title: ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies.
abstract: BACKGROUND
  Treatment of the anterior cruciate ligament (ACL)-deficient knee in older patients remains a core debate.
  
  
  OBJECTIVE
  To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated with ACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluating ACL surgical outcomes: the ACL Methodology Score (AMS).
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusion criteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months after reconstruction. 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 stability measures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, and reported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specific at 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 the review. 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 that reported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcome scores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positively correlate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting that may not be taken into account by the classic level of evidence rating.
  
  
  CONCLUSIONS
  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-term efficacy and to better inform our patients with regard to expected outcomes.
authors.affiliation: Finger Lakes Bone and Joint Center and Sports Medicine, 875 Pre Emption Road, Geneva, NY 14456, USA. cbrown025@gmail.com
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Brown
authors.forename: Timothy R
authors.initials: TR
authors.lastname: McAdams
authors.forename: Alex H S
authors.initials: AH
authors.lastname: Harris
authors.forename: Nicola
authors.initials: N
authors.lastname: Maffulli
authors.forename: Marc R
authors.initials: MR
authors.lastname: Safran
mesh_terms: D000328:Adult; D059549:Anterior Cruciate Ligament Reconstruction; D006801:Humans; D007593:Joint Instability / Q000601:surgery; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications
keywords: ACL Methodology Score; anterior cruciate ligament reconstruction; clinical outcomes; older patients