Tom, a couple of quick comments on your particular paper. We published a very small series, retrospective. I think it was either 13 or 15 ACL reconstructions in patients over the age of 60. And they came in, they were just having instability with ADLs. They were told just live with it, you know. Then they came to me saying, you got to do something on my knee. I can't even go shopping without fear of falling down. And they're actually my happiest group. Of course, they also had the lowest demands. And on use of an allograft, if you look at the increased risk of using allograft in ACL reconstruction, the clinical significance of that increased risk pretty much goes away right around age 40. So over the age of 35 or 40, an allograft is totally appropriate from the MOON analysis. I have a quick question for the panel. We all know that. Can we bring, before we start this panel, can we bring up Dr. Sutton, who I introduced before. We're moving our day around, so we're bringing up these people. And then Dr. Kelly Middleton, who I asked to be on this panel because she's an attending surgeon now in Atlanta, but is a retired professional athlete. And I hope she's not embarrassed, helped write the book on the masterful care of the aging athlete. So she has a perspective on this, too. So thank you. I'm sorry. Great. Thanks, Vonda. I just have one question for the panel. We know after you tear your ACL, with or without reconstruction, that knee has an increased risk for getting arthritis later in life. What do you think, and I don't know if Johnny Ward's got a comment on this. What do you think the panel, what are your thoughts on why that is? Is it damage at the time of the ACL tear, chondral injury that subsequently, we get some chondral site death? Is it consequence of meniscus injury? Is it initiation of some cytokine biologic cascade that's initiated? Is the fact we've altered the biomechanics of that knee and the peak contact loading forces are altered? Now, what do you think, why does an ACL-injured knee have an increased risk for arthritis? Comments from the panel? So I think it's a couple things. I think the first thing is we can't let ourselves off the hook. And if you look at where that comment started from, I think it was really Dale Daniel's studies. And, you know, he was a real pioneer in ACL surgery. But if you really look at how those ACLs were being done, it's probably not the way we're doing them right now. So I think biomechanically, I think the knees were over-constrained. They're getting tension to 30, 40 degrees of flexion. We thought it was great to do a really tight ACL because that was how we're really solid. And those are the people that we're at. So first of all, I think it's our, you know, and then you get to fast forward to Freddy Fu teaching us more about how to be more anatomic. And I think a lot of that data in the future might not be quite as big. Second thing, though, I think is really cartilage damage at the time of injury. I'm a firm believer in that. And when I see my patients in the office now, I say the good news is you only tore your ACL. And we're pretty good at fixing that. We're not so good at fixing meniscus, no matter how good we are. We're not as good as the data is overstated on meniscus and the articular cartilage injury. So I think it's cartilage injury at the time of injury and how we're doing the ACLs. So I don't think it's going to be as much arthritis moving forward. And I think your comment that a lot of the data that we quote about ACL injured knees having risk for arthritis, I think you're right. That's data from the, you know, the pre-modern era of ACL reconstruction. And the paper that Warren presented showing that at 10 years, the Moon Group, which I hope was doing a more modern ACL technique and rehab protocol, showed that it was actually pretty stable. Warren, do you have comments on etiology? Yeah. I mean, I think it is a complex multifactorial thing. I think that there probably is a biological component to things and there's a cascade that takes place at the time of injury. Even the cartilage might appear grossly normal to us at the time of arthroscopy, the bone bruise. And does it take a while? And then that cytokine cascade that takes place after the initial injury. And then when you also have the gross obvious insult to the cartilage and meniscus, that plays a role. I think there's probably a mechanical role, like you pointed out. Maybe they were over-constrained in the past. And then now, hopefully, that's not the case. But then there's also just the mechanical role of the demands that that person is going to put on the knee. You know, I think it's been said in the past, you know, are we doing them a disservice by just providing them a stable enough knee to then go out and trash it over the next 5 to 10 years? So activity level, I think, plays a role as well. And who knows, there's probably maybe some family history, genetic component that gets factored in as well. But, like, I think it would be interesting if there was a cohort of ACL reconstructed patients where we know a lot of them return to a