Socioeconomic Status Impacts Outcomes Following Anterior Cruciate Ligament Reconstruction Status

Abstract

Objectives: Delays in pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) are associated with increased prevalence of concomitant knee injuries and worse post-operative outcomes. However, few studies have described the factors that may contribute to these delays and adverse events. This study seeks to determine the impact socioeconomic status has on outcomes following ACLR. Method(s): Patients who underwent primary ACLR at a pediatric hospital between 2009 and 2015 were retrospectively reviewed. Variables included clinical outcomes and post-operative complications, as well as chronologic, demographic, and socioeconomic factors. Post-operative complication variables included graft failure, return to operating room, stiffness, and infection. Socioeconomic status was measured using health insurance type (commercial vs. government) and city block group level median household income levels derived from 2009-2015 U.S. Census Bureau data. Patients were excluded if they had multiligamentous knee injuries, prior ACLR, presented more than 365 days after injury, or had missing medical record data. Result(s): Overall, 127 patients (69 male, 58 female) were included in data analysis. The mean age at time of surgery was 15.0 +/- 2.3 years (range = 9 to 21 years). There were 68 patients in the commercial insurance group and 59 patients in the government insurance group. Patients in the commercial insurance group had an average household median income of $87,767 (SD = $38,325) compared to $51,366 (SD = $25,330) in the government insurance group, p = < 0.0001. Patients in the government insurance group demonstrated greater delays in time from injury to first appointment (p = 0.0003), injury to MRI (p = 0.021), injury to surgery (p = < 0.0001), first appointment to surgery (p = 0.0036), and injury to return to play, p = 0.044 (Table 1). At time of surgery, 81% (48/59) of patients in the government insurance group presented with concomitant meniscal injuries compared 65% (44/68) of patients in the commercial insurance group, p = 0.034 (Odds Ratio = 2.38). Post-operatively, 22% (13/58) of patients in the government insurance group experienced decreased knee range of motion ("stiffness") compared to 9% (6/68) in the commercial insurance group, p = 0.033 (Odds Ratio = 2.99). No significant differences were found between insurance types for rates of concomitant chondral injuries, graft failure, re-operation, or post-operative infection. Conclusion(s): Pediatric patients with government health insurance may experience delays in receiving definitive knee injury management and be at risk for complications and diminished outcomes. These delays are likely multifactorial, and may be attributed to decreased access to care, familial resources, and social support. Of note, our findings suggest a significant discrepancy in time to treatment as well as rates of concomitant knee injuries and post-operative complications between government and commercial insurance types.