Sociodemographic Predictors of Postpresentation Delay to Pediatric ACL Reconstruction and Associated Intra-articular Injury Severity
Christopher D. Hamad, Shannon Wu, Kole Joachim, Esther Chung, Timothy Liu, Mauricio Silva, Richard Bowen, Soroush BaghdadiBackground:
Delayed anterior cruciate ligament reconstruction (ACLR) in pediatric patients is associated with progressive intra-articular injury. Although disparities in access to orthopaedic care have been reported, it remains unclear whether structural determinants of health influence postpresentation surgical delay and downstream functional recovery.
Purpose:
To determine whether sociodemographic and structural determinants are associated with prolonged postpresentation delay to pediatric ACLR and with intra-articular injury severity and postoperative functional outcomes.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
The records of 443 pediatric patients who underwent ACLR (2013-2025) at an urban academic referral center with a pediatric orthopaedic urgent care were reviewed. Exposures included race/ethnicity, insurance type, and neighborhood deprivation (Childhood Opportunity Index [COI]). Delay was defined as time from first orthopaedic presentation to surgery, with prolonged delay defined as >120 days. Outcomes included high-grade cartilage injury (Outerbridge grade 3 or 4), meniscal tear presence, failure to return to sport (≥365 days of follow-up), hop test symmetry, isometric strength symmetry, and graft failure. Multivariable regression models were adjusted for race/ethnicity, age, sex, insurance, and national COI.
Results:
The median time from injury to presentation was 5 days, while the median postpresentation time to surgery was 101 days; 38.6% experienced prolonged delay. In adjusted logistic regression, non-Hispanic Black, Hispanic, and other/unknown race/ethnicity; public insurance; and lower neighborhood opportunity were each independently associated with prolonged delay. Continuous postpresentation delay was independently associated with increased odds of high-grade cartilage injury (OR, 1.004 per day; 95% CI, 1.000-1.008;
Conclusion:
Disparities in pediatric ACLR are driven primarily by postpresentation system-level delays and are associated with an incrementally greater risk of cartilage injury.