Old Man and the Knee

Who says you’re too old for knee surgery to reconstruct a torn anterior cruciate ligament (ACL)? Doctors Miller and Sullivan recently reported on a rancher who had a successful surgery on his ACL. Nothing new, right? Except that the patient was 84 years old at the time of surgery.

Surgery to reconstruct a torn ACL is usually only done on younger patients. Most doctors consider 40 to be old for an ACL surgery. The authors were unaware of anyone older than 62 having this type of surgery.

According to the doctors, the patient had been trying to get along without surgery, but ranching was too much of a challenge. Walking around on the uneven ground caused his knee to give out on him. Rather than change his lifestyle, he opted for surgery.

The surgery was a success. Three months later, the patient was back to his normal activities. When he went back to the doctor for a six-month recheck, he had full knee movement and near normal strength in his leg muscles. He also scored nearly 100% on a questionnaire about knee surgery results.

The authors conclude that “physiologic age and activity level is more important than chronologic age when considering ACL reconstruction.”

Cartilage, Meniscus, and Ligaments–Oh My!

Oz’s tin man needed a heart, and people undergoing anterior cruciate ligament (ACL) reconstruction need a healthy knee. As long as the meniscus isn’t torn and the joint surfaces are in good shape at the time of surgery, this is a reasonable goal. In fact, of the 1231 patients in this study who weren’t having problems with the meniscus or articular cartilage, 97% were found to have excellent knee health up to 15 years after their ACL surgery. Even their X-rays showed that their knee had good health over this time period. And most patients had returned to their sports and were performing at an intensity level equal to or above their presurgical condition.

The “wizard” is not as optimistic when there are problems with the meniscus or joint cartilage at the time of ACL surgery. People with damaged cartilage or who needed to have part or their entire meniscus removed at the time of ACL surgery reported having more pain and problems as time passed. More damage was related to more symptoms. The knee X-rays taken at follow-up checks (which ranged up to 15.8 years later) showed considerably more arthritis, depending on the amount of damage at the time of surgery. The journey along the yellow brick road of ACL surgery rehab will likely be more challenging for people with damaged cartilage or meniscus at the time of ACL surgery.

Making Dollars and “Sense” of ACL Surgery

Choosing between types of medical treatments requires a careful look at which treatments are most cost-effective. The yardstick to measure whether a treatment is cost-effective has to do with quality of life and the costs to achieve it.

Not everyone with a torn anterior cruciate ligament (ACL) requires surgery. But people who participate in high-level recreation and sports activities usually believe that that their quality of life would be poor if a knee problem kept them from taking part in the sports they enjoy. While surgery for a torn ACL can be expensive, it can help young, active patients remain active. In this respect, ACL surgeries for many young, active people make sense–the surgery is cost-effective.

Cost-effectiveness is also influenced by the overall results of treatment. Doctors rely on various tests to measure the outcomes of surgery. Treatment results are also determined by how well a person is able to function with activity. When people can better participate in their regular activities, they feel a greater sense of well-being and satisfaction–important ingredients of a successful treatment outcome. As technology advances and as doctors learn new and better ways to do ACL surgery, these outcomes will improve. As a result, it is likely that ACL surgery will continue to become even more cost-effective.

ACL Patients Move and Groove Safely Back to High-Level Activity

One of the concerns of people with anterior cruciate ligament (ACL) injuries is whether they can safely return to high-level sports and activity. With or without surgery, patients generally benefit from standard rehabilitation programs designed to improve knee movement, strength, and ability. In some cases, patients can return to high-level activity. Other patients have pain or unsteadiness in their knee that keeps them from doing demanding sports or activities. Either the knee doesn’t hold steady, or it actually slips out.

By adding a new form of training to the standard rehabilitation program, the authors found that a greater number of patients with ACL problems could safely return to vigorous sports and work activities. This new training regiment is called perturbation training. Perturbation training involves standing on an unstable platform. The platform shifts at pre-set speeds, and the patient has to regain balance. As the knee starts to hold better, the exercises gradually get harder. Patients will then stand on a special board with rollers while a therapist carefully pushes the knee back and forth in various directions. The training gets even more difficult by having the patients stand on one leg.

Patients who went through perturbation training had better knee stability and fewer problems with their knee feeling like it was going to slip. Also, they were nearly five times more likely to be able to safely go back to rigorous activity. According to the authors, patients who received the special training had much better long-term results than other patients.

These excellent results may partly be the result of carefully selecting the patients for the study. Some people might not be able to do these advanced forms of exercise. But for ACL patients who are up for the challenge, perturbation training seems able to move and groove them back to optimal health and ability.

Preventing Knee Injuries: It’s a “Gal” Thing

Call it hormones; call it anatomy. Females have nearly six times the risk of having a knee injury when doing jump-and-cut sports compared to males in the same sports. Depending on the sport, women athletes have up to 10 times the risk of serious knee injury than men. “Lowering these high figures by even a small percentage could have a significant effect on the number of knee injuries,” say the authors of this study.

To this end, these researchers put an idea to the test: namely, that female athletes would have fewer knee injuries if they did a program of stretching, jump training, and weight lifting. Participants included sports team members from 12 high schools. Half of the female teams went through this specialized training program. The other half did not. The authors also included a control group of 13 untrained male teams.

The training program lasted six weeks, during which female participants worked out three days per week for up to 90 minutes. The training paid off. They had a lower injury rate and fewer serious injuries than the untrained group. And even though the exercise group had a higher incidence of injury than untrained males, the rate was far lower than among females who didn’t train.

Jump training, also called plyometrics, improves muscle strength and dampens joint impact. The authors believe that female athletes benefit from this type of training by gaining improved hamstring muscle strength. The authors suggest that strengthening this muscle helps keep the knee in better alignment and cushions the knee during high-level sport activities, like landing a jump.

In view of their findings, the authors recommend that “young female athletes in sports that entail jumping, pivoting, and cutting, such as basketball, volleyball, and soccer, be trained before participation with a proven effective jump training program that includes progressive resistance weight training for the lower extremity.” They conclude that “such training, if effectively used on a widespread basis, might help to significantly decrease the number of athletes injured each year.”