Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

Abstract

Purpose of Review Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury. Recent Findings Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Summary Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Differentiation in Posterior Tibial Slope by Sex, Age, and Race: A Cadaveric Study Utilizing 3-Dimensional Computerized Tomography

“…Ethnicity as a risk factor for primary ACL injury has shown conflicting data with limited studies and no ability to draw any substantial conclusions. 8,16 When examining revision ACL surgery, data are also conflicting among potential effects of ethnicity and failure risk. 20,23 Large multicenter studies are needed to help understand the true potential effect of ethnicity on ACL injury.…”

Anterior cruciate ligament reconstruction and concomitant procedures in Finland between 2004 and 2018 based on national registers

“…Although the overall incidence of ACLR decreased after 2014, the incidence increased slightly between 2014 and 2018 for female patients. The risk of an ACL rupture has been reported as 2-8 times higher for women than for men (13,14). This may be due to anatomical differences as women generally have a higher quadriceps angle, a greater tibial slope, and a smaller intercondylar space (14).…”

“…The incidence of ACLR has been widely reported as varying between 30 and 74 per 10 5 person-years, but the numbers have been rising (6)(7)(8)(9)(10)(11)(12). Women are at a higher risk of both ACL rupture and ACLR; however, the total number appears to be higher among men, likely due to their greater participation in contact sports (11,13,14). The peak age for ACL rupture and ACLR among females is slightly earlier, between 11 and 20 years of age, whereas the incidence of ACLR peaks in males in the third decade of life (1,6).…”

Concerns About the Evaluation of Diversity in “Current Perceptions of Diversity Among Head Team Physicians and Head Athletic Trainers”: Response

“…We are subject to the implicit and explicit biases of the patients and athletes we take care of every day based on the color of our skin. We take issues of diversity, equity, and inclusion very seriously, not only from an academic standpoint 1 , 2 , 5 , 6 , 8 , 10 , 11 , 14 – 16 but also from a personal standpoint. Patients view us, however, through the color of our skin, making assumptions about us regardless of how we self-report/self-identify.…”