16(7%)
Moderate: < 50% impingement or 2-4 mm space 4(2%) 2(1%)
Severe: >50% impingement or < 2 mm space
Not known 6(3%)
IKDC score < 0.001 < 0.001 <0.001 0.002
A 84(37%) 64(49%)
B 11(5%) 22(17%) 96(42%) 61(47%)
C 109(48%) 85(65%) 29(13%) 4(3%)
D 102(45%) 23(18%) 8(4%) 1(1%)
Not known 6(3%) 11(5%)
Dichotomized IKDC score < 0.001 < 0.001 < 0.001 < 0.001
A&B 11(5%) 22(17%) 180(79%) 125(96%)
C&D 211(93%) 108(83%) 37(16%) 5(4%)
Not known 6(3%) 11(5%)
a
Overall Chi2 test.
b
Pairwise comparison: ≥ 50 vs. ≤ 40 years.

IKDC score increased significantly in both groups, but also sig-
nificantly differed: 79% IKDC A or B in group 1 versus 96% in group
2; p < 0.001. The radiologic component was the main negative fac-
tor. Osti et al. [7], comparing 2 groups similar to the present, found
no significant difference in IKDC scores (85% versus 90% A or B)
at a minimum 2 years’ follow-up; they did not, however, assess
radiologic IKDC scores. None of the 3 studies comparing ACL recon-
struction between over-50 and under-40 year-olds took account of
pre- and post-operative osteoarthritis [3,6,7]. In the present study,
over-50 year-olds showed significantly higher rates of pre- and
post-operative osteoarthritis, which follows logically from the age
difference; however, there was no postoperative increase in either
group. This finding, however, is to be taken with caution in view of
the short follow-up.
The rate of intraoperative findings of meniscal lesions was sig-
nificantly higher in group 1. Only 34% of group-1 patients were
exempt, compared to 62% in group 2 (p < 0.001). This is worrying,
as it led to a 34% rate of meniscectomy, with likelihood of pro-
gression toward osteoarthritis in a near future. Trojani et al. [8]
demonstrated that medial meniscectomy in this population is a
factor for poor outcome, with elevated postoperative pain.
Most studies reported no difference in complications rates
between over-50 year-olds and younger patients. However, only
3 studies compared these two populations [3,6,7], only one of
which effectively compared complications rates [3]. Cinque et al.
[3] reported no difference in complications between over-50 and
under-40 year-olds in terms of failure rates, with failure defined as
retear, whether requiring repeat surgery or not. The present rate of
failure due to retear was 1% in group 1 and 4% in group 2; in the
literature, rates range from 0% to 9% [2–5,7,8]. The present study
found no inter-group difference in late complications rates (14%
versus 11%; p = 0.247). This is to be weighed against the higher rate
of early complications in group 1, although only 1 out of the 228
patients required surgical revision.
The two groups were not equivalent, in terms of sport, type of
sport or trauma-to-surgery time; there was also a difference in rates
of preoperative meniscal and cartilage lesions. This is due partly to
the greater fragility of these tissues with tissue aging, and partly to
the longer trauma-to-surgery time in the over-50 year-olds. Surgi-
cal results, however, at comparable follow-up, were similar in the
two groups, with return to sport at previous level at fairly compa-
rable intervals.
The study involved several limitations. The multicenter design
entailed variations in management: surgical techniques, and post-
operative rehabilitation protocols. Secondly, mean follow-up was
14 months, and caution is needed in extrapolating results toward
the future, especially in terms of development of osteoarthritis.
Thirdly, this was a non-randomized study with a non-matched con-
trol group, limiting statistical impact and strength of comparison.
Even so, this was the largest series of ACL reconstruction in over-
50 year-olds. Moreover, comparison was with a large control group,
operated on over the same period.
5. Conclusion
The present study showed that functional results of ACL
reconstruction were equivalent between over-50 and under-40
year-olds, with identical rates of late complications. This treatment
was thus justified and effective.
The procedure was also effective in correcting laxity. Time to
return to sport and to the initial level did not differ. ACL recon-
struction can therefore be proposed to over-50 year-olds just as to
under-40 year-olds.
Disclosure of interest
JC Panisset: Royalties from SBM, BBraun Aesculap and Xnov for
implant development.
 J.-C. Panisset et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) S259–S265
JF Gonzalez: Consultant with Corin and Leo Pharma.
C de Lavigne: no conflicts of interest.
Q Ode: no conflicts of interest.
D Dejour: Royalties from SBM.
JM Fayard: Consultant for Arthrex and NewClip Technics.
S Lustig: consulting fees from Stryker, Smith Nephew, Heraeus,
Medacta, Depuy Synthes, Groupe Lepine. Institutional support from
Amplitude and Corin.
Funding
None.
Author contributions
All authors contributed to study design.
Acknowledgments
Resurg for methodology and statistical analyses.