high activity level and then we know a lot of them didn't and compare the rates of OA, those two groups would be interesting at least to tease out how much of the mechanical factor is playing a role. Other comments from the panel? I would add one more thing, you know, echoing off of what Tom was saying. I do think it's really important, as much as we're reconstructing the ACL insufficient athlete above the age of 50, but also that post arthritis, the post ACL arthritis that comes along at that time too. And I think really looking into the research that's coming down the pipeline on PRP and stem cell, as well as I will talk to a lot of my patients if I'm doing an older, I'll say it, ACL reconstruction about hyaluronate or other ways to preserve the cartilage down the road. So I think that'll be interesting as we see some cartilage preservation going down the pipeline and so I think that's important to discuss with our patients too. And I'd like to make one more comment as to hypothesizing on the why and it's something we're starting to work on is that both men and women go through drastic hormone fluctuations starting in their early 40s and cartilage has estrogen, alpha and beta receptors on it and once you have a decline in that hormone there are changes in cartilage and so I think looking at how that affects our recovery and progression is something that would be exciting to continue and look at. Chris, just to bring it back to the topic of this session, to advocate for really viewing your patients with their physiologic age and not their chronologic age, I think one of the reasons that you see the data being actually a lower complication rate in people over 50 is because maybe the demands are not going back to lacrosse or football or whatever but now, you know, the rates of pickleball, tennis, golf, a lot of those sports, they want to be active but it's not the high impact, it's not the severity so these patients even if they do already have a little bit of arthritis, I'm not convinced we're going to see this progression of arthritis that we do in the younger population. There's one more reason. Yeah, and one additional thing about the progression of arthritis particularly in patients with ACL reconstruction is one thing we have to look at too is additional procedures that are required if somebody already has medial compartment arthritis or lateral compartment arthritis. If a uni is required with a high tibial osteotomy or other type of cartilage procedures and, you know, I would actually like to ask the audience because one thing I've had difficulty with and even getting insurance companies to pay for is if there's any type of cartilage procedure or even an access realignment procedure that's required for an ACL reconstruction over the age of 50, it's not always covered. There's actually a hard stop at 50 years old despite whether or not somebody's active in 51 or just turned 51 for multiple insurance companies and I've come across that. I'm not sure if anyone else has if that's required for the patient. Yeah, that needs to be addressed in the future. Questions, comments from the audience? Dr. Birkfeldt. I'd like to ask the audience about the patient that I see. How am I doing? Average age 75. Come in and say, I came to see you, doctor, and I don't want surgery. Usual patient, medial joint arthritis, a little bit of a varice knee. I just want to be able to walk my dog, go shopping, play pickleball. What is your approach to that patient? 75 years old, medial joint arthritis, no injury, it's just age-old arthritis. I want to be active, I want to be able to do my yard work, but I don't want surgery. I just don't want them to see a surgeon that they don't want to do a goatee. Yes, that's a common patient, right? I'm happy. I also see that patient pretty frequently and interestingly in your practice, I think it's nice to have those patients see you because then I know a lot of us certainly want the surgical patients, but they have family members who need surgery as well. So really treating them appropriately, conservatively, I think is critical. And supporting what they want to do, to Vanda's point, understanding what activity level they want to pursue. So the fact that, one, you understand that they want to walk their dog. OK, so how can we get them active in that standpoint? And I give everybody, I have a PDF, a colored PDF that I make for those patients, and I'll go through that with them. And first starting, I think, turmeric or curcumin, I think having that as a supplement, that's been proven in orthopedic literature to decrease musculoskeletal inflammation. So I'll start, a lot of patients now are looking at natural ways to decrease any inflammation. There have been studies comparing turmeric with diclofenac, and it has much less side effect profile and can decrease their symptoms. So I'll start with some natural supplements. Then the other thing I talk to patients about is, at least in my area, we have pretty amazing physical therapists who are also strength and conditioning coaches. So getting that patient feeling comfortable with balance, with doing