Sociodemographic Predictors of Postpresentation Delay to Pediatric ACL Reconstruction and Associated Intra-articular
Christopher D Hamad1, Shannon Wu1, Kole Joachim2
1Department of Orthopaedic Surgery, University of California, Los Angeles, California, USA.
Insights
Delayed anterior cruciate ligament reconstruction (ACLR) in children is linked to socioeconomic factors and increased injury risk. System-level delays in care significantly impact outcomes, highlighting disparities in pediatric orthopaedic treatment.
Area of Science:
- Pediatric Orthopaedics
- Sports Medicine
- Health Services Research
Background:
- Delayed anterior cruciate ligament reconstruction (ACLR) in pediatric patients correlates with worsening intra-articular damage.
- Existing research indicates disparities in pediatric orthopaedic care access.
- The influence of social determinants of health on surgical delays and functional recovery post-ACLR remains unclear.
Purpose of the Study:
- To investigate the association between sociodemographic factors, structural determinants, and delayed pediatric ACLR.
- To examine the relationship between these determinants and intra-articular injury severity.
- To assess the impact on postoperative functional outcomes.
Main Methods:
- A retrospective cohort study of 443 pediatric patients undergoing ACLR.
- Analysis of factors including race/ethnicity, insurance, and neighborhood deprivation (Childhood Opportunity Index).
- Outcomes measured: delay to surgery (>120 days), cartilage injury, meniscal tears, return to sport, hop test symmetry, and graft failure.
Main Results:
- 38.6% of patients experienced prolonged delay (>120 days) from presentation to surgery.
- Minority race/ethnicity, public insurance, and lower neighborhood opportunity were linked to delayed ACLR.
- Prolonged delay correlated with increased odds of high-grade cartilage injury.
- Public insurance was associated with greater hop test asymmetry postoperatively.
Conclusions:
- Disparities in pediatric ACLR are significantly influenced by system-level delays after initial presentation.
- These delays are associated with a progressively higher risk of cartilage damage.
- Addressing system-level barriers is crucial for equitable pediatric orthopaedic care.
Background:
Delayed anterior cruciate ligament reconstruction (ACLR) in pediatric patients is associated with progressive intra-articular injury. Although disparities in access to orthopaedic care have been reported, it remains unclear whether structural determinants of health influence postpresentation surgical delay and downstream functional recovery.
Purpose:
To determine whether sociodemographic and structural determinants are associated with prolonged postpresentation delay to pediatric ACLR and with intra-articular injury severity and postoperative functional outcomes.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
The records of 443 pediatric patients who underwent ACLR (2013-2025) at an urban academic referral center with a pediatric orthopaedic urgent care were reviewed. Exposures included race/ethnicity, insurance type, and neighborhood deprivation (Childhood Opportunity Index [COI]). Delay was defined as time from first orthopaedic presentation to surgery, with prolonged delay defined as >120 days. Outcomes included high-grade cartilage injury (Outerbridge grade 3 or 4), meniscal tear presence, failure to return to sport (≥365 days of follow-up), hop test symmetry, isometric strength symmetry, and graft failure. Multivariable regression models were adjusted for race/ethnicity, age, sex, insurance, and national COI.
Results:
The median time from injury to presentation was 5 days, while the median postpresentation time to surgery was 101 days; 38.6% experienced prolonged delay. In adjusted logistic regression, non-Hispanic Black, Hispanic, and other/unknown race/ethnicity; public insurance; and lower neighborhood opportunity were each independently associated with prolonged delay. Continuous postpresentation delay was independently associated with increased odds of high-grade cartilage injury (OR, 1.004 per day; 95% CI, 1.000-1.008; P = .048). Among patients with ≥365 days of follow-up (n = 228), public insurance was not independently associated with failure to return to sport (OR, 1.69; P = .398). Among those completing functional testing (n = 150), public insurance (β = +9.14; P = .046), higher national COI (β = +0.14 per unit; P = .045), and male sex (β = +9.59; P = .010) were each independently associated with greater hop test asymmetry, whereas no independent associations were observed for isometric strength symmetry or graft failure.
Conclusion:
Disparities in pediatric ACLR are driven primarily by postpresentation system-level delays and are associated with an incrementally greater risk of cartilage injury.