Sociodemographic Predictors of Postpresentation Delay to Pediatric ACL Reconstruction and Associated Intra-articular Injury Severity.

Abstract

Background 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; P = .048). Among patients with ≥365 days of follow-up (n = 228), public insurance was not independently associated with failure to return to sport (OR, 1.69; P = .398). Among those completing functional testing (n = 150), public insurance (β = +9.14; P = .046), higher national COI (β = +0.14 per unit; P = .045), and male sex (β = +9.59; P = .010) were each independently associated with greater hop test asymmetry, whereas no independent associations were observed for isometric strength symmetry or graft failure. Conclusion Disparities in pediatric ACLR are driven primarily by postpresentation system-level delays and are associated with an incrementally greater risk of cartilage injury.