Non-Operative Treatment of Ruptures of the Anterior Cruciate Ligament in Middle-Aged Patients

We retrospectively reviewed the records of fifty-two patients who had had a rupture of the anterior cruciate ligament between the ages of forty and sixty years, to determine the results of aggressive non-operative treatment. We were able to locate and re-examine thirty of these patients (mean age, forty-six years) after a mean duration of follow-up of seven years (range, five to thirteen years), and to assess the clinical, radiographic, and functional results. The mean score, according to the scale of Lyshoim and Giliquist, was 82 points; eight of the eleven patients who had combined ligamentous injuries had a score of less than 84 points (symptoms with daily activities). Thirteen substantial reinjuries had occurred in eleven patients (37 per cent) during the follow-up period. Twenty-nine patients (97 per cent) had a grade-2 or 3 Lachman test, and a positive pivot-shift test was elicited in twenty-five patients (83 per cent). Plain radiographs revealed minimum or no changes in twenty-six patients (87 per cent). Magnetic resonance imaging in nine patients revealed scarring of the remnant of the anterior cruciate ligament to the posterior cruciate ligament in six. The mean difference in anterior-posterior laxity between the injured knee and the normal, contralateral knee, as measured with the KT-1000 arthrometer, was five millimeters at twenty pounds (eighty-nine newtons). Twenty-five (83 per cent) of these thirty middleaged patients, who had had guided rehabilitation and had modified activity, had a satisfactory outcome without an operation. However, a few patients, who had combined instabilities and who wished to resume competitive sports activity that required pivoting, were dissatisfied. Such patients may need operative reconstruction to achieve their goals. *No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. tThomas Jefferson University Hospital and Rothman Institute, 800 Spruce Street, Philadelphia, Pennsylvania 19107. tKerlan-Jobe Orthopaedic Clinic. 501 East Hardy Street. Inglewood, California 90301. §Biomechanics Laboratory, Centinela Hospital. 555 East Hardy Street. Inglewood, California 90301. Many authors have suggested that the outcome of a rupture of the anterior cruciate ligament in young, athletic patients follows a predictable course of progressive dysfunction of the knee, often culminating in a poor nesult52 23. We have found little information, however, about the results of this injury in middle-aged patients with which to determine if the course parallels that in a younger population. McCanroll et al. reviewed the results after reconstruction of the anterior cruciate ligament in athletes who were thirty to fifty years old and advised reconstruction as a reasonable alternative to non-operative treatment. We undertook the present study to evaluate the long-term results in middle-aged patients after non-operative treatment of a rupture of the anterior cruciate ligament. Materials and Methods The records of fifty-two patients who had sustained a rupture of the anterior cruciate ligament between the ages of forty and sixty years (mean, forty-seven years) were reviewed retrospectively, five to eighteen years (mean, seven years) after the injury. All patients had been evaluated at the Kerlan-Jobe Orthopaedic Clinic and had been managed with a non-operative course of treatment; operative reconstruction had not been offered. There were thirty men (58 per cent) and twentytwo women (42 per cent). The injury had involved the right knee in twenty patients (38 per cent) and the left knee in thirty-two (62 pen cent). The retrospective analysis included the mechanism of the injury, the presenting symptoms, the results of the initial examination, the preliminary diagnosis, and the type of treatment. An attempt was made to contact all fifty-two patients. Thirty patients seventeen men (57 per cent) and thirteen women (43 per cent) were located and agreed to return for a follow-up evaluation, which ineluded clinical, functional, and radiographic assessments, five to thirteen years (mean, seven years) after the injury. The ages of this subgroup at the time of the injury also ranged from forty to sixty years (mean, fortysix years). The right knee was involved in thirteen patients (43 pen cent) and the left knee, in seventeen (57 per cent). 1316 M. G. CICCOTTI. 5. J. LOMBARDO. BLAKE NONWEILER. AND MARILYN PINK THE JOURNAL OF BONE AND JOINT SURGERY The clinical evaluation consisted of a subjective appraisal and a physical examination. The subjective appraisal included the assignment of a knee scone according to the scale of Lysholm and Gillquist and an assessment of the patients’ compliance with the treatment regimen. their extent of return to activity, and any occurrence of neinjuny. The Lysholm and Gillquist score consisted of eight items related to the function of the knee. Each item, as well as the total scone, was analyzed separately. A total score of 95 to 100 points mdicated normal function: 84 to 94 points, symptoms in association with vigorous activities: and less than 84 points, symptoms in association with daily activities. We assessed the compliance of the patients with the rehabilitation program, with the physician’s instructions neganding activities, and with the use of a brace for sports in which pivoting maneuvers are needed. The patients were also questioned about their level of function before and after the injury, according to the classification system of the International Knee Documentation Committee5’. With use of this system, class I comprises activities of daily living: class II, manual labor involving lifting, straight running, and sports that do not involve agility of the lower limbs: class III, sports involving agility of the lower limbs but not jumping, hard cutting, or pivoting: and class IV, sports involving jumping, hand cutting, or pivoting. Reinjuny was defined as a noteworthy event involving giving-way of the knee and subsequent pain, swelling, and limitation of activities lasting more than forty-eight hours. The physical examination of the knee included an assessment of the range of motion, swelling, and laxity. Anterior and posterior drawer tests, Lachman27 and pivot-shift2’ tests, and tests involving varus and valgus stress at 0 and 30 degrees of flexion were all performed. The circumference of the thigh was measured five centimeters proximal to the superior pole of the patella and was compared with that of the uninjured thigh. The functional assessment consisted of tests of laxity and isokinetic muscle strength, all performed by the same examiners. Instrumented laxity testing in the sagittal plane was performed bilaterally at 20 degrees of flexion with loads of twenty pounds (eighty-nine newtons), thirty pounds (133 newtons), and a maximum manual load, with use of the KT-1000 anthrometen (MedMetnic, San Diego, California7). Isokinetic torque and work values for the quadriceps and hamstrings were measured bilaterally with use of the Lido dynamometer (Loredan Biomedical, West Sacramento, California) at 200, 240, 270, and 300 degrees pen second. The peak values were established, and the ratio of the value for the involved limb to that for the uninvolved limb was then calculated. A difference of 20 pen cent in the torque on work value for the injured knee compared with that for the uninjured knee was considered to be a minimum deficit: 21 to 40 pen cent, a moderate deficit: and more than 40 per cent, a severe deficit23. Antenopostenior and lateral nadiographs of the knee, made while the patient was standing, and a skyline patellan radiograph were graded for degenerative changes. Minimum changes were represented by squaring of the femonal and tibial margins, subchondnal sclerosis, no nanrowing of the joint space, and no substantial formation of osteophytes: moderate, a narrow joint-cartilage space and substantial subchondnal sclerosis and formation of osteophytes: and severe, obliteration of the apparent joint space in addition to moderate changes . Magnetic resonance imaging studies of nine patients (five men and four women) were performed to evaluate the soft tissues in the femonal notch. A descriptive analysis was carried out on thirty sepanate variables of the retrospective data for all fifty-two patients. Means with standard deviations on frequency counts were established for all variables. The follow-up data generated by the subgroup of thirty patients were also studied for the same descriptive statistics and were analyzed as well with stepwise regression, to determine the predictive value of twelve variables (age, sex, side, contact injury, injury sustained during jumping, occurnence of a pop at the time of the injury, Lachman grade, pivot shift, valgus laxity, tenderness oven the joint line, a positive result on the McMurray test, and reinjuny) for the final Lysholm and Gillquist score. The value of alpha was 0.05.