Influence of Area Deprivation Index and Social Vulnerability Index on PROMIS Outcomes and MCID Achievement Following ACL Reconstruction

Abstract

Background:

Anterior cruciate ligament (ACL) reconstruction typically yields excellent outcomes, but recent attention has turned to how social determinants of health affect recovery. This study evaluates the association of the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) with scores on the Patient-Reported Outcomes Measurement Information System (PROMIS) and the likelihood of patients undergoing ACL reconstruction surgery achieving the minimal clinically important difference (MCID) postoperatively.

Hypothesis:

Greater social deprivation and vulnerability correlate with worse outcomes and lower odds of achieving the MCID after ACL reconstruction surgery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors retrospectively reviewed patients aged ≥13 years who underwent arthroscopic ACL reconstruction between 2015 and 2023 and completed preoperative and ≥6-month postoperative PROMIS surveys. ADI and SVI scores were based on geocoded addresses and zip codes, respectively, and divided into quartiles based on percentile rank (0-25th, 25th-50th, 50th-75th, and 75th-100th). The least deprived quartile was quartile 1 and the most was quartile 4. Statistical analyses included analysis of variance, chi-square test, and logistic regression to assess associations with PROMIS scores and MCID achievement.

Results:

A total of 576 patients met inclusion criteria (mean ± SD age, 27.9 ± 11.7 years). ADI and SVI quartiles were evenly distributed. Significant differences were found in race, body mass index, insurance status, and smoking history across quartiles. Patients in the highest ADI/SVI quartiles had higher body mass index, more Black representation, and greater use of public insurance. Preoperative PROMIS scores were mostly similar, except for higher pain interference in the most deprived quartile. Postoperative improvements were significant across all domains after surgery (P < .05). ADI quartile 4 had worse pain interference and depression scores as compared with the less deprived quartiles. MCID achievement was generally high, but logistic regression showed lower odds of achieving the MCID for pain interference in ADI quartile 4 after ACL reconstruction surgery (odds ratio, 0.55; P = .018).

Conclusion:

Despite socioeconomic disparities, ACL reconstruction surgery led to meaningful improvements in function and mental health outcomes. Although patients in higher ADI quartiles demonstrated worse postoperative pain interference and depression scores, overall MCID achievement was not associated with ADI or SVI, suggesting that ACL reconstruction benefits patients across socioeconomic backgrounds. These findings suggest that social determinants of health may influence the magnitude of postoperative outcomes, but patients of varying socioeconomic backgrounds benefit from ACL reconstruction surgery.

Keywords

ACL reconstruction socioeconomic status orthopaedic surgery patient-reported outcomes

Arthroscopic-assisted anterior cruciate ligament reconstruction (ACLR) remains the gold standard treatment for anterior cruciate ligament tears.^11,12 Although outcomes are generally excellent, a subset of patients continues to experience suboptimal recovery. Recent literature has emphasized the intricate connections between social-environmental factors and overall physical and mental well-being.³ Factors such as poverty, limited education, malnutrition, and exposure to violence, along with several others, collectively represent social deprivation.^22,25 These biopsychosocial factors are often important determinants of patient risk and may significantly influence postoperative orthopaedic outcomes, including those of ACLRs.

Patient-reported outcomes are a key tool for evaluating results after surgical treatment.^8,16 To provide a standardized framework for measuring patient-reported outcomes and health-related quality of life, the National Institutes of Health introduced the Patient-Reported Outcomes Measurement Information System (PROMIS) in 2004. PROMIS computer-adaptive tests are used to evaluate physical function and psychosocial health in patients with musculoskeletal injuries.^7,23 When incorporated into routine clinical practice, these assessments generate longitudinal data that help quantify the impact of injury and the effectiveness of treatment.

Health policies and interventions aimed at improving socioeconomic conditions may help reduce poor surgical outcomes linked to social deprivation.^26,28 However, demographic variables typically used for assessing socioeconomic status may be limited; thus, composite indices have been developed to better assess these influences. The Area Deprivation Index (ADI), which incorporates 17 socioeconomic variables, has been used to evaluate the impact of neighborhood-level deprivation on orthopaedic outcomes.¹⁴ Another validated metric to assess at-risk and vulnerable populations is the Social Vulnerability Index (SVI). This is composed of 15 US census tract variables grouped into 4 domains: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation.² Together, the ADI and SVI provide complementary frameworks for understanding how social environments may affect recovery and outcomes after ACLR.^10,24,30

There is limited literature that examines the influence of neighborhood-level factors such as the ADI or SVI on PROMIS outcomes after arthroscopic-assisted ACLR surgery. This study aims to evaluate how socioeconomic disadvantage and community vulnerability affect pre- and postoperative PROMIS scores and achievement of the minimal clinically important difference (MCID). We hypothesize that greater social deprivation, as measured by the ADI and SVI, will be associated with worse patient-reported outcomes and lower rates of achieving the MCID after ACLR surgery.

