Age over 50 years is not a contraindication for anterior cruciate ligament reconstruction

  • Giuseppe Gianluca CostaEmail author
  • Alberto Grassi
  • Simone Perelli
  • Giuseppe Agrò
  • Federico Bozzi
  • Mirco Lo Presti
  • Stefano Zaffagnini



To report clinical and functional results of ACL reconstruction in patients over 50 years old and investigate the influence of surgery on osteoarthritis progression in this cohort of patients.


A systematic review was performed on PubMed, Scopus, Google scholar, Cochrane library and EMBASE, using a strategy search design to collect clinical studies reporting outcomes of ACL reconstruction in patients aged 50 years or older. The primary outcome measure was clinical and functional results, including failure rate defined as reoperation for revision ACL surgery or conversion to total knee arthroplasty; secondary outcomes included radiological findings, expressed according to the validated grading score.


A total of 16 studies were found suitable and included. Overall, 470 arthroscopic ACL reconstructions were performed in 468 patients (278 males, 190 females), with a mean age of 53.6 years (50–75 years). The total failure rate, described as reoperation for revision ACL surgery was 2.7% (10 knees), ranging from 0 to 14.3% in the selected studies. All papers reviewed showed a statistically significant improvement of clinical and functional scores at final follow-up, comparable to younger control group, when reported. Post-operative objective stability testing with KT-1000 arthrometer device or equivalent was performed in seven studies, with a mean side-to-side difference of 2.2 mm (0.2–2.7 mm). Radiographic signs of progression of osteoarthritis were reported in six studies, where severe signs of degeneration (grade 3 or 4 according Kellgren–Lawrence or Ahlbäck classification) shifted from 4 out of 216 knees (1.9%) before surgery to 28 out of 187 knees (15%) following ACL reconstruction, after a mean period of follow-up ranging from 32 to 64 months.


ACL reconstruction in patients older than 50 years is a safe procedure with good results that are comparable to those of younger patients previously reported. Age itself is not a contraindication to ACL surgery because physiological age, clinical symptoms and functional requests are more important than chronological age in decision process. Since cohort size in the present study is not large enough, and taking into account the high occurrence of concomitant meniscal and chondral lesions, more high-quality studies are necessary to draw definitive conclusions about development of osteoarthritis of the knee after ACL surgery in these patients.

Level of evidence



Anterior cruciate ligament reconstruction Aging athletes Older patients Outcomes Osteoarthritis 



No external funding was received for the initiation or completion of this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

An institutional review board was not obtained because all data were extracted from previously published studies.


