ACL Allograft Is Rarely Indicated But May Be Considered for Older, Low Physical Demand Patients.

Graft selection for ACL reconstruction remains controversial. In addition, an increasing number of ACL reconstructions (ACLR) are being performed in an aging population, creating a potential gap in evidence. The goal is to restore functional stability to the knee, minimize the likelihood of graft failure, and provide patient satisfaction achieved primarily by a patient's ability to return to unrestricted physical activity. Due to an unacceptably high risk of allograft failure in younger patients, the use of allograft for ACL reconstruction has substantially decreased over the last two decades. However, postoperative activity, rather than age in isolation, determines ACL allograft reconstruction success. While allograft is rarely indicated in patients who regularly participate in cutting and pivoting activities, regardless of age, a patient-specific approach should consider age, potential donor site morbidity, and postoperative activity goals. In our experience, allograft ACLR is not indicated in patients younger than 35 years of age (with very rare exceptions of sedentary individuals preferring to minimize donor site morbidity). Allograft is not recommended in any patient, regardless of age, who regularly participates in cutting and pivoting sports, particularly level I sports that include jumping, cutting, and hard pivoting. Finally, while surgeons should err toward using autograft when in doubt, allograft may be selectively indicated in older and low physical demand patients.