Pediatric ACL - Socioeconomic Factors That Contribute to a Delay in Presentation, and the Increase in Pathology that Correlates with Delayed Reconstruction

OBJECTIVES: The pediatric anterior cruciate ligament (ACL) injury is being recognized as an increasingly important area of research interest. This study further investigates and augments the recently published data describing a delay in pediatric ACL reconstruction and concomitant pathology, which is limited in numbers and scope. Furthermore, this study is the first to investigate the socioeconomic factors that correlate with a delay to surgery. METHODS: All subjects that underwent primary anterior cruciate ligament reconstruction surgery at a single tertiary pediatric hospital between July 2005 and August 2009 were included. Demographic, clinical and socioeconomic variables were retrospectively collected from all patients less than nineteen years of age at the time of surgery. The operative reports of all eligible subjects were reviewed. The treatment, location and severity of all chondral and meniscal injuries were recorded. The demographics and clinical characteristics of all subjects were summarized using descriptive statistics. Univariable logistic regression analyses were used to identify factors related to chondral and/or mensical injuries that required additional operative treatment. Meniscal and chondral injuries were analyzed with Kaplan-Meier time to event models to compare time to surgery based on the severity of injury. RESULTS: A total of 133 subjects were included. (Figure 1) The average age at injury was 15 years old (range, 7.83 to 18.56) The median time to surgery among all subjects was 2.29 months [interquartile range 1.31 to 4.30]. A total of 26 subjects (19.55%) underwent ACL surgery greater than five months post injury. A total of 59 chondral and 119 meniscal injuries were identified. The prevalence of chondral and/or meniscal injuries requiring operative treatment was 57.14% [95% CI: 48.73 to 65.55%]. A delay in surgery of greater than 5 months [p = 0.0001] and a return to activity prior to surgery [p = 0.0007] were significantly related to increased severity of concomitant pathology. The odds of a subject presenting with a chondral and/or meniscal injury that required additional operative treatment were 7.81 [95% CI: 2.21 to 27.58] times greater for a subject that underwent surgery greater than five months after their initial injury. Demographic factors that were not significantly related include: gender [p = 0.1601], laterality [p =0.3940], BMI percentage [p =0.2969], ethnicity [p = 0.5233], bracing prior to surgery [p = 0.6848] and the subjective report of knee instability prior to surgery [p = 0.3940]. Age at injury [p= 0.0004], household income based on median income associated with zip code [p=0.0150] and type of insurance (private vs. none/government assisted) [p = 0.0491] were significantly related to the timing of ACL surgery. After controlling for household income, the rate at which surgery occurred was 1.19 times [95% CI: 1.09 to 1.30] greater for every one year increase in age at the time of injury. After controlling for age at injury, the rate at which surgery occurred was 1.13 times [95% CI: 1.04 to 1.21] greater for every $10,000 increase in household income. CONCLUSION: This study shows that a delay in surgery greater than five months correlated with increased number and severity of chondral and/or meniscal injuries. This is the first study of its kind to show that age at injury, insurance type and household income were significant, independent predictors of the rate at which ACL surgeries occurred.