One of the great things about doing research from the time you're a fellow to the time you're one of these aging athletes over 50 is that your interests can kind of evolve as well. It's basic science, clinical, and the fun thing about this part of a career is kind of trying to challenge kind of what you've been, the dogma, what you've been taught as a resident and taught as a fellow, but then maybe your own experiences as a clinician and your own practice of change. So we wanted to kind of look at this concept of older ACL reconstructions. When I was a resident in Boston, they said, you tore your ACL over 40, at the Brigham and Women's Hospital, Mass General, big arthroplasty centers, they just tell you to quit your sport and wait until you need your total knee and then you're done. I'm serious. That's what we were, Vonda's shaking her head, you probably heard the same thing, right? And then I got out to fellowship and there's a paper written, the first paper written by Kevin Plancher and Dick Steadman on ACLs over 40. And that was kind of like, wow, it's over 40, but now we're here talking about ACLs over 50. And I think there's some reasons why we're talking about that today. So we all know how common ACLs are and we don't have to go into the outcomes in younger patients. That's been extremely well reported, failure rates between 5 and 10 percent and people tend to get back to higher injury levels. But as our population does continue to age, I know in Boston, the senior women's and men's hockey leagues, tennis leagues, soccer leagues are extremely popular. People are increasing their activity levels more and more. And it's not just a question of because they want to, I think one of the reasons we are getting older as a population is because we are staying active longer and our overall health is staying better. And then as a result also, we see our neighbors next door, we see people on TV, we see people on social media, how active they are in their older age, and they say, hey, why not me? Why can't I be just as active now as I was five years, 10 years? I know during my run up the side of the mountain yesterday, I felt like one of these over age 50 athletes. I said, why couldn't I do this like when I was 20, but that's another story for another time. But I think another reason that we can do this is not only the expectations of the patients, but what societies like this have been able to do. I think we are ACL techniques that are much better. We have more options for graft selections, our rehabilitation schedules that we've come up with have improved. So this concept of don't do an ACL over 40, then don't do it over 45, then don't do it over 50. It's become a moving target. And I hope at the end of this talk, maybe at the end of this session with some discussion, hopefully five years from now, we can be up here talking about ACLs over 55, or if not ACLs something else, some other type of sports. It's actually tough to find data on the number of ACLs over 50 that are being done. And this was a Pearl Diver paper that Zaleski did kind of last year, and looking at patients over 50 and under 50. And it's actually about an eight times greater rate under 50 than over 50, as you might expect. There may be a slight decline in the number of ACLs being done. But it was my experience with my practice, I thought my patients were doing reasonably well. So what do we do? We study the problem. So we looked at kind of a single surgeon series, age 50 at the time of surgery, ACL deficient, and at least one symptomatic instability episode. Not just the injury, but you tried rehab, and then you had some instability after that. PROs were all filled out, minimum two-year follow-up. Excluded were any kind of multiligamentous injury. If we did an osteotomy at the same time, or obviously if they had some Cogman-Lawrence grade four disease or previous ACLs, so no revisions were included in this work. And that's actually probably a paper that we're working on right now, is revision ACLs over 50, because we're starting to see more and more of those as we've been pushing the limits more and more. So kind of the standard types of activity outcome scores we looked at, including, for those of you who may not be familiar with it, there's something called the patient acceptable symptom state, which was actually brought on as a way to have patient-derived or patient-driven outcomes. What do they define as a successful outcome? And it's actually, when you're doing your own research, take a look at it. It's actually a nice little way to give us some more objective definition of what we're doing. Pretty standard kind of post-ACL rehab that we did. We had 50 patients, average age was 55, mean follow-up of about five years, and fairly even split with men and women. If you look at the results, just a couple of things to highlight. You know, Tegner scores went up significantly, post-op IKDC at 81, Leisholm, we had about three-quarters good and excellent results on the Leisholm, and then the short-form physical component of the SF12 was 54. But here's that kind of pass we were talking about. But 70% of people qualified for an acceptable or successful outcome from the patient's perspective on the IKDC, and three-quarters achieved an MCID for the activity score. This slide actually, I think, ought to be your take-home, because when I was, again, when I was being taught in early out, everyone's like, why are you operating on this patient over 40? Do you have any idea what the complication rate's going to be? They're going to do terribly, they're going to have pain, they're going to swell, they're never going to get back. I wish my under-50 patients, I could put that slide up and be like this, I guarantee you I cannot. And I think that's, hopefully after discussion, we can talk about why this is the case. No clinical failures, not a lot of the things. If you look what's in the literature on this topic, the same paper by Silesky reported a higher rate of DVTs and PEs, but then you had lower rates of subsequent surgery. And there's, I think, a reason, obviously, for that. Predictions of worse results in the literature, talked about, quote, if the patient had a pre-op explosive pivot shift, you should add an ALL. I am not one of those people that thinks we ought to be adding ALLs in a lot of these over-50 people. I think we over-constrain them, I think you have underlying chondral injuries, and I think that's what makes these over-50 ACLs not do well. So I would caution you on adding an ALL. And the other big difference is, I'm a big believer in this population in BTB allografts. I think the nice thing about a BTB allograft compared to a soft tissue graft is you can move them faster, weight-bear them faster, get them, strengthen them faster, they lose less muscle, they're back at their jobs faster, and I think that it's something that, you know, it's a shorter graft, it's a stiffer graft, and I encourage you to take a look at it in your own practice. And then as one of our moderators, Dr. Kading, taught us, it looks like, you know, we say, well, allografts, don't they have a higher failure rate for our senior athletes? There's probably not a difference in this age group in allografts, failures between autografts and autografts. So again, maybe something good for discussion. So just to conclude, I think I'm going to take home from this that I was really excited to see patients over 50 can do well and do do well with ACLs. I don't use age alone as an indicator. It's more physiologic age than chronologic age. I've got a lot of 30-year-olds I have no desire to do an ACL on, and I've done ACLs on 68-year-old skiers who ski 150 days a year. Andrea Soudabecke, if you're in here, that's going to be you. I'm going to do your ACL when you're 75, because you do it about 200 days a year. I know you will be. And the other key question, just in your history, and I always say, because you always see this, a little bit of arthritis, ACL deficient knee, I say, what is your chief complaint? Is it pain or is it instability? If it's pain, don't necessarily do an ACL reconstruction. ACLs don't cause pain. You're not going to solve your pain with an ACL. If it's instability, then I think that's a good patient to do. And obviously select a motivated patient, set their rehab goals early. Thanks very much.

ACL reconstructions

older patients

evolution

advancements

physiologic age