Methods

Cohort Summary

After approval by our institutional review board, we identified patients who underwent arthroscopic ACLR at our institution from January 1, 2015, to December 31, 2023, by searching for Current Procedural Terminology code 29888. Surgical technique and graft choice were surgeon dependent, and all patients completed a graduated postoperative physical therapy protocol based on patient-specific goals. All surgical procedures were performed at a large academic institution by fellowship-trained orthopaedic sports medicine surgeons. The inclusion criteria consisted of patients aged ≥13 years with a diagnosis of partial or complete anterior cruciate ligament tear, as determined by clinical evaluation and confirmed by preoperative magnetic resonance imaging, who underwent arthroscopic ACLR. Exclusion criteria consisted of patients who did not have an address on file, failed to complete a PROMIS questionnaire before their surgical intervention, or failed to complete a questionnaire at or beyond 6 months postoperatively.

Patient-Reported Outcomes

As part of a standardized process in our institution, all patients were asked to complete a PROMIS questionnaire via an electronic tablet (Apple Inc) or through their electronic medical record patient portal during their clinical visits. Metrics collected for data analysis included physical function (PF), pain interference (PI), and depression. Preoperative PROMIS scores within 6 months before surgical intervention and closest to the date of surgery were used in this study for preoperative assessment. Postoperative scores were collected at every clinical encounter thereafter. Postoperative PROMIS outcomes were assessed according to the highest recorded PROMIS score obtained between 6 months and 3 years after surgery, rather than at a fixed postoperative timepoint. PROMIS surveys were normalized⁵ to a mean of 50 with a standard deviation of 10. Moreover, we stratified preoperative PROMIS scores into previously validated subcategories: within normal limits, mild to moderate symptoms, and severe symptoms. Finally, the MCID was determined through distribution-based methods, calculated by one-half the standard deviation of the preoperative PROMIS scores.¹⁷

ADI and SVI

A chart review was conducted to obtain demographic data, including age, sex, body mass index (BMI), race, insurance, address, time from initial presentation to surgery, mechanism of injury, medical and surgical history, and no-show rates for postoperative clinic follow-up appointments. Areas with lower social deprivation and scores closer to 100 correspond to higher social deprivation. The score was normalized relative to the national mean score of 50. ADI scores were assigned to patients based on their 9-digit zip code at the time of surgery and the ADI reference provided by the Center for Health Disparities, University of Wisconsin,¹³ representing higher levels of social deprivation or vulnerability. This score incorporates 16 US Census variables into a single score.⁶ These scores were assigned to patients based on their 5-digit zip code at the time of surgery using SVI data from 2022 (Zip Code Tabulation Area; Centers for Disease Control and Prevention) and split into quartiles for a separate analysis. For the ADI and SVI quartiles, quartile 4 was considered the most deprived/vulnerable and quartile 1 the least. ADI and SVI values were divided into quartiles according to percentile rank (0-25th, 25th-50th, 50th-75th, and 75th-100th). Quartile 1 (0-25th percentile) was the least deprived and quartile 4 (75th-100th) the most.

Statistical Analysis

Statistical analysis was performed in RStudio Version 2025.05.0+496. Mean and standard deviation were reported for continuous variables and compared between groups by 1-way analysis of variance (ANOVA); categorical variables (eg, sex, race) were analyzed by chi-square test. A 1-way ANOVA power analysis determined a 45-patient requirement to achieve a power of 80% with a value of 0.05 for distinguishing PROMIS improvement scores greater than an MCID value of 4 (based on previous MCID calculations).²⁴ For significant findings found in the ANOVA tests for PROMIS scores, a Tukey post hoc analysis was performed to assess pairwise comparisons between quartiles. A multivariate logistic regression analysis was performed to determine if the highest and lowest ADI and SVI quartiles were predictive of MCID achievement. A separate logistical regression was performed to determine if any of the 4 themes of SVI (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation)² were predictive of MCID achievement. Statistical significance was set at P < .05.

