Impact of Socioeconomic Status on Concomitant Injuries and Access to Care following Anterior Cruciate Ligament Rupture

OBJECTIVES: The primary aim of this study was to further define the impact of socioeconomic factors on the timing of ACL reconstruction. The secondary goal was to determine if these variables were associated with bucket handle tears of the meniscus at the time of surgery. METHODS: All patients undergoing ACL reconstruction at our institution from October 2015 through November 2018 were sent a survey to determine socioeconomic variables, income, primary language, and education level. A chart review was then performed for insurance status, dates of injury, first visit with orthopeadics, and surgery, intraoperative pathology, and length of follow-up. Univariate analysis was performed, as well as multivariate regression analysis to select independent predictors of outcome variables. A multiple linear regression model with stepwise backward elimination was used for continuous outcome variables. Multivariate logistic analysis was used for the presence of a bucket handle meniscal tear at the time of surgery. RESULTS: Univariate analysis was utilized to determine how insurance type, language spoken, education level, and family income affected: (1) the time from initial injury to clinic visit, (2) number of repeat injuries, and (3) frequency of bucket-handle meniscal tears (Table 1). Speaking a language other than English was associated with significantly longer times to seeing an orthopedic surgeon, more repeat injuries, and a higher likelihood of bucket-handle meniscal tears. Lower educational level correlated with longer wait times and more bucket-handle meniscal tears. Family income level less than $100,000 per year was also associated with a greater incidence of bucket-handle meniscal tears. Multivariate regression analysis was performed to further assess for independent predictors of outcomes. Patients on Medicaid saw an orthopaedic surgeon 39.4 weeks later than those on private insurance (P=0.012). English speakers saw an orthopaedic surgeon 55.68 weeks earlier than Spanish speakers (P=0.027), and patients with a college degree saw a surgeon 36 weeks earlier than patients without a college degree (P=0.023). Non-English speakers had an increased risk of having a bucket handle tear at the time of surgery (OR=4.62; 95CI%=1.677-21.33). Patients with an annual household income less than $100,000 were more likely to have a bucket handle tear (OR=7.37; 95CI%=1.20-53.39). English speakers had an average of 0.8 less instability episodes before surgery (P<0.001); income greater than $100,000/year had 0.25 less instability episodes before surgery (P=.040). CONCLUSIONS: Patients with government insurance and who were non-English-speaking experienced later access to care and later surgery after orthopaedic surgery evaluation. Non-English-speaking patients also experienced higher rates of repeat injury, instability, and bucket handle medial meniscus tears. Patients without a college degree also experienced later access to care. Patients with a household income less than $100,000 per year experienced higher rates of instability and bucket handle medial meniscus tears. Delayed access to orthopaedic care longer than 13 weeks was associated with higher rates of meniscus tears, and after 30 weeks bucket handle meniscus tears were significantly increased. These findings may inform the orthopaedic and broader medical communities of the impact of lower socioeconomic status on patients’ access to care and higher rates of concomitant injuries.