Decreasing Incidence of Anterior Cruciate Ligament Tears and Increasing Utilization of Anterior Cruciate Ligament Reconstruction in the United States From 2010 to 2020

PURPOSE: To characterize the incidence of anterior cruciate ligament (ACL) tears, anterior cruciate ligament reconstruction (ACLR), and ACL nonoperative management from 2010 to 2020, stratifying by age, biological sex, and Charlson Comorbidity Index (CCI) score. METHODS: A retrospective cohort analysis was performed using the PearlDiver national insurance claims database. Cohorts of patients with ACL tears, ACLR, and nonoperative management were identified using International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes between 2010 and 2020. All patients with ACL tears were included. Patients were stratified by age, sex, and CCI. Compound annual growth rate (CAGR) analysis, t tests, and Cohen d tests were performed to analyze trends and demographic variables. RESULTS: Of 931,186 ACL tears during the study period, 196,589 were managed with ACLR and 734,597 were managed nonoperatively. The cumulative incidence of ACL tears was 75.19 tears per 100,000 person-years. There was a modest decrease in the incidence of ACL tears, ACLR, and nonoperative management from 2010 to 2020, with CAGRs of -3.43%, -3.55%, and -5.35%, respectively. The relative use of ACLR compared with nonoperative management increased from 2010 to 2020 (CAGR 2.15%). Patients aged 10 to 19 years accounted for the majority of ACL tears (22.31%) and ACLRs (30.97%). A slight majority of ACL tears (51.2%, P < .001), ACLR (50.7%, P < .001), and ACL tears with nonoperative management (51.6%, P < .001) occurred in female patients. The mean CCI of patients who underwent ACLR (mean = 0.32; standard deviation SD = 0.77) was significantly lower than that of the general ACL tear cohort (mean = 0.54; SD = 1.19; P = .005), and the nonoperative management cohort (mean = 0.64; SD 1.32; P = .0004). CONCLUSIONS: The overall decrease in ACL tears, ACLR, and nonoperative management found in this study is a reversal from trends reported in the literature from previous decades. LEVEL OF EVIDENCE: Level IV, retrospective case series.