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Editorial Commentary: Revision Anterior Cruciate Ligament Surgery, Unlike Cheese, Is Not Improved With Age but Nationality and Culture May Matter

      Abstract

      Recurrent instability and future joint damage occur if there is a repeated anterior cruciate ligament injury after reconstruction. This prognostic declaration is said to those who have sustained a rupture to the repaired anterior cruciate ligament. Both younger and older patients seek stable knees to allow a return to stability and twisting activity without the risk of added joint damage. To achieve this goal, revision ligament surgery is needed.
      When primary anterior cruciate ligament (ACL) repair is performed, it has become accepted that patients aged 40 to 50 years may expect stability and outcomes similar to those in younger patients. Patients older than 50 years have similar results regarding knee strength and anteroposterior stability after ACL reconstruction to those in younger patients.
      • Kim D.K.
      • Park G.
      • Kuo L.-T.
      • Park W.H.
      Patients older than 50 years had similar results of knee strength and anteroposterior stability after ACL reconstruction compared to younger patients.
      ,
      • Barber F.A.
      • Aziz-Jacobo J.
      • Oro F.B.
      Anterior cruciate ligament reconstruction using patellar tendon allograft: An age-dependent outcome evaluation.
      These findings have supported the recommendation for reconstructive surgery, when appropriate, without regard to age.
      Although both young and old patients do well with primary repair, failure of a primary ACL reconstructive surgical procedure is not the same when comparing age groups. When we look at risk factors of primary repair failure, being young and a male patient increases the chance of recurrent ligament injury.
      • Maletis G.B.
      • Chen J.
      • Inacio M.C.
      • Funahashi T.T.
      Age-related risk factors for revision anterior cruciate ligament reconstruction: A cohort study of 21,304 patients from the Kaiser Permanente Anterior Cruciate Ligament Registry.
      This leads one to assume the same factors that lead to higher primary failures may cause a disruption of the graft in revision surgery. The young male population should have less surgical success and a greater risk of recurrent instability after revision of a failed primary repair. This is the subject of the article “Clinical Outcomes and the Failure Rate of Revision Anterior Cruciate Ligament Reconstruction Were Comparable Between Patients Younger Than 40 Years and Patients Older Than 40 Years: A Minimum 2-Year Follow-Up Study” by Yoon, Lee, Park, Kim, and Kim.
      • Yoon K.H.
      • Lee H.W.
      • Park J.-Y.
      • Kim S.J.
      • Kim S.-G.
      Clinical outcomes and the failure rate of revision anterior cruciate ligament reconstruction were comparable between patients younger than 40 years and patients older than 40 years: A minimum 2-year follow-up study.
      They compared the clinical outcomes and failure rates of revision ACL surgery in young and middle-aged patients (>40 years). This study is both interesting and unusual because it evaluates surgery from a single surgeon centered in the Republic of Korea. The presentation of this unique demographic grouping and focused study results in significant findings. Yoon et al. concluded that at 2 years, patients younger than 40 years and patients older than 40 years had comparable results.
      These findings are significant in that they allow one to provide guidance to the patient with a tear of a reconstructed ACL. After such an injury, the success of surgery is equal in both age groupings. Being young does not predispose patients to a greater risk of failure when considering repeated ligament surgery.
      • Yoon K.H.
      • Lee H.W.
      • Park J.-Y.
      • Kim S.J.
      • Kim S.-G.
      Clinical outcomes and the failure rate of revision anterior cruciate ligament reconstruction were comparable between patients younger than 40 years and patients older than 40 years: A minimum 2-year follow-up study.
      However, one is cautioned before applying the broad sword of acceptance to these findings and applying them to all patients. Before one can declare that all patients, older and younger than 40 years, will have similar success with revision surgery, it must be appreciated that everyone is not the same the world over.
      When reviewing and analyzing orthopaedic manuscripts, one is blinded regarding authorship. This prevents bias. Yet, authorship does give critical information regarding the demographic characteristics of the study. In this case, the patients were located in the Republic of Korea, and the surgical procedures were performed there. Moreover, when considering the results of surgery, the location, culture, and nationality may matter.
      It has been well accepted that Asian knees are different from Western knees (research comparing ethnic differences in anatomy often refer to the European-American nationality as “white”). Studies have shown that Chinese, Korean, and Iranian patients tend to have a more asymmetrical tibial plateau.
      • Chiu K.Y.
      • Zhang S.D.
      • Zhang G.H.
      Posterior slope of tibial plateau in Chinese.
      • Yoo J.H.
      • Kang Y.G.
      • Chang C.B.
      • et al.
      The relationship of the medially-offset stem of the tibial component to the medial tibial cortex in total knee replacements in Korean patients.
      • Hosseinzadeh H.R.S.
      • Tarabichi S.
      • Shahi A.S.
      • et al.
