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Operative management for anterior cruciate ligament injury in patients over 40 years old yields increased clinical outcome: A systematic review

      Abstract

      Purpose

      To evaluate outcomes of anterior cruciate ligament (ACL) rupture in patients ≥40 years treated non-operatively or with ACL reconstruction (ACLR).

      Methods

      A review of MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases from inception to June 1, 2021, was performed to identify randomized controlled trials, prospective or retrospective cohorts, case-controls, or case series that met the following criteria: English-language studies reporting at least one subjective and/or objective outcome measure in ACL rupture patients ≥40 years treated non-operatively or by ACLR. No limits were placed on graft type, time-to-surgery/follow-up, or concomitant procedures. Variability in patient-reported outcome scores, including subjective IKDC score, Lysholm score, Tegner activity score, and Knee Injury and Osteoarthritis Outcome Score, was assessed to evaluate the utility of applying previously established clinically meaningful thresholds to pooled outcome data.

      Results

      12,605 citations were identified using screening criteria. Sixty studies satisfied criteria following full-text review. As previous systematic reviews reported on earlier literature evaluating ACLR outcomes in patients ≥40 years, studies in this review were limited to include only those published in the last 10 years (40 studies). An additional 16 studies were excluded based on aims of the review not identified during initial screen. Although pre-operative to post-operative population-based improvements in Lysholm score, Tegner score, and IKDC score surpassed minimal clinically important differences (MCID) in at least 50% of studies the variability present in the pooled data may limit its application. No studies evaluated non-operative outcomes.

      Conclusions

      Evidence supports operative management in patients ≥40 years, as studies generally demonstrated pre-operative to post-operative improvements in clinical outcomes based on population-level changes. However, application of patient-level clinically relevant thresholds to pooled outcome data should be undertaken with caution as reporting of population-based outcome scores may not accurately reflect changes in individual patients.
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