  1. 1.
    Ahlbäck S (1968) Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh) Suppl 277:7–72Google Scholar
  2. 2.
    Aït Si Selmi T, Fithian D, Neyret P (2006) The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up. Knee 13:353–358CrossRefGoogle Scholar
  3. 3.
    Anderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ (2005) International Knee Documentation Committee: the International Knee Documentation Committee Subjective Knee Evaluation Form: normative data. Am J Sports Med 34:128–135CrossRefGoogle Scholar
  4. 4.
    Arbuthnot JE, Brink RB (2010) The role of anterior cruciate ligament reconstruction in the older patients, 55 years or above. Knee Surg Sports Traumatol Arthrosc 18:73–78CrossRefGoogle Scholar
  5. 5.
    Asano H, Muneta T, Ikeda H, Yagishita K, Kurihara Y, Sekiya I (2004) Arthroscopic evaluation of the articular cartilage after anterior cruciate ligament reconstruction: a short-term prospective study of 105 patients. Arthroscopy 20:474–481CrossRefGoogle Scholar
  6. 6.
    Baker CL Jr, Jones JC, Zhang J (2014) Long-term outcomes after anterior cruciate ligament reconstruction in patients 60 years and older. Orthop J Sports Med 2(12):2325967114561737CrossRefGoogle Scholar
  7. 7.
    Bali T, Nagraj R, Kumar MN, Chandy T (2015) Patellar tendon or hamstring graft anterior cruciate ligament reconstructions in patients aged above 50 years. Indian J Orthop 49(6):615–619CrossRefGoogle Scholar
  8. 8.
    Blyth MJ, Gosal HS, Peake WM, Bartlett RJ (2003) Anterior cruciate ligament reconstruction in patients over the age of 50 years: 2- to 8-year follow-up. Knee Surg Sports Traumatol Arthrosc 11:204–211CrossRefGoogle Scholar
  9. 9.
    Brittberg M, Winalski CS (2003) Evaluation of cartilage injuries and repair. J Bone Jt Surg Am 85-A(Suppl 2):58–69CrossRefGoogle Scholar
  10. 10.
    Brown CA, McAdams TR, Harris AH, Maffulli N, Safran MR (2013) ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies. Am J Sports Med 41(9):2181–2190CrossRefGoogle Scholar
  11. 11.
    Ciccotti MG, Lombardo SJ, Nonweiler B, Pink M (1994) Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. J Bone Jt Surg Am 76:1315–1321CrossRefGoogle Scholar
  12. 12.
    Cinque ME, Chahla J, Moatshe G, DePhillipo NN, Kennedy NI, Godin JA, LaPrade RF (2017) Outcomes and complication rates after primary anterior cruciate ligament reconstruction are similar in younger and older patients. Orthop J Sports Med 5(10):2325967117729659CrossRefGoogle Scholar
  13. 13.
    Cinque ME, Dornan GJ, Chahla J, Moatshe G, LaPrade RF (2018) High rates of osteoarthritis develop after anterior cruciate ligament surgery: an analysis of 4108 patients. Am J Sports Med 46(8):2011–2019CrossRefGoogle Scholar
  14. 14.
    Cohen M, Amaro JT, Ejnisman B, Carvalho RT, Nakano KK, Peccin MS, Teixeira R, Laurino CF, Abdalla RJ (2007) Anterior cruciate ligament reconstruction after 10–15 years: association between meniscectomy and osteoarthrosis. Arthroscopy 23:629–634CrossRefGoogle Scholar
  15. 15.
    Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 10:2–11CrossRefGoogle Scholar
  16. 16.
    Crawford SN, Waterman BR, Lubowitz JH (2013) Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy 29(9):1566–1571CrossRefGoogle Scholar
  17. 17.
    Dahm DL, Wulf CA, Dajani KA, Dobbs RE, Levy BA, Stuart MA (2008) Reconstruction of the anterior cruciate ligament in patients over 50 years. J Bone Jt Surg Br 90:1446–1450CrossRefGoogle Scholar
  18. 18.
    Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R (1985) Instrumented measurement of anterior laxity of the knee. J Bone Jt Surg Am 67:720–726CrossRefGoogle Scholar
  19. 19.
    Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR (1994) Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 22:632–644CrossRefGoogle Scholar
  20. 20.
    Ekdahl M, Wang JH, Ronga M, Fu FH (2008) Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16(10):935–947CrossRefGoogle Scholar
