A new study presented during the 2026 AAOS Annual Meeting in New Orleans early this month found that age alone should not be a restriction to surgical intervention for anterior cruciate ligament (ACL) injuries in appropriately selected patients.

As older individuals maintain active lifestyles, surgical interventions for ACL injuries are increasing. However, limited data exist on outcomes and failure rates in patients older than 50 undergoing ACL reconstruction (ACLR).

“We undertook this research in response to a clear demographic shift,” said the study’s authors. “More patients in their 50s, 60s, and beyond are remaining athletically active and are participating in sports that require cutting and pivoting types of movements — during which an intact ACL is critically important. Despite this, there remains hesitation in some circles about offering ACL reconstruction purely based on age. We thought that it was important to generate data that informs that conversation and helps surgeons counsel patients using outcomes rather than assumptions. Our hope is that this study supports thoughtful, individualized decision making and reassures both surgeons and patients that age alone should not be viewed as a contraindication to ACLR when quality of life and activity level are at stake.”

A retrospective review was conducted on patients older than 50 years old who underwent primary ACLR at a single institution between 2011 and 2023, with a minimum follow-up of two years. The researchers collected demographics, injury details, and surgical variables via chart review. Then they gathered (via phone survey) patient-reported outcomes (PROs), including anchor questions, Tegner Activity Scale (TAS), International Knee Documentation Committee (IKDC) score, and ACL Return to Sport Index (ACL-RSI). Patient acceptable symptom state (PASS) thresholds were determined using anchor-based receiver operating curve (ROC) analyses. Regression analyses assessed predictors of graft failure and PROs.

The study included 155 patients with a mean age of 56.1 ± 4.8 years; mean BMI of 26.1 ± 4.4; and 42.6% male, with a mean follow-up of 6.2 ± 2.9 years.

The most common graft types used were the bone–patellar tendon–bone (56.8%) and tibialis anterior allografts (12.9%). Of the patients, 82.5% had meniscal lesions: 60.6% managed with meniscectomy, 11.6% with repair, and 10.3% with both. The mean IKDC and ACL-RSI scores were 78.1 ± 13.9 and 56.6 ± 28.7, respectively. Patients’ TAS scores improved by 1.8 ± 2.3, and 63.8% of patients returned to their prior activity level. Graft failure occurred in 7.1% of patients, meniscal repair failure in 20.6% with meniscal root repair, and 2.6% proceeded to total knee arthroplasty.

Most patients rated their outcome as very good or excellent (83.9%); 91.5% reported their surgery met expectations; and 88.2% achieved an acceptable symptom state. The PASS threshold for IKDC was 66.2 (sensitivity: 88.2%; specificity: 88.9%). No significant predictors of outcome or failure were identified.

This study has several important limitations. First, according to the authors, “given the fact that it is a retrospective, single-center study, there is the potential for recall bias, which may limit the generalizability of the findings to broader populations and practice settings. Second, although our mean follow-up of just over six years provides meaningful mid-term data, longer-term outcomes are still needed to better understand durability, late graft survival, and progression to osteoarthritis or arthroplasty in this age group. Additionally, there is the possibility of selection bias as well, because the patients over 50 who were offered surgery were likely healthier, more active, and more motivated than the general population of individuals with ACL injuries in this age range. As such, our outcomes may best reflect appropriately selected, physiologically young patients rather than all individuals over age 50.”

The study’s senior author, Kirk A. Campbell, MD, FAAOS, commented: “It’s critically important to treat patients with ACL injuries based on their physiologic age, overall health, and functional goals rather than just relying on their chronological age. Our study clearly shows that in well selected patients over 50, ACL reconstruction can reliably restore knee stability, facilitate a return to meaningful activity, and deliver high satisfaction with low failure rates.”

Dr. Cambell’s coauthors on “ACL Reconstruction Over 50: High Satisfaction and Low Failure Rates” are Benjamin W. Padon, Emily A. Berzolla, Nicole Oberlag, and Alexander Golant, MD, FAAOS.

Theresa Witham is managing editor of AAOS Now.