Results

Demographics

A total of 804 patients were identified, of which 606 had preoperative and 6-month postoperative PROMIS data. Out of these, 576 patients had ADI and SVI values and met the inclusion criteria, with a mean ± SD age of 27.9 ± 11.7 years and mean follow-up of 13.0 ± 8.0 months. This group of patients was split into 2 groups based on age: the adult group (≥18 years) and the pediatric group (<18 years). For the adult group, the distribution by ADI and SVI quartiles yielded 116 patients for quartile 1, 115 for quartile 2, 115 for quartile 3, and 116 for quartile 4. Age was similar across ADI and SVI quartiles (all P > .05). In contrast, significant differences were observed by race, insurance status, BMI, smoking history, and no-show rate. The highest ADI and SVI quartiles had a greater proportion of Black patients (P < .001), higher BMI (28.4 ± 5.9 vs 26.1 ± 4.5; P = .009 for the ADI), and greater likelihood of insurance status utilization of either Medicare/Medicaid or workers’ compensation as compared with lower quartiles (P = .003 for the ADI). Patients in higher ADI quartiles were more likely to smoke (P < .001). The most deprived quartiles for the ADI and SVI also had a higher no-show rate (P < .001) when compared with the least deprived quartiles. Last, in the ADI quartile analysis, the least deprived quartile had a longer time to surgery than the other quartiles (114.7 ± 125.5 days; P = .003). Demographic information for the ADI and SVI quartile groups is given in Tables 1 and 2.

Table 1

Characteristics of Adult Patients by Area Deprivation Index Quartile Group^a

	Quartile, Mean ± SD or No. (%)				P Value
	1 (n = 116)	2 (n = 115)	3 (n = 115)	4 (n = 116)	P Value
Age at surgery, y	31.5 ± 12.5	30.8 ± 11.6	30.2 ± 9.7	31.2 ± 10.3	.836
Race					<.001
White	111 (95.7)	103 (89.6)	103 (89.6)	81 (69.8)
Black	2 (1.7)	6 (5.2)	8 (7.0)	25 (21.6)
Other	3 (2.6)	6 (5.2)	4 (3.5)	10 (8.6)
Smoker history					<.001
No	109 (94.0)	95 (82.6)	88 (76.5)	82 (70.7)
Yes	7 (6.0)	20 (17.4)	27 (23.5)	34 (29.3)
Body mass index	26.1 ± 4.5	27.4 ± 5.5	27.0 ± 4.8	28.4 ± 5.9	.009
Insurance					.003
Commercial	107 (92.2)	99 (86.1)	89 (77.4)	80 (69.0)
Medicaid/Medicare	5 (4.3)	12 (10.4)	17 (14.8)	25 (21.6)
Workers’ compensation	4 (3.4)	4 (3.5)	9 (7.8)	11 (9.5)
No-show rate	0.021 ± 0.056	0.022 ± 0.067	0.028 ± 0.065	0.068 ± 0.123	<.001
Time to Surgery, d	61.7 ± 85.5	70.5 ± 117.2	97.8 ± 135.3	114.7 ± 125.5	.003

Quartiles 1 and 4 represent the least and most deprived, respectively. Bold indicates statistical significance at P < .05.

Table 2

Characteristics of Adult Patients by Social Vulnerability Index Quartile Group^a

	Quartile, Mean ± SD or No. (%)				P Value
	1 (n = 116)	2 (n = 115)	3 (n = 115)	4 (n = 116)	P Value
Age at surgery, y	31.8 ± 12.7	31.5 ± 11.5	31.0 ± 10.9	29.5 ± 8.7	.397
Race					<.001
White	109 (94.0)	108 (93.9)	107 (93.0)	74 (63.8)
Black	1 (0.9)	3 (2.6)	5 (4.3)	32 (27.6)
Other	6 (5.2)	4 (3.5)	3 (2.6)	10 (8.6)
Smoker history					.085
No	102 (87.9)	94 (81.7)	91 (79.1)	87 (75.0)
Yes	14 (12.1)	21 (18.3)	24 (20.9)	29 (25.0)
Body mass index	26.3 ± 5.1	26.9 ± 5.0	27.5 ± 5.1	28.1 ± 5.7	.059
Insurance					.222
Commercial	99 (85.3)	95 (82.6)	96 (83.5)	85 (73.3)
Medicaid/Medicare	13 (11.2)	12 (10.4)	14 (12.2)	20 (12.2)
Workers’ compensation	4 (3.4)	8 (7.0)	5 (4.3)	11 (9.5)
No-show rate	0.027 ± 0.067	0.021 ± 0.058	0.031 ± 0.089	0.061 ± 0.109	.001
Time to surgery, d	83.7 ± 145.7	81.4 ± 104.8	76.9 ± 82.0	100.6 ± 130.4	.475

Quartiles 1 and 4 represent the least and most vulnerable, respectively. Bold indicates statistical significance at P < .05.

In the pediatric analysis (<18 years), patients were divided into 4 quartiles, with 29 in quartile 1, 28 in quartile 2, 28 in quartile 3, and 29 in quartile 4. There were no differences in age, race, smoking history, BMI, or insurance status among the groups. In the ADI analysis, quartile 3 had a longer time to surgery (91.0 ± 107.3 days; P = .003), while in the SVI analysis, quartiles 2 and 4 had higher utilization of Medicaid insurance (P = .019). Demographic information for pediatric ADI and SVI quartile analysis is given in Supplemental Tables 1 and 2.

