Graft Choice Does Not Influence Outcomes After Anterior Cruciate Ligament Reconstruction in Patients Aged 50 Years and Older: A Systematic Review and Meta-analysis

AbstractAim Anterior cruciate ligament reconstruction (ACLR) in patients over 50 years has traditionally been considered controversial due to concerns about graft failure, limited healing potential, and risk of degenerative progression. However, with increasing life expectancy and higher physical activity in older adults, the demand for ACLR in this population has grown, and the role of graft selection remains unclear. The aim of this study was to evaluate the influence of graft choice on clinical outcomes, graft survival, and re-rupture rates after ACLR in patients aged 50 years and older. It was hypothesized that (1) ACLR in this population would result in low re-rupture rates and satisfactory functional outcomes, and (2) no significant differences would be observed among different graft types. Evidence Review A systematic literature search of PubMed, Embase, and the Cochrane Library was performed from database inception to July 20, 2025, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included skeletally mature patients ≥50 years undergoing primary ACLR with different grafts (hamstring tendon HT, bone–patellar tendon–bone BPTB, quadriceps tendon QT, allograft, or synthetic). Outcomes of interest included graft re-rupture, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score. Random-effects meta-analyses were conducted to pool results, and subgroup analyses were performed by graft type. Findings Twenty-one studies including a total of 1,093 patients were analyzed. The overall weighted mean age at surgery was 55.88 years (95% Confidence Interval CI, 54.6–57.2). The majority of patients underwent HT reconstruction (n=744 - 68.1%), followed by QT (n=142 - 12.9%), BPTB (n=81 – 7.4%), allograft (n=110 – 10.1%), and synthetic grafts (LARS; n=16 – 1.5%). The overall re-rupture rate was 0.3% (95% CI, 0.0–1.4), with no statistically significant differences among graft types (p > 0.05), ranging from 0.0% for BPTB/QT to 1.8% for allograft/ligament augmentation and reconstruction system (LARS). The pooled mean Lysholm score was 91.2 (95% CI, 89.5–92.9), and the pooled mean IKDC score was 81.4 (95% CI, 77.9–84.9), showing no statistically significant graft-related differences. Odds ratio analysis confirmed no increased risk of re-rupture across graft types. Conclusions ACL reconstruction in patients aged 50 years and older is associated with excellent functional outcomes and very low re-rupture rates. No statistically significant differences were observed among graft types. These findings should be interpreted with caution due to limited data for some graft categories and heterogeneity of the available evidence. Graft selection should be individualized based on patient characteristics and surgeon expertise rather than chronological age. Study Registration PROSPERO Registry (CRD420251118537) Study Design Systematic review and meta-analysis; Level of evidence, III.