Unequal Regional Access to ACL Reconstruction in Romania: A Nationwide Epidemiologic Assessment (2017–2023)

Abstract

<i>Background and Objectives</i>: Access to anterior cruciate ligament reconstruction (ACLR) varies substantially across health systems, yet national-level data from Eastern Europe remain limited. This study provides the first nationwide, regionally stratified assessment of ACLR activity in Romania, examining geographic variation, socioeconomic and workforce determinants, and inequality. <i>Materials and Methods</i>: We conducted a retrospective cross-sectional analysis of all ACLRs reported in the national administrative hospital database (2017-2023), supplemented with demographic, GDP, and workforce statistics. Outomes included incidence per 100,000 population, private-sector share, and sex distribution. Regional differences were tested using Kruskal-Wallis and Dunn post hoc comparisons. Predictors of ACLR incidence and private-sector utilization were identified through multivariable Poisson and logistic models. Inequality metrics (Gini coefficients, P90/P10 ratios) and sensitivity analyses excluding Bucharest-Ilfov were also performed. <i>Results</i>: A total of 11, 080 ACLRs were recorded. Incidence varied markedly across regions, from a median of 40.0 per 100,000 in Bucharest-Ilfov to <1-3 per 100,000 in the South, South-East, and South-West (<i>p</i> < 0.001). Higher GDP per capita correlated with incidence (ρ = 0.36) and explained 45% of its variance. Private-sector involvement ranged from <5% in Bucharest-Ilfov and the South to 80-100% in the Centre, North-West, and South-East. In adjusted Poisson models, GDP, surgeon availability, and private-sector share were strong independent predictors of incidence (all <i>p</i> < 0.001). Private-sector access was primarily determined by the proportion of private orthopedic surgeons (OR 21.03). National inequality was extreme (Gini 0.842-0.752; P90/P10 > 10⁹), reflecting the concentration of procedures within a small number of counties. Results were consistent across sensitivity analyses. <i>Conclusions</i>: ACLR in Romania displays severe territorial inequities driven by socioeconomic development, workforce distribution, and uneven private-sector capacity. Targeted regional investment and coordinated workforce strategies are necessary to improve equitable access to surgical care.

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