Operative Factors

Among adults, there were differences among ADI quartiles but no significant differences among SVI quartiles. Meniscal procedure type varied significantly by ADI quartile (P = .009), with higher ADI quartiles demonstrating a greater proportion of meniscectomy and lower rates of meniscal repair. Graft choices also differed by ADI quartiles (P = .037), with patients in higher ADI quartiles less likely to receive bone–patellar tendon–bone autografts and more likely to receive hamstring, quadriceps, or alternative graft types. These factors are summarized in Tables 3 and 4.

Table 3

Operative Factors by Area Deprivation Index Quartiles^a

	Quartile, No. (%)				P Value
	1 (n = 116)	2 (n = 115)	3 (n = 115)	4 (n = 116)	P Value
Meniscal procedure					.009
Meniscectomy	42 (36.2)	42 (36.5)	48 (41.7)	53 (45.7)
Repair	24 (20.7)	36 (31.3)	16 (13.9)	15 (12.9)
None	50 (43.1)	37 (32.2)	51 (44.3)	48 (41.4)
Concomitant MCL/LCL repair	3 (2.6)	7 (6.1)	4 (3.5)	6 (5.2)	.55
Graft choices					.037
BTB	109 (94.0)	107 (93.0)	93 (80.9)	95 (81.9)
Hamstring	4 (3.4)	5 (4.3)	10 (8.7)	10 (8.6)
Quadriceps	3 (2.6)	1 (0.9)	6 (5.2)	5 (4.3)
Other	0 (0.0)	2 (1.7)	6 (5.2)	6 (5.2)
Graft					.47
Autograft	77 (66.4)	75 (65.2)	85 (73.9)	77 (66.4)
Allograft	39 (33.6)	40 (34.8)	30 (26.1)	39 (33.6)

Bold indicates statistical significance at P < .05. BTB, bone–patellar tendon–bone; LCL, lateral collateral ligament; MCL, medial collateral ligament.

Table 4

Operative Factors by Social Vulnerability Index Quartiles^a

	Quartile, No. (%)				P Value
	1 (n = 116)	2 (n = 115)	3 (n = 115)	4 (n = 116)	P Value
Meniscal procedure					.762
Meniscectomy	41 (35.3)	45 (39.1)	47 (40.9)	52 (44.8)
Repair	26 (22.4)	25 (21.7)	19 (16.5)	21 (18.1)
None	49 (42.2)	45 (39.1)	49 (42.6)	43 (37.1)
Concomitant MCL/LCL repair	4 (3.4)	4 (3.5)	4 (3.5)	8 (6.9)	.482
Graft choices					.276
BTB	107 (92.2)	97 (84.3)	104 (90.4)	96 (82.8)
Hamstring	4 (3.4)	7 (6.1)	7 (6.1)	11 (9.5)
Quadriceps	2 (1.7)	7 (6.1)	1 (0.9)	4 (3.4)
Other	3 (2.6)	4 (3.5)	3 (2.6)	5 (4.3)
Graft					.161
Autograft	76 (65.5)	74 (64.3)	76 (66.1)	87 (75.0)
Allograft	39 (33.6)	41 (35.7)	39 (33.9)	29 (25.0)

BTB, bone–patellar tendon–bone; LCL, lateral collateral ligament; MCL, medial collateral ligament.

Among pediatric patients, there was a difference only in concomitant meniscal procedures done (P = .035), with quartile 2 having higher rates of meniscectomies and quartile 1 having higher rates of meniscal repairs. Otherwise, no other differences were seen in the ADI or SVI quartile analysis. These factors are summarized in Supplemental Tables 3 and 4.

PROMIS Outcomes

Preoperative PROMIS PF, PI, and depression scores did not differ significantly across ADI or SVI quartiles. At final follow-up, all ADI and SVI quartiles demonstrated significant improvements in PROMIS PF, PI, and depression scores (all P < .001 within group). Between-group differences persisted for PROMIS PI and depression, where patients in the highest ADI quartile reported worse scores as compared with the other quartiles at latest follow-up (PI, 53.9 ± 9.6 [P < .001]; depression, 45.3 ± 10.6 [P = .006]). In the post hoc analysis, quartile 4 was significantly worse when compared with all quartiles in postoperative PI scores (all P < .05); quartile 4 also had worse postoperative depression scores when compared with quartile 2 (P = .027) and quartile 3 (P = .0077). No significant differences in latest PF scores were observed across ADI or SVI quartiles. For PROMIS outcomes by ADI and SVI quartiles as well as post hoc analysis results, see Tables 5 to 7. In the pediatric patient analysis, there were no differences seen in pre- and postoperative PROMIS outcomes, including improvement (P > .05), and all quartiles experienced significant improvement in PF, PI, and depression scores (P < .05) (Supplemental Tables 5 and 6).