their activities. And physical therapy now isn't just you sit in a corner, or if that is the case, you shouldn't be sending your patients there, but sit in the corner and do some leg raises. But getting them to an active lifestyle and a home exercise program, I think, is key. The next thing I would talk about would be bracing for them, an offloader brace or unloader brace. I think that that's really important, and the unloader braces have gotten a lot more low profile, where I think in the days that I was training with Tom, it was just this massive brace that nobody wanted to wear. So those are the three initial ones. You can talk about anti-inflammatories, but I'm very conservative, which is why I like the supplements, because of the reflux that could be happening and all the side effects for a 75-year-old with NSAIDs. I think you have to be very careful with that. So Tylenol would be my option there. And then finally, going into injections, certainly steroid injections. I try to really encourage VSCO supplementation in that patient population, not rely as much on the steroid injections. And then obviously, you talk to them about if down the road they need surgery. But that would be my initial discussion, and I really would focus on what is their goal and how can you get them to that goal. There's also just the one thing to add. I agree with everything Karen said. Starting with cortisone, if it's just really, really, really painful, but then the longer term results, whether it's VSCO, PRP, but it's not covered, so they have to be willing to pay for it. But the one thing, there's a great old article that I make all of our residents read called Don't Throw Away the Cane. I'm not sure if you ever read that from the hip arthroplasty world. But if you do the physics on how much a joint is unloaded by the use of one cane in the opposite extremity, obviously, and so if you can walk the dog in one hand, have the cane in the other. My father's 90 now, and I'm trying to keep him going. I've made him, he's been fighting it forever. I'm too proud, too proud. But you get him like the hiking sticks and you don't call it a cane. And you'd be amazed at how much pain you can get rid of just with the use of a cane, which is something to think of. I think the comment about the therapy is even more important for the master athlete. That sarcopenia, you get some muscle strength back, and it's amazing how much that will decrease joint pain. Agreed. Over here. Physical therapist that has access to the experience and the knowledge. Just gait analysis. So not even just 3D, but 2D. So if you could identify a bear's thrust in that patient, the corrective exercises that you can do to minimize or eliminate their bear's thrust is kind of invasive. So there's some dislikes, by the way. Some therapists that have that training are going to do better. Chris, I just want to reiterate what Tommy said about minimizing the hit to the knee. And that's why I'm a big fan of non-graded allografts. But the other thing I want to share with the audience is Pablo Costa would do a part where he's not clasping a rabbit. He would do fibrillation in the truncated. So it would be very minimalistic for these older folks. And I feel like zero for non-clasping on these non-graded grabs. The question I have is, and Rhonda knows whether or not there's new age antioxidants and injections people have been using. Any experience of the panel, some of these cocktails with cysteine and Gatoralac and so forth? There are a lot of options in various clinics all over the place that are charging good hard cash for it. And my comment to my patients always is that in this house, we only do evidence-based medicine. So there's a lot out there. But I don't think the evidence sustains it, at least to my reading. I only use it in total knees. I haven't used it in ACLs. I don't know. I'll use it on occasion, depending on trying to decrease the hematoma afterwards or just trying to, if it seems a little bit more bone bleeding than the average, I'll use it for that. So it's kind of on an as-needed basis. It's not on a specific every case basis. And I'll use it sparingly. John, that's one of the things that, though, I have no disclosure. I am not paid by the BTB allograft companies or where else I'm not conflicted here. But one of the beauties of a BTB allograft, as you know, with a soft tissue allograft, you still have a ton of bone tunnel bleeding that's getting. There's no aperture fixation. You're not sealing it off. In my opinion, there is so much less hemarthrosis from sealing off the joint and having a nice bone plug that fills it up. And then I do believe in CPM. I know there's plenty of literature. I'm not sure I'd make it in Vonda's evidence-based camp on the CPM. You can find it both ways. But I think by minimizing the hemarthrosis before it ever happens, we have to rely on these cocktails less and less. So again, your technique, I think, can make up a lot of it. All right. In the interest of time, we'll keep moving. Great discussion. Have a nice day.

arthritis

ACL injury

biomechanics

conservative approaches

PRP