ACL and Graft Choices in the Aging Athlete

Anterior cruciate ligament reconstruction (ACLR) is a well-established procedure utilized in the setting of ACL injuries in patients under age 40. The management of ACL injuries in older populations is controversial as best practices are not clear with regard to candidacy for surgery, graft choice, fixation, and rehabilitation. In this review, we examined the body of literature surrounding controversies in management of ACL tears in older patients. Specific foci include nonoperative management, clinical course of osteoarthritis with ACLR, graft choice, graft fixation, complications, and alternative surgical options. The aging athlete with ACL-deficiency may benefit from non-operative management with rehabilitation if they are low demand, have minimal instability, and do not have moderate to severe or multi-compartmental osteoarthritis. Prehabilitation may also be beneficial to patients in the to determine if they can recover from injury to achieve an acceptable state of function before deciding upon surgery. ACLR is a viable option in older patient populations with minimal osteoarthritis and instability who have failed conservative management. Patients undergoing ACLR are likely to develop worsening radiographic OA. Despite this radiographic OA, majority of patients have improvements in PROMs and return to function. Given the risks of TKA after ACLR, shared clinical decision making should be prioritized with each patient regarding pursuit of ACLR versus conservative management.