Torn anterior cruciate ligaments, well-known as knee injuries suffered by football players and star athletes, are increasing in young people and older adults.
More adolescents suffer torn ACLs because so many are playing intense organized sports. And more older adults are affected because they lead vigorous lives.
These developments have prompted questions among physicians about how young is too young -- and how old is too old -- for ACL surgery.
Numbers are unavailable nationwide, but many knee surgeons say they are seeing more anterior cruciate ligament tears in a wider spectrum of ages.
The ligament is a key stabilizer of the knee. It prevents the lower leg from slipping forward. When the ligament tears, it frays like rope and cannot be tied back together. A graft from the hamstrings, a cadaver or the patellar tendon in the knee typically is used to replace it.
Nancy Oerter, who teaches in a Grand Island, Neb., elementary school, competed in college athletics and didn't want to surrender sports and fitness in her 40s.
Oerter tore her right ACL playing volleyball last September. It was repaired in November and she has resumed working out on a treadmill and lifting weights.
When volleyball season rolls around in September, Oerter, 47, most likely will play again.
"I intend to, but my husband doesn't think I should," she said. "But I'm the boss of me." Fifteen years ago, orthopedic surgeons didn't like to repair torn anterior cruciate ligaments in people in their 40s and 50s. "We just historically said you only do ACLs in young people," said Dr. Thomas J. Connolly, an orthopedic surgeon and faculty member at Creighton University. A person can function with a torn ACL but the knee generally won't support strenuous activity. Dr. Phil Cahoy, an orthopedic surgeon in Grand Island and Hastings, Neb., said he sees more injured weekend warriors than he did just a few years ago. Many people are not inclined to be sidelined by age today, he said. "More people are not going quietly into the night," said Cahoy, whose 13-year-old son tore his ACL while running in gym class and whose wife, 40, tore hers a few weeks ago skiing. Cahoy, a former champion gymnast at the University of Nebraska-Lincoln, said he doesn't operate on people in their 50s if they have a certain amount of arthritis in their knees. Rather than surgery, Cahoy said, he might put a brace on an older person's knee and try to strengthen it. But that doesn't work for everyone, he said, and if a person skis or is active in some other sport, Cahoy likely would repair the ACL.
Cahoy said he would even operate on people in their 60s who want to stay extremely active. A few years ago, he repaired the ACL of a farmer in his 60s whose knee kept buckling while he worked in the fields. Connolly said the technology is better than it was a decade ago. Arthroscopic equipment helps surgeons place a graft exactly where the ligament had been, he said. The screws to clamp down the graft are better, too, he said. Dr. Ted Ganley, a spokesman for the American Academy of Orthopedic Surgeons, agreed. "The surgery is not as invasive as it previously had been. There's not really a specific age cutoff," said Ganley, director of sports medicine at the Children's Hospital of Philadelphia. Connolly said his oldest ACL surgery patient was 55. Older people tend to have more arthritis in their knees, have a higher risk of blood clots and don't heal as quickly as younger people, he said. In Omaha, Neb., North High School senior Patrick Roy and Central High School junior Jasmyn Flowers know a lot about ACL tears. Each has torn both ACLs while in high school. Flowers, 17, had one knee repaired and will have surgery on the other in the spring. She suffered both injuries while playing basketball, but her best sport is track.
"I plan on coming back my senior year and running," said Flowers. "As far as basketball, I'm done." Roy, also 17, decided to forgo sports this year. "I didn't want to risk messing my legs up worse," he said. ACL injury prevention programs have sprouted nationwide. In Omaha, Alegent Health Sports Medicine offers a program used primarily by female athletes. Surgeons and others say girls have far higher odds of tearing an ACL. The program shows high school athletes how to jump and land with bent knees; how to keep their hips, ankles and knees in alignment when jumping; and how to land softly by rolling from toe to heel when they strike the ground. Dr. Paul Watson, an orthopedic surgeon in Omaha, said surgeons are seeing increasing numbers of children ages 10 and older with torn ACLs. Damaged ligaments in children that young pose a special challenge. At issue are growth plates, one at the top of the knee and the other at the bottom. The plates, where bones grow, are wider on less mature children, and drilling tunnels across them to repair the ACL can stop growth or cause the bone to grow abnormally. That can lead to a deformity and affect how a person walks or runs. If a child has wide growth plates, physicians try to keep him or her in a brace until the plate is just about closed. The age at which the plate closes varies, but with girls it can be around 14 or 15, and with boys a year or two later.
If the brace doesn't stabilize the knee, though, the child can damage knee cartilage. Some children desperately want to keep playing, too, so many surgeons at that point recommend fixing the tear. "Today, it depends a little on how eager they are," Watson said. A patient's desire for a solution also is a factor for adults, although there are limits. Ganley said his mother tore up a knee several years ago while playing tennis. She was in her early 70s at the time. "I said 'Mom, you're done with tennis,'" Ganley said. Source: Omaha World-Herald, Neb. Distributed by McClatchy-Tribune Information Services. Powered by Yellowbrix.
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