Table 5

PROMIS Outcomes by Area Deprivation Index Quartile^a

	Quartile, Mean ± SD				P Value
	1 (n = 116)	2 (n = 115)	3 (n = 115)	4 (n = 116)	P Value
PF
Preoperative	39.4 ± 7.4	40.3 ± 10.1	40.8 ± 9.1	39.9 ± 8.0	.659
Postoperative	47.5 ± 9.6	47.6 ± 8.1	48.0 ± 10.8	45.5 ± 9.5	.184
Improvement	8.1 ± 12.2	7.3 ± 12.0	7.3 ± 12.1	5.6 ± 10.3	.445
P value	<.001	<.001	<.001	<.001
PI
Preoperative	58.6 ± 6.8	58.2 ± 7.7	57.9 ± 7.4	60.3 ± 7.1	.050
Postoperative	49.1 ± 9.2	50.1 ± 8.4	50.0 ± 9.0	53.9 ± 9.6	<.001
Improvement	9.5 ± 9.2	8.0 ± 10.4	7.9 ± 9.9	6.4 ± 8.4	.112
P value	<.001	<.001	<.001	<.001
Depression
Preoperative	46.0 ± 8.5	46.4 ± 8.5	45.6 ± 9.4	48.4 ± 10.0	.095
Postoperative	42.1 ± 9.2	41.7 ± 9.0	41.2 ± 9.6	45.3 ± 10.6	.006
Improvement	3.9 ± 9.1	4.6 ± 8.8	4.4 ± 8.1	3.1 ± 9.3	.561
P value	<.001	<.001	<.001	<.001

Bold indicates statistical significance at P < .05. PF, physical function; PI, pain interference; PROMIS, Patient-Reported Outcomes Measurement Information System.

Table 6

Post Hoc Analysis of Significant Findings in Area Deprivation Index Quartiles^a

PROMIS Domain	Quartile, P Value
PROMIS Domain	1 vs 2	1 vs 3	1 vs 4	2 vs 3	2 vs 4	3 vs 4
Postoperative PI	.83	.87	<.001	≥.99	.0085	.0062
Postoperative depression	.99	.91	.053	.98	.027	.0077

Bold indicates statistical significance at P < .05. PI, pain interference; PROMIS, Patient-Reported Outcomes Measurement Information System.

Table 7

PROMIS Outcomes by Social Vulnerability Index Quartile^a

	Quartile, Mean ± SD				P Value
	1 (n = 116)	2 (n = 115)	3 (n = 115)	4 (n = 116)	P Value
PF
Preoperative	39.2 ± 8.7	40.5 ± 9.3	40.0 ± 8.7	40.6 ± 8.2	.639
Postoperative	48.2 ± 8.6	46.9 ± 9.6	46.0 ± 8.6	47.5 ± 11.2	.364
Improvement	8.9 ± 12.0	6.4 ± 11.7	6.0 ± 11.2	7.0 ± 11.6	.227
P value	<.001	<.001	<.001	<.001
PI
Preoperative	58.8 ± 7.0	58.4 ± 7.4	59.2 ± 6.5	58.6 ± 8.3	.892
Postoperative	49.3 ± 8.6	50.9 ± 9.6	51.3 ± 9.2	51.7 ± 9.5	.195
Improvement	9.6 ± 9.1	7.5 ± 9.8	7.8 ± 8.7	6.9 ± 10.4	.173
P value	<.001	<.001	<.001	<.001
Depression
Preoperative	46.0 ± 8.7	45.5 ± 8.6	47.8 ± 9.2	46.9 ± 10.0	.229
Postoperative	41.6 ± 9.7	42.5 ± 9.5	43.0 ± 9.7	43.2 ± 10.0	.571
Improvement	4.5 ± 8.7	3.0 ± 9.3	4.8 ± 7.6	3.7 ± 9.5	.397
P value	<.001	<.001	<.001	<.001

Bold indicates statistical significance at P < .05. PF, physical function; PI, pain interference; PROMIS, Patient-Reported Outcomes Measurement Information System.