  21. 21.
    Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: key indicators of well-being. Accessed 6 June 2012
  22. 22.
    Figueroa D, Figueroa F, Calvo R, Vaisman A, Espinoza G, Gili F (2014) Anterior cruciate ligament reconstruction in patients over 50 years of age. Knee 21(6):1166–1168CrossRefGoogle Scholar
  23. 23.
    Fitzgerald GK, Axe MJ, Snyder-Mackler L (2000) A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 8(2):76–82CrossRefGoogle Scholar
  24. 24.
    Foster TE, Wolfe BL, Ryan S, Silvestri L, Kaye EK (2010) Does the graft source really matter in the outcome of patients undergoing anterior cruciate ligament reconstruction? An evaluation of autograft versus allograft reconstruction results: a systematic review. Am J Sports Med 38(1):189–199CrossRefGoogle Scholar
  25. 25.
    Frank CB, Jackson DW (1997) The science of reconstruction of the anterior cruciate ligament. J Bone Jt Surg [Am] 79-A:1556–1576CrossRefGoogle Scholar
  26. 26.
    Hootman JM, Macera CA, Ainsworth BE, Martin M, Addy CL, Blair SN (2001) Association among physical activity level, cardiorespiratory fitness, and risk of musculoskeletal injury. Am J Epidemiol 154(3):251–258CrossRefGoogle Scholar
  27. 27.
    Iorio R, Iannotti F, Ponzo A, Proietti L, Redler A, Conteduca F, Ferretti A (2018) Anterior cruciate ligament reconstruction in patients older than fifty years: a comparison with a younger age group. Int Orthop 42(5):1043–1049CrossRefGoogle Scholar
  28. 28.
    Jomha NM, Borton DC, Clingeleffer AJ, Pinczewski LA (1999) Long-term osteoarthritic changes in anterior cruciate ligament reconstructed knees. Clin Orthop Relat Res 358:188–193CrossRefGoogle Scholar
  29. 29.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502CrossRefGoogle Scholar
  30. 30.
    Khan RM, Prasad V, Gangone R, Kinmont JC (2010) Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 18(1):68–72CrossRefGoogle Scholar
  31. 31.
    Kinugasa K, Mae T, Matsumoto N, Nakagawa S, Yoneda M, Shino K (2011) Effect of patient age on morphology of anterior cruciate ligament grafts at second-look arthroscopy. Arthroscopy 27:38–45CrossRefGoogle Scholar
  32. 32.
    Lebel B, Hulet C, Galaud B, Burdin G, Locker B, Vielpeau C (2008) Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone autograft: a minimum 10-year follow-up. Am J Sports Med 36:1275–1282CrossRefGoogle Scholar
  33. 33.
    Lysholm J, Gillquist J (1982) Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 10:150–154CrossRefGoogle Scholar
  34. 34.
    Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr, Paletta GA Jr (2014) Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 42(10):2363–2370CrossRefGoogle Scholar
  35. 35.
    Marquass B, Hepp P, Engel T, Dusing T, Lill H, Josten C (2007) The use of hamstrings in anterior cruciate ligament reconstruction in patients over 40 years. Arch Orthop Trauma Surg 127(9):835–843CrossRefGoogle Scholar
  36. 36.
    Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF (2001) Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 29:213–218CrossRefGoogle Scholar
  37. 37.
    Marx RG, Wilson SM, Swiontkowski MF (2015) Updating the assignment of levels of evidence. J Bone Jt Surg Am 97(1):1–2CrossRefGoogle Scholar
  38. 38.
    Miller MD, Sullivan RT (2001) Anterior cruciate ligament reconstruction in an 84-year-old man. Arthroscopy 17(1):70–72CrossRefGoogle Scholar
  39. 39.
    Miller SL, Gladstone JN (2002) Graft selection in anterior cruciate ligament reconstruction. Orthop Clin N Am 33:675–683CrossRefGoogle Scholar
  40. 40.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535CrossRefGoogle Scholar
  41. 41.
    Noyes FR, Barber SD (1991) The effect of an extra-articular procedure on allograft reconstructions for chronic ruptures of the anterior cruciate ligament. J Bone Jt Surg Am 73:882–892CrossRefGoogle Scholar
  42. 42.
