O3228: The Child Opportunity Index and Outcomes Following ACL Reconstruction: How Do Social Determinants of Health Influence Surgical Care and Functional Outcomes?

Background: Research at the intersection between social determinants of health (SDOHs) and orthopaedics remains an area of active exploration, with recent literature demonstrating significant disparities through a wide array of orthopaedic outcomes in patients with different SDOHs. This study uses a validated composite measure of SDOHs mapped to census tracts (the Child Opportunity Index, or COI) to explore disparities in anterior cruciate ligament (ACL) reconstruction functional outcomes and surgery.

Methods: Following institutional review board approval, a query was conducted for all primary ACL reconstruction patients ≤18 years of age seen at our institution from 2009-2019. Demographic, surgical, and functional outcomes data was extracted. Strength deficits were evaluated, and COI quintile scores were obtained. One-way ANOVA, Chi-Square, and Fisher Exacts tests were performed to compare variables of interest between the upper two quintiles (HIGH) versus the lower two quintiles (LOW).

Results: Of 1,027 patients, 226 (22.01%) were in the LOW group, while 801 (77.99%) were in the HIGH group. There was a significant difference in race, age, BMI, and obesity (p < 0.01 for all variables), with older, black, and obese patients making up a higher proportion of the LOW cohort compared to the HIGH. Public insurance utilization data was available for 726 patients; 43.48% (n=75) of the LOW group had public insurance, while only 8.51% (n=47) of the HIGH group had public insurance. There was a significantly greater delay in time from injury to reconstruction between the LOW and HIGH groups (98.15 ± 102.65 days versus 71.79 ± 101.88 days, respectively, p< 0.01) (Table 1).

There was a significant difference in knee extension-flexion range of motion at 1- and 3-month follow-up (p=0.03 and 0.02, respectively), but no difference in ROM at 6-month follow-up (p=0.27). The LOW group attended a significant amount of fewer physical therapy visits than the HIGH group (24.82 ± 10.55 vs 37.81 ± 18.07, p< 0.01). There were significant differences on isokinetic dynamometer quadriceps strength testing at 3-months, 6-months, and 9-months at 180˚ (p=0.03, < 0.01, and 0.01, respectively) and at 6-months and 9-months (p < 0.01 and 0.01, respectively) at 300˚ (Table 2).

Conclusion: In this study, we found significant disparities in strength, range of motion, and surgical care between post-ACL reconstruction patients in the lower two quintiles and upper two quintiles of the Child Opportunity Index. There is a demonstrated need for continued attention to SDOHs in order to identify areas of intervention outside of the traditional patient-physician relationship.