MCID Analysis

Quartiles 1 (least deprived) and 4 (most deprived) were labeled ADI_LOW/SVI_LOW and ADI_HIGH/SVI_HIGH, respectively. MCID achievement was high across quartiles for PF (60%-70%), PI (60%-75%), and depression (40%-45%). In the chi-square analysis, no differences were seen in MCID achievement among groups for the ADI and SVI. The number and percentage of patients achieving MCID in each quartile are shown in Tables 8 and 9. In the multivariate logistic regression analysis, patients in the highest ADI quartile (quartile 4, ADI_HIGH) had significantly lower odds of achieving the MCID for the PROMIS PI (OR, 0.50; P = .043) when compared with other quartiles. In the multivariate logistic regression for SVI quartiles, quartiles were not predictive of MCID achievement.

Table 8

Patients Achieving MCID by ADI^a

PROMIS	MCID Threshold	Patients Achieving MCID, No. (%)				P Value
PROMIS	MCID Threshold	ADI_LOW	Quartile 2	Quartile 3	ADI_HIGH	P Value
Physical function	4.26	97 (67.4)	87 (60.4)	87 (60.4)	89 (61.8)	.58
Pain interference	3.59	106 (73.6)	94 (65.3)	91 (63.2)	87 (60.4)	.10
Depression	4.59	63 (43.8)	64 (44.4)	64 (44.4)	65 (45.1)	.99

Bold indicates statistical significance at P < .05. ADI, Area Deprivation Index; ADI_HIGH, most socioeconomically disadvantaged; ADI_LOW, least socioeconomically disadvantaged; MCID, minimal clinically important difference; PROMIS, Patient-Reported Outcomes Measurement Information System.

Table 9

Patients Achieving MCID by SVI^a

PROMIS	MCID Threshold	Patients Achieving MCID, No. (%)				P Value
PROMIS	MCID Threshold	SVI_LOW	Quartile 2	Quartile 3	SVI_HIGH	P Value
Physical function	4.26	92 (63.9)	90 (62.5)	84 (58.3)	94 (65.3)	.65
Pain interference	3.59	99 (68.8)	97 (67.4)	92 (63.9)	90 (62.5)	.65
Depression	4.59	65 (45.1)	56 (38.9)	70 (48.6)	65 (45.1)	.41

Bold indicates statistical significance at P < .05. MCID, minimal clinically important difference; PROMIS, Patient-Reported Outcomes Measurement Information System; SVI, Social Deprivation Index; SVI_HIGH, most socioeconomically disadvantaged; SVI_LOW, least socioeconomically disadvantaged;.

Smoking history was a significant predictor for achievement of the PF MCID, with smokers having worse odds (OR, 0.35; P = .0045). A higher BMI predicted lower odds of MCID achievement for depression (OR, 0.92; P = .0017), while a smoking history predicted worse odds of MCID achievement for PF (OR, 0.30; P = .00062). No other significant differences were observed in the covariate multivariate regression analysis. ORs and P values are given in Tables 10 and 11 for ADI and SVI quartiles and the covariates.

Table 10

Multivariate Logistic Regression for MCID Achievement: ADI^a

Variable	Physical Function			Pain Interference			Depression
Variable	β	OR	P Value	β	OR	P Value	β	OR	P Value
ADI
ADI_LOW ^b	—	—	—	—	—	—	—	—	—
ADI_HIGH	−0.53	0.95	.85	−0.59	0.56	.043	0.24	1.3	.38
Body mass index	0.023	1.02	.40	0.019	1.02	.26	−0.040	0.96	.12
Age	−0.0054	0.99	.63	−0.013	0.99	.26	−0.017	0.98	.38
Smoking history
No^b	—	—	—	—	—	—	—	—	—
Yes	−1.05	0.35	.0045	0.49	1.64	.22	0.43	1.53	.24
Race
Black^b	—	—	—	—	—	—	—	—	—
Other	−0.69	0.50	.30	−1.03	0.36	.13	−0.61	0.55	.38
White	−0.070	0.93	.88	0.45	1.56	.32	0.23	1.25	.61
Insurance
Commercial^b	—	—	—	—	—	—	—	—	—
Medicaid	−0.0039	0.99	.99	−0.13	0.88	.77	−0.77	0.46	.087
Workers’ compensation	−0.33	0.72	.58	0.57	1.77	.38	−0.040	0.96	.95

β denotes standardized regression coefficient. Bold indicates statistical significance at P < .05. ADI, Area Deprivation Index; ADI_HIGH, most socioeconomically disadvantaged; ADI_LOW, least socioeconomically disadvantaged; MCID, minimal clinically important difference; OR, odds ratio.

Reference value.

