ACL Reconstruction in Patients Aged 40 Years and Older: A Systematic Review and Introduction of a New Methodology Score for ACL Studies.

Background: Treatment of the anterior cruciate ligament (ACL)–deficient knee in older patients remains a core debate.Purpose: To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated withACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluatingACL surgical outcomes: the ACL Methodology Score (AMS).Study Design: Systematic review.Methods: A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusioncriteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months afterreconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus.Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stabilitymeasures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, andreported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specificat critically analyzing ACL outcome studies and used to examine each study design.Results: Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in thereview. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies thatreported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcomescores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positivelycorrelate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting thatmay not be taken into account by the classic level of evidence rating.Conclusion: Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However,the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-termefficacy and to better inform our patients with regard to expected outcomes. [ABSTRACT FROM AUTHOR]