Existing studies have suggested that patients with lower socioeconomic status experience a longer time from injury to surgery for pediatric anterior cruciate ligament (ACL) reconstructions. Evaluating a multifaceted set of potential factors related to injury-to-surgery timing may reveal additional variables for clinicians to consider.
The purpose of this study was to examine which demographic characteristics, injury/surgery characteristics, and pre-operative patient-reported-outcomes predicted time from ACL injury to surgery. We hypothesized a greater proportion of patients with public insurance would have an injury-to-surgery time =45 days post injury compared to those with private insurance.
We completed a retrospective chart review from January 15, 2019 to May 18, 2021. ACL surgery was completed by two surgeons at one pediatric sports medicine center. Patients were categorized as those who underwent surgery = 45 days post-injury vs. those who underwent surgery =45 days post-surgery (median split). Patients completed an array of pre-operative assessments that included demographics, injury/surgical characteristics, and patient-reported outcomes (grit, mobility [PROMIS], and physical activity [ HSS Pedi-FABS]). We compared each potential predictor variable between groups. Those which demonstrated potential significant differences (defined as p<0.05) between groups were then entered as predictors into a multivariable linear regression model, where the outcome variable was time to surgery (as a continuous variable).
A higher proportion of those who underwent surgery =45 days post-injury were on public insurance (48% vs. 14%; p<0.001), were skeletally mature (81% vs. 61%; p=0.03),and underwent transphyseal surgery (71% vs. 53%; p=0.02) compared to those who underwent surgery within 45 days of injury, while a significantly lower proportion were competitive athletes (79% vs. 93%; p=0.03). Those who underwent surgery =45 days post-injury reported lower physical activity (Pedi-FABS 22.9±7.1 vs. 25.3±4.7; p=0.03) and higher mobility scores (38.4±9.4 vs. 34.1±6.5; p=0.005) compared to those who underwent surgery within 45 days of injury (Table 3, Figure 1). Within the multivariable model, both public insurance status (ß=41.7; 95% CI=17.4-65.9; p=0.001) and higher PROMIS mobility scores (ß=2.0; 95% CI=0.7-3.4; p=0.003) were associated with a significantly longer time from injury to surgery.
Our data indicate that after screening for a variety of different intrinsic and extrinsic factors, the two most prominent predictors of delays in time from ACL injury to surgery are public insurance status and better self-reported post-injury mobility. Surgeons may consider the reasons for delays for ACL surgery may have to do with self-reported functional status in addition to insurance status.