      Special considerations in Asian knee arthroplasty.
      Additional studies have found a smaller distal femoral diameter in Chinese, Japanese, Korean, and Indian populations compared with their white counterparts.
      • Cheng F.B.
      • Ji X.F.
      • Lai Y.
      Three dimensional morphometry of the knee to design the total knee arthroplasty for Chinese population.
      • Hovinga K.R.
      • Lerner A.L.
      Anatomic variations between Japanese and Caucasian populations in the healthy young adult knee joint.
      • Kwak D.S.
      • Surendran S.
      • Pengatteeri Y.H.
      • et al.
      Morphometry of the proximal tibia to design the tibial component of total knee arthroplasty for the Korean population.
      • Vaidya S.V.
      • Ranawat C.S.
      • Aroojis A.
      • et al.
      Anthropometric measurements to design total knee prostheses for the Indian population.
      Adding to the fact that sizes and plateaus in Asian populations have different configurations, there is a difference in the rotational configuration and alignment. Differences in the posterior tibial slope, mechanical axis, and Whiteside epicondylar angle have been noted in the Asian population.
      • Yip D.K.
      • Zhu Y.H.
      • Chiu K.Y.
      • et al.
      Distal rotational alignment of the Chinese femur and its relevance in total knee arthroplasty.
      In addition, well-appreciated flexion differences have been recorded between Asian and Western counterparts.
      • Hitt K.
      • Shurman II, J.R.
      • Greene K.
      • et al.
      Anthropometric measurements of the human knee: correlation to the sizing of current knee arthroplasty systems.
      These anthropomorphic differences have been analyzed and used to explain the higher failure rate of total knee replacement in a Japanese population. It has been suggested that knee arthroplasty, based on the morphology of the Western knee, is not as successful because of anatomic difference between Asian and Western populations.
      • Iorio R.
      • Kobayashi S.
      • Healy W.L.
      • et al.
      Primary posterior cruciate-retaining total knee arthroplasty: a comparison of American and Japanese cohorts.
      Given that there is a clear but subtle difference in the anatomy of the Asian knee and Western knee, one must consider that this may also influence the success of ligament surgery. In the study by Maletis et al.,
      • Maletis G.B.
      • Chen J.
      • Inacio M.C.
      • Funahashi T.T.
      Age-related risk factors for revision anterior cruciate ligament reconstruction: A cohort study of 21,304 patients from the Kaiser Permanente Anterior Cruciate Ligament Registry.
      they concluded that young age did predispose patients to failure of the primary ACL repair and the need for revision surgery. However, if one parses their data, it is also apparent that the incidence of failure in the Asian population is less than that in patients categorized as white. The numbers of Asians in the study was not sufficient to allow for a statistically significant statement, but the revision rate was 4% lower than that of patients categorized as white.
      When considering how activity relates to failure, there is no description or analysis of activity type in the study by Maletis et al.
      • Maletis G.B.
      • Chen J.
      • Inacio M.C.
      • Funahashi T.T.
      Age-related risk factors for revision anterior cruciate ligament reconstruction: A cohort study of 21,304 patients from the Kaiser Permanente Anterior Cruciate Ligament Registry.
      The study by Yoon et al.
      • Yoon K.H.
      • Lee H.W.
      • Park J.-Y.
      • Kim S.J.
      • Kim S.-G.
      Clinical outcomes and the failure rate of revision anterior cruciate ligament reconstruction were comparable between patients younger than 40 years and patients older than 40 years: A minimum 2-year follow-up study.
      also fails to categorize sporting activities. A review of current sporting activities when comparing Western and Asian culture finds a disparity between the most popular pursuits.
      Woods RA
      US Bureau of Labor Statistics. Sports and exercise activities by age.
      • Kim M.
      • Park S.
      • Kim H.
      • Yi E.
      • Jeon S.
      Trend of daily sports participation in Korean aged population and sports policy: A review of research on public daily sports participation.
      • Oh J.W.
      • Lee E.Y.
      • Lim J.
      • et al.
      Results from South Korea's 2018 Report Card on physical activity for children and youth.
      These cultural activity differences could be an added factor in analyzing failure rates between different countries.
      There is a great deal to be learned from the study by Yoon et al.
      • Yoon K.H.
      • Lee H.W.
      • Park J.-Y.
      • Kim S.J.
      • Kim S.-G.
      Clinical outcomes and the failure rate of revision anterior cruciate ligament reconstruction were comparable between patients younger than 40 years and patients older than 40 years: A minimum 2-year follow-up study.
      The equal success of revision ligament reconstruction in both groups is encouraging information to the practicing knee surgeon. However, it is important to remember that results can and will be affected by more than just age, sex, and weight. It is just as important to consider that there are anthropomorphic and societal influences that will affect the ultimate outcome of any surgical procedure. Age may have no effect on the success of revision ACL surgery, but nationality and culture may matter.

      Supplementary Data

      References

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