Anterior cruciate ligament (ACL) injuries are one of the most common knee injuries sustained during sports, and over 250,000 ACL reconstructions are performed per year. While surgery is often indicated for younger patients, surgical indications in the adult patient are determined based on patient preference, level of functional disability and their desire to return to cutting and pivoting sports. The purpose of this study was to report on the clinical and social predictors of patients undergoing surgical vs nonsurgical treatment for ACL injury, and to compare differences between males and females.
Patient who were evaluated for ACL injury at our institution were identified and those who subsequently underwent surgery were compared to those who did not. Clinical factors collected included sex, age, BMI, Charlson Comorbidity Index (CCI) and smoking status, while social factors collected included race, English-speaking, educational level, insurance type, and marital status. Functional disability was determined by preoperative PROMs scores based on KOOS-PS and PROMIS PF. Descriptive statistics were used to report on the surgical and nonsurgical cohorts with subgroup analysis by sex. Odds ratios were calculated to determine predictors of surgery, with a subgroup analysis of patients over 30 years of age. Multivariate analysis was performed to determine the relationships between clinical and social factors and KOOS-PS and PROMIS PF scores.
3656 patients were included in this study. 1734 females (mean age 34.7y) and 1922 males (mean age 32.8y) were identified with a diagnosis of ACL tear, of whom 53.8% of females and 53.4% of males went on to surgery (p=0.84). KOOS PS and PROMIS PS did not show a relationship with future surgical intervention, although they were lower in females, those with increased BMI, and lower educational levels. In all patients, CCI (OR 0.867, p<0.001) and current smoking status (OR 0.70, p=0.06) were associated with lower rates of surgical treatment, as were Medicare status (OR 0.54, p=0.04) and having subsidized insurance (OR 0.47, p<0.001). In patients over the age of 30, females were more likely than males to undergo surgical treatment (OR 1.36, p=0.04), while CCI (OR 0.89, p=0.07), current smoking status (OR 0.43, p=0.06) and subsidized insurance (OR 0.60, p=0.06) negatively affected rates of surgery in this group.
In our cohort, comorbidity index, smoking status and insurance status were found to negatively influence surgical treatment of ACL injury. In patients aged >30y, females were more likely to undergo surgical treatment than males. Additionally, our study identified lower PROMs scores associated with ACL injury in females, those with increased BMI, and lower educational levels. Further studies are needed to understand the social and clinical factors that can influence variability in functional disability and decisions to proceed with surgical treatment in patients with ACL injuries.