Unequal Regional Access to ACL Reconstruction in Romania: A Nationwide Epidemiologic Assessment (2017-2023)

Background and Objectives: Access to anterior cruciate ligament reconstruction (ACLR) varies substantially across health systems, yet national-level data from Eastern Europe remain limited. This study provides the first nationwide, regionally stratified assessment of ACLR activity in Romania, examining geographic variation, socioeconomic and workforce determinants, and inequality. Materials and Methods: We conducted a retrospective cross-sectional analysis of all ACLRs reported in the national administrative hospital database (2017-2023), supplemented with demographic, GDP, and workforce statistics. Outomes included incidence per 100,000 population, private-sector share, and sex distribution. Regional differences were tested using Kruskal-Wallis and Dunn post hoc comparisons. Predictors of ACLR incidence and private-sector utilization were identified through multivariable Poisson and logistic models. Inequality metrics (Gini coefficients, P90/P10 ratios) and sensitivity analyses excluding Bucharest-Ilfov were also performed. Results: A total of 11, 080 ACLRs were recorded. Incidence varied markedly across regions, from a median of 40.0 per 100,000 in Bucharest-Ilfov to <1-3 per 100,000 in the South, South-East, and South-West (p < 0.001). Higher GDP per capita correlated with incidence (ρ = 0.36) and explained 45% of its variance. Private-sector involvement ranged from <5% in Bucharest-Ilfov and the South to 80-100% in the Centre, North-West, and South-East. In adjusted Poisson models, GDP, surgeon availability, and private-sector share were strong independent predictors of incidence (all p < 0.001). Private-sector access was primarily determined by the proportion of private orthopedic surgeons (OR 21.03). National inequality was extreme (Gini 0.842-0.752; P90/P10 > 10⁹), reflecting the concentration of procedures within a small number of counties. Results were consistent across sensitivity analyses. Conclusions: ACLR in Romania displays severe territorial inequities driven by socioeconomic development, workforce distribution, and uneven private-sector capacity. Targeted regional investment and coordinated workforce strategies are necessary to improve equitable access to surgical care.