Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 30, boulevard Sébastien-Brant, 67400 Ilkirch, France.
Centre ostéo-articulaire des Cèdres, parc Sud Galaxie, 5, rue des Tropiques, 38130 Échirolles, France.
Orthop Traumatol Surg Res. 2021 Dec;107(8S):103039. doi: 10.1016/j.otsr.2021.103039. Epub 2021 Aug 8.
In patients aged over-50 years, although data are sparse, results of anterior cruciate ligament (ACL) surgery are good if selection is correctly performed. However, non-operative treatment is usually proposed for this age group, as patients generally prefer just to scale down their sports activities. Non-operative results are acceptable, but with a high risk of residual instability, secondary lesions and lifestyle alteration. The main aim of the present study was to compare results between surgical versus non-surgical treatment of ACL tear in over-50 year-olds. Secondary objectives comprised assessing prognostic factors for poor functional outcome, and comparing the 2 groups epidemiologically to identify clinical decision-making factors. The study hypothesis was that results are comparable between operative and non-operative treatment of ACL tear.
Three hundred twenty patients were followed up prospectively: 92 non-surgical (NS group) and 288 surgical (S group). Classical epidemiological data were collected. Clinical laxity, differential laximetry, KOOS, IKDC, Tegner and ACL-RSI scores and radiologic assessment were collected pre- and postoperatively, as were intraoperative data. Early and late complications were collected.
All patients were followed up. Patients were principally female, and were older, less athletic, with more stable knee and less severe functional impact in the NS group. Functional scores improved in both groups, and especially in group S, where sports scores were also better. In the NS group, laximetry at follow-up correlated with preoperative marked pivot-shift (p=0.024). Severe differential laxity was predictive of poor IKDC score (p=0.06). In the S group, laximetry at follow-up correlated with preoperative explosive pivot-shift (p<0.001), lateral meniscal lesion (p=0.007), use of hamstring tendon (p=0.007), and non-operated early complications (p=0.004). Factors for poor global KOOS score in group S comprised female gender (p<0.001), high BMI (p<0.001) and skiing (p=0.038). Factors for poor Tegner scores comprised skiing or team sport (p<0.05), isolated moderate medial osteoarthritis (p=0.01), and non-operated early complications (p=0.022). Factors for poor IKDC score comprised female gender (p=0.064), and non-operated early complications (p=0.019). Complications did not differ between groups.
DISCUSSION/CONCLUSION: Results were satisfactory in both groups, with significant improvement in functional scores, but were better in group S. For NS patients, pivot sport was barely feasible and sports activity scores decreased. In case of severe laxity at diagnosis, surgical treatment should be proposed.
III; non-randomized prospective comparative series.
在 50 岁以上的患者中，尽管数据有限，如果选择正确，前交叉韧带（ACL）手术的结果是良好的。然而，由于患者通常只是希望减少他们的体育活动，所以通常会为这个年龄段的患者提供非手术治疗。非手术治疗的结果是可以接受的，但存在高度的残余不稳定、继发损伤和生活方式改变的风险。本研究的主要目的是比较手术与非手术治疗 50 岁以上 ACL 撕裂的结果。次要目标包括评估功能结局不良的预测因素，并比较两组以确定临床决策因素。研究假设是手术和非手术治疗 ACL 撕裂的结果是可比的。
前瞻性随访了 320 例患者：92 例非手术（NS 组）和 288 例手术（S 组）。收集了典型的流行病学数据。术前和术后均采集临床松弛度、差异松弛度、KOOS、IKDC、Tegner 和 ACL-RSI 评分和影像学评估，同时还采集了术中数据。收集了早期和晚期并发症。
所有患者均得到随访。患者主要为女性，年龄较大，运动能力较差，膝关节更稳定，NS 组的功能影响较小。两组的功能评分均有所改善，尤其是 S 组的运动评分也更好。在 NS 组中，随访时的松弛度与术前明显的枢轴移位（p=0.024）相关。严重的差异松弛与较差的 IKDC 评分相关（p=0.06）。在 S 组中，随访时的松弛度与术前爆发性枢轴移位（p<0.001）、外侧半月板损伤（p=0.007）、使用腘绳肌腱（p=0.007）和非手术早期并发症（p=0.004）相关。S 组中，全球 KOOS 评分较差的因素包括女性（p<0.001）、高 BMI（p<0.001）和滑雪（p=0.038）。Tegner 评分较差的因素包括滑雪或团队运动（p<0.05）、单纯中度内侧骨关节炎（p=0.01）和非手术早期并发症（p=0.022）。IKDC 评分较差的因素包括女性（p=0.064）和非手术早期并发症（p=0.019）。两组的并发症无差异。
讨论/结论：两组的结果均令人满意，功能评分均有显著改善，但 S 组的效果更好。对于 NS 患者，枢轴运动几乎不可行，运动活动评分下降。如果诊断时出现严重松弛，应建议手术治疗。
III；非随机前瞻性比较系列。