References
[1] Evans S, Shaginaw J, Bartolozzi A. ACL reconstruction - It’s all about timing. Int
J Sports PhysTher 2014;9:268–73.
[2] Blyth MJ, Gosal HS, Peake WM, Bartlett RJ. Anterior cruciate ligament recon-
struction in patients over the age of 50 years: 2- to 8-year follow-up. Knee Surg
Sports Traumatol Arthrosc 2003;11:204–11.
[3] Cinque ME, Chahla J, Moatshe G, DePhillipo NN, Kennedy NI, Godin JA, LaPrade
RF. Outcomes and complication rates after primary anterior cruciate ligament
reconstruction are similar in younger and older patients. Orthop J Sports Med
2017;5 [2325967117729659].
[4] Dahm DL, Wulf CA, Dajani KA, Dobbs RE, Levy BA, Stuart MA. Reconstruction
of the anterior cruciate ligament in patients over 50 years. J Bone Joint Surg Br
2008;90:1446–50.
[5] Figueroa D, Figueroa F, Calvo R, Vaisman A, Espinoza G, Gili F. Anterior cru-
ciate ligament reconstruction in patients over 50 years of age. Knee 2014;2:
1166–8.
[6] Iorio R, Iannotti F, Ponzo A, Proietti L, Redler A, Conteduca F, Ferretti A. Anterior
cruciate ligament reconstruction in patients older than fifty years: a compari-
son with a younger age group. Int Orthop 2018;42:1043–9.
S265
[7] Osti L, Papalia R, Del Buono A, Leonardi F, Denaro V, Maffulli N. Surgery
for ACL deficiency in patients over 50. Knee Surg Sports Traumatol Arthrosc
2011;19:412–7.
[8] Trojani C, Sane JC, Coste JS, Boileau P. Four-strand hamstring tendon autograft
for ACL reconstruction in patients aged 50 years or older. Orthop Traumatol
Surg Res 2009;95:22–7.
[9] Ventura A, Legnani C, Terzaghi C, Borgo E. Single- and double-bundle anterior
cruciate ligament reconstruction in patients aged over 50 years. Arthroscopy
2012;28:1702–9.
[10] Wolfson TS, Epstein DM, Day MS, Joshi BB, McGee A, Strauss EJ, et al. Outcomes
of anterior cruciate ligament reconstruction in patients older than 50 years of
age. Bull Hosp Joint Dis 2014;72:277–83.
[11] Arbuthnot JE, Brink RB. The role of anterior cruciate ligament reconstruction
in the older patients, 55 years or above. Knee Surg Sports Traumatol Arthrosc
2010;18:73–8.
[12] Baker CL, Jones JC, Zhang J. Long-term outcomes after anterior cruciate liga-
ment reconstruction in patients 60 years and older. Orthop J Sports Med 2014;2
[2325967114561737].
[13] Toanen C, Demey G, Ntagiopoulos PG, Ferrua P, Dejour D. Is there any benefit in
anterior cruciate ligament reconstruction in patients older than 60 years? Am
J Sports Med 2017;45:832–7.
[14] Costa GG, Grassi A, Perelli S, Agrò G, Bozzi F, Lo Presti M, Zaffagnini
S. Age over 50 years is not a contraindication for anterior cruci-
ate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2019,
http://dx.doi.org/10.1007/s00167-019-05450-1 [in press].
[15] Ciccotti MG, Lombardo SJ, Nonweiler B, Pink M. Non-operative treatment of
ruptures of the anterior cruciate ligament in middle-aged patients: results after
long-term follow-up. J Bone Joint Surg Am 1994;76:1315–21.
[16] Dejour D, Ntagiopoulos PG, Saggin PR, Panisset JC. The diagnostic value of
clinical tests, magnetic resonance imaging, and instrumented laxity in the
differentiation of complete versus partial anterior cruciate ligament tears.
Arthroscopy 2013;29:491–9.
[17] Anderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ. International knee
documentation committee: the international knee documentation commit-
tee subjective knee evaluation form: normative data. Am J Sports Med
2005;34:128–35.
[18] Tegner Y, Lysholm J, Lysholm M, Gillquist J. A performance test to monitor
rehabilitation and evaluate anterior cruciate ligament injuries. Am J Sports Med
1986;14:156–9.
[19] Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and
Osteoarthritis Outcome Score (KOOS)-development of a self-administered out-
come measure. J Orthop Sports Phys Ther 1998;28:88–96.
[20] Webster KE, Feller JA. Development and validation of a short version of the
Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) Scale. Orthop
J Sports Med 2018;6 [2325967118763763].
[21] Wytrykowski K, Cavaignac E, Reina N, Murgier J, Chiron P. Valeur moyenne du
score KOOS dans une population saine en fonction de l’âge, du sexe et de l’IMC.
RCO 2017;103:S255.