    Noyes FR, Matthews DS, Mooar PA, Grood ES (1983) The symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Jt Surg Am 65:163–174CrossRefGoogle Scholar
  43. 43.
    Noyes FR, Mooar PA, Matthews DS, Butler DL (1983) The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Jt Surg Am 65:154–162CrossRefGoogle Scholar
  44. 44.
    Osti L, Papalia R, Del Buono A, Leonardi F, Denaro V, Maffulli N (2011) Surgery for ACL deficiency in patients over 50. Knee Surg Sports Traumatol Arthrosc 19:412–417CrossRefGoogle Scholar
  45. 45.
    Outerbridge RE (1961) The etiology of chondromalacia patellae. J Bone Jt Surg Br 43-B:752–757CrossRefGoogle Scholar
  46. 46.
    Seng K, Appleby D, Lubowitz JH (2008) Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients aged 40 years or older: an expected-value decision analysis. Arthroscopy 24:914–920CrossRefGoogle Scholar
  47. 47.
    Sommerlath K, Lysholm J, Gillquist J (1991) The long-term course after treatment of acute anterior cruciate ligament ruptures. A 9 to 16 year followup. Am J Sports Med 19:156–162CrossRefGoogle Scholar
  48. 48.
    Stein DA, Brown H, Bartolozzi AR (2006) Age and ACL reconstruction revisited. Orthopedics 29:533–536CrossRefGoogle Scholar
  49. 49.
    Strehl A, Eggli S (2007) The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma 62(5):1159–1162CrossRefGoogle Scholar
  50. 50.
    Struewer J, Ziring E, Oberkircher L, Schüttler KF, Efe T (2013) Isolated anterior cruciate ligament reconstruction in patients aged fifty years: comparison of hamstring graft versus bone-patellar tendon-bone graft. Int Orthop 37(5):809–817CrossRefGoogle Scholar
  51. 51.
    Tandogan RN, Taşer O, Kayaalp A, Taşkiran E, Pinar H, Alparslan B, Alturfan A (2004) Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 12(4):262–270CrossRefGoogle Scholar
  52. 52.
    Toanen C, Demey G, Ntagiopoulos PG, Ferrua P, Dejour D (2017) Is there any benefit in anterior cruciate ligament reconstruction in patients older than 60 years? Am J Sports Med 45(4):832–837CrossRefGoogle Scholar
  53. 53.
    Trojani C, Sane JC, Coste JS, Boileau P (2009) Four-strand hamstring tendon autograft for ACL reconstruction in patients aged 50 years or older. Orthop Traumatol Surg Res 95:22–27CrossRefGoogle Scholar
  54. 54.
    Vaishya R, Dhiman RS, Vaish A (2014) Anterior cruciate ligament reconstruction in a 75 years old man: a case report with review of literature. Chin J Traumatol 7(2):121–124Google Scholar
  55. 55.
    van der Hart CP, van den Bekerom MP, Patt TW (2008) The occurrence of osteoarthritis at a minimum of ten years after reconstruction of the anterior cruciate ligament. J Orthop Surg 3:24CrossRefGoogle Scholar
  56. 56.
    Ventura A, Legnani C, Terzaghi C, Borgo E (2012) Single- and double-bundle anterior cruciate ligament reconstruction in patients aged over 50 years. Arthroscopy 28(11):1702–1709CrossRefGoogle Scholar
  57. 57.
    Wolfson TS, Epstein DM, Day MS, Joshi BB, McGee A, Strauss EJ, Jazrawi LM (2014) Outcomes of anterior cruciate ligament reconstruction in patients older than 50 years of age. Bull Hosp Jt Dis 72(4):277–283Google Scholar
  58. 58.
    Yüksel HY, Erkan S, Uzun M (2006) The evaluation of intraarticular lesions accompanying ACL ruptures in military personnel who elected not to restrict their daily activities: the effect of age and time from injury. Knee Surg Sports Traumatol Arthrosc 14(11):1139–1147CrossRefGoogle Scholar
  59. 59.
    Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, Roberti di Sarsina T, Raggi F, Signorelli C, Urrizola F, Spinnato P, Rimondi E, Marcacci M (2017) Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up. Am J Sports Med 45(14):3233–3242CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.II Orthopaedic Clinic and Biomechanics LaboratoryIRCCS Istituto Ortopedico RizzoliBolognaItaly
  2. 2.Università Cattolica del Sacro Cuore-Fondazione PoliambulanzaBresciaItaly

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