Long Term Follow Up of Pediatric ACL Reconstruction in New York State: High Rates of Subsequent ACL Reconstruction

OBJECTIVES: The primary aim of this study was to determine the rate of subsequent ACL reconstruction and additional non-ACL knee surgery in children that had previously undergone ACL reconstruction in New York State. The secondary aim was to assess factors associated with additional ACL and non-ACL knee surgery. METHODS: Pediatric patients (age < 21) who underwent ACL reconstruction between 1997 and 2010 in New York State were identified using the Statewide Planning and Research Cooperative System (SPARCS) database. Patients were tracked for subsequent ACL reconstruction and additional non-ACL knee surgery. Each case had a minimum of one year follow up. A Cox proportional hazards model was used to assess time to subsequent surgery, adjusting for age, sex, race, comorbidity index, insurance type, surgeon and hospital ACL volume, and poverty prevalence. RESULTS: 23,912 primary pediatric ACL reconstructions were identified. 1955 patients (8.2%) underwent subsequent ACL reconstruction. 7.4% had one additional ACL reconstruction and 0.7% had two or more additional ACL reconstructions. 3341 patients (14%) had subsequent non-ACL knee surgery with 11.1% having one subsequent surgery and 2.9% having two or more additional knee surgeries. Risk factors for revision ACL surgery were younger age at time of primary ACL surgery (p<0.001), male gender (p<0.001), white race (p=0.003), private insurance (p<0.001), higher hospital ACL volume (>20 per year; p=0.002), and higher surgeon ACL volume (>10 per year; p=0.003). Risk factors for return to the OR for other non-ACL knee surgeries were younger age at the time of primary ACL reconstruction (p<0.001), white race (p<0.001), private insurance (p=0.016), and higher hospital ACL volume (>20 per year; p=0.007). CONCLUSION: This study aims to provide information on the rate of return to the operating room and rate of secondary ACL reconstruction in an adolescent population over the past 20 years in New York State. Males and younger patients had a higher rate of subsequent ACL reconstruction. Higher rates of ACL reconstruction in younger children may be due to greater at-risk activities in younger children, longer follow up, or inherently less reliable reconstructions given the non-anatomic reconstructions that are frequently required in the skeletally immature. The association between socioeconomic factors and increased subsequent knee surgeries likely represents a disparity in access to care for low socioeconomic status patients.