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Systematic review
High rate of return to activity after ACL reconstruction in patients over 40 years of age: a systematic review
  1. Guido Wierer1,
  2. Elmar Herbst2,
  3. Christian Hoser3,
  4. Peter Gföller3,
  5. Christian Fink3
  1. 1 Department of Orthopaedics and Traumatology, Paracelsus Medical University of Salzburg, Salzburg, Austria
  2. 2 Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, TU Munich, Munich, Germany
  3. 3 Gelenkpunkt—Sports and Joint Surgery, Innsbruck, Austria
  1. Correspondence to Dr Christian Fink, Gelenkpunkt - Sports and Joint Surgery, Olympiastraße 396020, Innsbruck, Austria; c.fink{at}


Importance The incidence of anterior cruciate ligament (ACL) reconstructions in patients 40 years of age or older is increasing rapidly. However, return to activity has been inconsistently reported in clinical outcome studies.

Objective The objective of this systematic review was to analyse the level of activity in patients 40 years of age and older, following ACL injury treated either conservatively or surgically.

Evidence review The Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist was used for this systematic review. A MEDLINE search with predefined keywords was performed and articles were screened for eligibility. Inclusion criteria were (1) primary ACL injury, (2) >40 years of age, (3) follow-up of at least 12 months, (4) reported preoperative and postoperative Tegner activity level and (5) clinical outcome study. Articles were excluded if they were (1) on revision ACL surgery, (2) written in language other than English and (3) not original research article (eg, case reports, reviews or meta-analyses). Articles published between January 1990 and September 2016 were considered for this systematic review.

Findings 12 studies met the criteria and a total of 370 patients with a mean average age of 50 years (range, 40–71 years) were enrolled. All studies evaluated return to activity after ACL reconstruction, while no non-operative study reported postoperative Tegner activity levels. Eight studies employed autografts, one study used allografts and three studies used both autografts and allografts. After a weighted mean follow-up of 43 months (range, 12–173 months) the overall weighted mean Tegner score was 4.7 (range, 0–9) compared with the weighted mean, preoperative Tegner score of 4.5 (range, 1–9). No included studies reported on return to specific preinjury sports.

Conclusions and relevance ACL surgery in patients over 40 years of age does not result in a lower activity level when compared with the preoperative Tegner score. However, there is a lack of evidence regarding return to activity in middle-aged patients with an ACL injury and conservative treatment. Of note, return to particular sports and preinjury activity level following ACL reconstruction is rarely reported, especially when considering that the Tegner score has not been specifically designed to investigate return to sport.

Level of evidence Level III.

  • Knee
  • Orthopaedic Sports Medicine
  • Arthroscopy
  • Outcome Studies
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  • Contributors All authors were substantially involved in terms of contributions to the conception, design of the work, analysis and interpretation of data, drafting the work and revising it critically.

    All authors gave final approval of the version published.

  • Funding CF received support from Karl Storz and Medacta.

  • Competing interests CF is a consultant for Karl Storz (Tuttlingen, Germany) and Medacta (Frauenfeld, Switzerland).

  • Provenance and peer review Commissioned; externally peer reviewed.

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