Table 11

Multivariate Logistic Regression for MCID Achievement: SVI^a

Variable	Physical Function			Pain Interference			Depression
Variable	β	OR	P Value	β	OR	P Value	β	OR	P Value
SVI
SVI_LOW ^b	—	—	—	—	—	—	—	—	—
SVI_HIGH	0.17	1.18	.54	−0.30	0.74	.27	0.18	1.19	.50
Body mass index	0.020	1.02	.44	0.014	1.01	.58	−0.082	0.92	.0017
Age	0.011	1.01	.37	−0.0055	0.99	.64	0.0025	1.00	.82
Smoking history
No^b	—	—	—	—	—	—	—	—	—
Yes	−1.21	0.30	.00062	0.22	1.25	.54	0.15	1.16	.68
Race
Black^b	—	—	—	—	—	—	—	—	—
Other	−1.12	0.33	.066	−0.76	0.47	.19	−0.34	0.714	.58
White	−0.51	0.60	.24	−0.028	0.97	.95	0.084	1.09	.84
Insurance
Commercial^b	—	—	—	—	—	—	—	—	—
Medicaid	−0.29	0.75	.46	−0.28	0.76	.47	−0.17	0.84	.66
Workers’ compensation	−0.96	0.39	.11	−0.24	0.79	.68	−0.59	0.55	.35

β denotes standardized regression coefficient. Bold indicates statistical significance at P < .05. MCID, minimal clinically important difference; OR, odds ratio; SVI, Area Deprivation Index; SVI_HIGH, most socioeconomically disadvantaged; SVI_LOW, least socioeconomically disadvantaged.

Reference value.

SVI Themes: Logistic Regression Analysis

Logistic regression analysis demonstrated that none of the 4 themes of the SVI—socioeconomic status, household composition and disability, minority status and language, and housing type and transportation—were identified as significant predictors of achieving the MCID for the PROMIS PF, PI, or depression (P > .05).

Discussion

In this study, patients undergoing ACLR surgery experienced significant improvements in PROMIS PF, PI, and depression scores regardless of neighborhood deprivation or social vulnerability. Notably, patients in the most deprived ADI quartile reported worse pre- and postoperative PROMIS PI scores and worse PROMIS depression scores at latest follow-up as compared with those in the least deprived quartile. Across all ADI and SVI quartiles, most patients achieved the MCID, indicating clinically meaningful recovery. Patients in the most deprived ADI quartile had lower odds of achieving the MCID for the PROMIS PI than the other quartiles. These findings suggest that although ACLR reliably produces clinically significant improvements across socioeconomic strata in all PROMIS domains, the ADI may influence patients’ baseline level and perception of pain, as reported in prior literature.¹⁹

Prior orthopaedic research has highlighted the role of social determinants of health in shaping surgical outcomes, although no reliable standard metric exists to assess how socioeconomic status can predict postoperative outcomes.¹⁵ Prior literature has reported that public insurance, race and ethnicity, and lower education level are associated with delayed access to care, worse function, and greater injury burden after anterior cruciate ligament injury and reconstruction.^20,31 In addition, Patel et al¹⁸ demonstrated that pediatric patients with government-assisted insurance had significantly delayed access to care. Our findings suggest that higher ADI and SVI quartiles were associated with different baseline demographic differences as compared with lower quartiles, including a greater proportion of patients identifying as Black, as well as increases in BMI and no-show rate, a longer time to surgery, and more reliance on Medicare/Medicaid or workers’ compensation insurance.

Shaikh et al²⁴ recently evaluated a cohort of 306 patients who underwent arthroscopic rotator cuff repair and found that patients in the highest ADI quartile had significantly lower odds of achieving the MCID in all PROMIS domains as compared with those in the lowest ADI quartile. Similarly, Timoteo et al²⁷ analyzed a cohort 467 patients who underwent rotator cuff repair with a minimum 1-year follow-up and reported that patients with higher ADI scores had worse PROMIS PI and upper extremity scores as well as reduced range of motion. Our study did not demonstrate similar relationships between ADI and PROMIS after ACLR surgery, which may be in part due to our younger cohort of patients and the inherent differences in postoperative recovery of ACLR versus rotator cuff repair. However, Cruse et al⁹ analyzed 170 patients who underwent hip arthroscopy for femoral acetabular impingement with a mean follow-up of 2.52 years and reported that the ADI was not associated with odds of MCID achievement in any PROMIS domain; their high ADI cohort also had worse PROMIS PI scores at all recorded timepoints after hip arthroscopy. Our finding that higher ADI negatively influences PROMIS PI after ACLR appears to be consistent with prior sports medicine literature for other injuries. Regardless of the sports injury being studied, social deprivation seems to negatively influence pain management and perception.¹⁹

