title: Delay to Reconstruction of the Adolescent Anterior Cruciate Ligament: The Socioeconomic Impact on Treatment.
abstract: BACKGROUND
  A delay in pediatric and adolescent anterior cruciate ligament (ACL) reconstruction is associated with an increase in the number of concomitant meniscal and chondral injuries. Factors that contribute to this delay have not been well described.
  
  
  OBJECTIVE
  Socioeconomic and demographic factors are related to ACL surgery timing.
  
  
  METHODS
  Cohort study; Level of evidence, 3.
  
  
  METHODS
  All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. Variables included concomitant knee injuries (cartilage or meniscus injuries requiring additional operative treatment) and chronologic, demographic, and socioeconomic factors. Multivariable Cox proportional-hazards analyses were used to identify factors related to ACL surgery timing.
  
  
  RESULTS
  The mean age of the 272 subjects was 15.2 ± 2.12 years. Time to surgery was significantly different among subjects who required multiple additional surgical procedures at time of ACL reconstruction (median, 3.3 months) compared with subjects with 1 (median, 2.0 months) or no additional injuries (median, 1.6 months). Subjects underwent ACL reconstruction significantly sooner if they were older at the time of injury (hazard ratio [HR], 1.2 per 1 year; 95% CI, 1.1-1.2; P < .0001) or were covered by a commercial insurance plan (HR, 2.0; 95% CI, 1.6-2.6; P < .0001). Median time to ACL surgery was 1.5 months (95% CI, 1.3-1.7) for subjects with commercial insurance plans compared with 3.0 months (95% CI, 2.3-3.3) for subjects with noncommercial insurance coverage.
  
  
  CONCLUSIONS
  The risk of delayed ACL surgery was significantly higher among pediatric and adolescent subjects who were less affluent, who were covered by a noncommercial insurance plan, and who were younger. This study also confirms previous studies that have reported an association between a delay in ACL surgery and the presence of additional knee injuries requiring operative treatment, accentuating the importance of timely care.
  
  
  CONCLUSIONS
  Access to care is a current area of research interest and health policy formation. Information in this arena drives 2 important aspects of health: most immediately, care provided to patients, and over a broader scope, the policy that directs health care. The orthopaedic surgeon should be aware of the association between socioeconomic and demographic factors and ACL surgery timing to optimize outcomes.
authors.affiliation: Department of Orthopaedic Surgery, University of Colorado Denver, Aurora, Colorado, USA.
authors.forename: Justin T
authors.initials: JT
authors.lastname: Newman
authors.affiliation: Musculoskeletal Research Center, Children's Hospital Colorado, Aurora, Colorado, USA.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Carry
authors.affiliation: Musculoskeletal Research Center, Children's Hospital Colorado, Aurora, Colorado, USA.
authors.forename: Elizabeth B
authors.initials: EB
authors.lastname: Terhune
authors.affiliation: Department of Orthopaedic Surgery, University of Colorado Denver, Aurora, Colorado, USA.
authors.forename: Murray
authors.initials: M
authors.lastname: Spruiell
authors.affiliation: Department of Orthopaedic Surgery, University of Colorado Denver, Aurora, Colorado, USA.
authors.forename: Austin
authors.initials: A
authors.lastname: Heare
authors.affiliation: Department of Orthopaedic Surgery, University of Colorado Denver, Aurora, Colorado, USA.
authors.forename: Meredith
authors.initials: M
authors.lastname: Mayo
authors.affiliation: Department of Orthopaedic Surgery, University of Colorado Denver, Aurora, Colorado, USA.
authors.forename: Armando F
authors.initials: AF
authors.lastname: Vidal
keywords: ACL reconstruction; delay in surgery; socioeconomic factors