In addition to the ADI, the SVI has emerged as another tool to assess the impact of social determinants of health on patient outcomes. The SVI has mostly been utilized in total joint arthroplasty and spine orthopaedic literature, with fewer studies utilizing this metric in sports medicine.^19,28 Rahman et al²¹ analyzed 19,321 total knee arthroplasty cases and demonstrated that higher SVI quartiles were correlated with a greater number of medical comorbidities, a higher rate of discharge to a skilled nursing facility, and increased readmissions after total knee arthroplasty. This is similar to findings in the Baxter et al study,⁴ which revealed that patients with high levels of social vulnerability had an increased 90-day risk of returning to the emergency department after total joint arthroplasty.²¹ Yacoubian et al²⁹ showed that higher SVI scores led to prolonged hospitalizations and a higher incidence of pulmonary and cardiac complications after lumbar fusion surgery. Similarly, Yang et al³⁰ reported that patients undergoing elective 1- and 2-level posterior lumbar fusion had lower odds of achieving the MCID for the PROMIS PI and PF if the patients belonged to higher ADI and SVI quartiles. When compared with the ADI, the SVI provides greater granularity in its ability to isolate themes of disadvantage and vulnerability for a specific patient population. Other studies have shown that specific SVI themes (housing type, transportation, socioeconomic status, racial and ethnic minority status) correlate with negative postoperative outcomes.^1,30 The present study did not find a significant relationship between specific SVI themes of housing type, transportation, socioeconomic status, and racial and ethnic minority status and postoperative PROMIS scores after ACLR surgery. This suggests that the influence of social vulnerability in the SVI themes may be procedure specific but also that ACLR remains a surgical procedure that patients will consistently benefit from regardless of their social status. The social determinants of health, such as limited access to transportation or lower economic means, did not negatively influence ACLR outcomes in our study.

Limitations

There are limitations to the present study. This retrospective study of a prospectively collected database of patients was completed at a single academic medical center in a midsized city, which can limit the generalizability of our results. The study population was diverse in ADI and SVI quartiles. Next, patients were excluded if they did not have PROMIS surveys filled out beyond 6 months or did not have an address on file, which may introduce selection bias into the study analysis, as patients from higher deprivation backgrounds may be disproportionately affected. Additionally, our follow-up time is sufficient to capture short- to midterm outcomes after ACLR; however, this study may not reflect longer-term differences that can occur over time. We also did not control for surgeon graft choice, technique, or postoperative rehabilitation protocol. Last, a distribution-based approach, rather than an anchor-based approach, was used for MCID analysis, which may not capture the degree of improvement perceived as meaningful by patients.

Conclusion

Despite socioeconomic disparities, ACLR surgery led to meaningful improvements in function and mental health outcomes. Although patients in higher ADI quartiles demonstrated worse postoperative PI and depression scores, overall MCID achievement was not significantly affected by the ADI or SVI, suggesting that ACLR benefits patients across socioeconomic backgrounds. These findings suggest that while social determinants of health may affect the magnitude of postoperative outcomes, patients of varying socioeconomic backgrounds benefit from ACLR surgery.

Footnotes

Appendix

Supplemental Table 6

PROMIS Outcomes by Social VulnerabilityIndex Quartile in Pediatric Patients^a

	Quartile 1 (least deprived)(n = 29)	Quartile 2 (n = 28)	Quartile 3(n = 28)	Quartile 4 (most deprived)(n = 29)	P Value
PF
Preoperative	42.0 (11.0)	39.2 (6.5)	40.3 (5.6)	39.3 (6.5)	0.499
Postoperative	50.8 (10.8)	47.7 (4.7)	50.9 (9.6)	51.2 (8.7)	0.403
Improvement	8.8 (16.5)	8.5 (6.4)	10.6 (11.5)	11.9 (12.5)	0.690
p-value	0.00793	<0.001	<0.001	<0.001
PI
Preoperative	54.0 (7.3)	55.8 (4.8)	53.9 (4.9)	55.8 (5.3)	0.403
Postoperative	48.3 (5.8)	47.5 (4.8)	47.0 (5.1)	47.9 (5.7)	0.837
Improvement	5.8 (9.0)	8.2 (6.5)	6.9 (7.0)	7.9 (8.0)	0.616
p-value	0.0019	<0.001	<0.001	<0.001
Depression
Preoperative	46.7 (8.4)	46.6 (8.8)	47.8 (11.9)	49.1 (8.0)	0.707
Postoperative	43.0 (7.2)	42.1 (6.8)	43.5 (7.8)	41.7 (7.5)	0.779
Improvement	3.6 (6.4)	4.5 (9.0)	4.3 (12.0)	7.4 (8.8)	0.413
	0.00462	0.013	0.0675	<0.001

Bold indicates statistical significance at P < .05. PF, physical function; PI, pain interference; PROMIS, Patient-Reported Outcomes Measurement Information System.

Final revision submitted February 25, 2026; accepted March 3, 2026.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

This study was reviewed and deemed exempt by the institutional review board at the University of Rochester (STUDY00006201).

ORCID iD

Omkar N. Prabhavalkar

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