Abstract
Background:
The increasing prevalence of marijuana usage has prompted research into the potential medical effects. Yet, there is a paucity of literature surrounding the impact on perioperative outcomes after orthopaedic surgeries among pediatric and adolescent populations.
Purpose:
To compare perioperative outcomes between pediatric and adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) and attested to marijuana use compared with those who did not attest to marijuana use, and whether sociodemographic factors were associated with positive self-reported marijuana attestation.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
This study evaluated perioperative outcomes in patients aged ≤20 years who underwent primary ACLR between January 2011 and December 2017. Patients were divided based on self-reported positive marijuana attestation on forms collected during the surgical intake process. Propensity score matching (3:1 ratio) was used to select matched controls based on age, sex, surgeon, and graft type. Perioperative outcomes and complications were compared between those who self-reported positive marijuana attestation and those who did not report marijuana use.
Results:
Of 4358 eligible patients, 42 self-reported positive marijuana use on attestation forms (0.96% [95% CI, 0.70-1.30]), with 126 patients in the matched cohort. The mean follow-up was 25.26 months (SD, 27.17 [range, 1-125 months). Patients who self-reported positive marijuana use (n = 42) experienced significantly higher rates of overnight admission for pain (90% vs 29%; P = .004), greater estimated blood loss (10 vs 3 mL; P < .001), lower maximum heart rate in the postanesthesia care unit (74.3 ± 12.8 vs 80.2 ± 14.8 beats per min; P = .04). Time to return to sports (RTS) was 76 days longer in the self-reported positive marijuana attestation cohort (95% CI, 1.1-1.5; P < .001). Higher odds of positive self-reported marijuana attestation were observed in patients living in lower Child Opportunity Index neighborhoods, those identifying as races other than White, and those of Hispanic ethnicity.
Conclusion:
Positive self-reported marijuana attestation in pediatric and adolescent patients undergoing ACLR was associated with higher rates of overnight admission for pain and prolonged time to RTS, suggesting potential implications for perioperative management and recovery.
Keywords: adolescent sports medicine, anterior cruciate ligament reconstruction, marijuana influencing surgery, marijuana usage
Marijuana use among the pediatric and adolescent population in the United States has increased in recent years, with 22% of people aged ≥12 years reporting marijuana use within the past year. 18 The annual Monitoring the Future report by the National Institute on Drug Abuse estimated that 29% of those in the 12th grade used marijuana within the last year, 18% in the 10th grade, and 8% in the 8th grade. 15 While the increased prevalence may be attributed to the legalization of medicinal and recreational marijuana use in 37 and 21 states, respectively, there has been a concurrent increase in the potency of marijuana. 9 Furthermore, Bello et al, 4 reported that adolescents from lower socioeconomic status had an increased risk of marijuana and nicotine use, suggesting a higher prevalence of use within vulnerable communities.
Most literature surrounding marijuana use within orthopaedic surgery has related to its use for pain management. However, further research is required to determine the effect on perioperative outcomes, particularly within the pediatric and adolescent population. 11 Basic science research suggests tetrahydrocannabinol (THC) may inhibit bone metabolism, 17 and its heavy use is associated with decreased bone mineral density. 23 Bhashyam et al 6 demonstrated that self-reported marijuana use during injury recovery was associated with increased opioid use and duration, contrasting with patients’ perceptions that marijuana reduced opioid requirements. 5 Moon et al 16 conducted a retrospective cohort study utilizing the National Inpatient Sample database, which suggested that marijuana use was associated with decreased inpatient mortality and increased risk of medical complications. Within the field of adult elective spine surgery, studies have demonstrated conflicting evidence. Some studies have suggested that marijuana use is associated with increased perioperative thromboembolism, respiratory and neurologic complications, increased length of stay, increased postoperative opioid use, and higher reoperation rates,6,8,12,19 while other studies show no difference in revisions or postoperative opioid prescriptions.20,21 Within pediatric orthopedics, Heath et al 10 found marijuana use associated with increased time to radiographic union after surgically treated extremity fractures when compared with nonmarijuana users. 10 This study highlighted the need to investigate the effect of marijuana on other pediatric orthopaedic conditions.
Given the progressive increase of anterior cruciate ligament (ACL) injuries among pediatric and adolescent patients 3 and the continued exposure to marijuana through legalization, it is necessary to examine the relationship with outcomes after anterior cruciate ligament reconstruction (ACLR). The primary aim of this study was to compare perioperative outcomes between pediatric and adolescent patients who underwent ACLR who attested to marijuana use compared with those who did not attest to marijuana use. The secondary aims were to determine whether sociodemographic factors were associated with positive self-reported marijuana attestation and whether the rate of self-reported positive marijuana attestation changed after the legalization of medicinal and recreational marijuana in 2012 and 2016, respectively.
Methods
Study Design
This is a single-center, retrospective matched-cohort study.
Eligibility Criteria
Following institutional review board approval, consecutive patients aged ≤20 years who underwent a primary ACLR at the study’s institution between January 2011 and December 2017 were screened according to the eligibility criteria. The inclusion criteria included the diagnosis of a complete ACL tear and undergoing primary ACLR at the study’s institution with no additional ligamentous or meniscal injury. Patients were excluded if there was a history of previous ipsilateral ACL surgery, previous contralateral ACL or meniscal injury, deformity correction surgery, congenital limb deformities, or concern of a non-idiopathic ACL tear (defined as tears resulting from underlying conditions or pathologies rather than trauma or sports injury). The eligible patients were identified through a standardized surgical intake questionnaire, which specifically asked about marijuana use, administered during the preoperative ACLR surgical intake assessment process. Patients who self-reported marijuana use formed the study group.
Matching Process
After identification of the study cohort, propensity score matching was used to select matched controls. Matching without replacement was implemented on age at time of surgery, sex, primary surgeon, and graft type. To determine the optimal ratio of controls to the cohort who positively attested to self-reported marijuana use, matching was conducted at a 1 to 1, 2 to 1, and 3 to 1 matching ratio. For each ratio, the standardized mean differences in covariates between those who positively attested to marijuana use and those who did not were calculated to assess covariate balance. A standardized mean difference threshold of <0.1 was considered to indicate adequate balance. The ratio of 3 to 1 was selected as it yielded the smallest average standardized mean difference across all covariates.
Data Collection
Data were retrospectively recorded and tabulated from the electronic medical record. Descriptive data were collected, including age at time of surgery, sex, race, ethnicity, and Child Opportunity Index (COI) calculated based on the patients’ addresses recorded at the time of surgery. The COI serves to assess the relative educational, health, and socioeconomic opportunity of a child based on their address and was recorded as a raw score ranging from 0, being the lowest opportunity, to 100, being the highest opportunity. 1
The number of days before surgery since the last marijuana use was recorded for those patients who reported a positive attestation, and the previous use was classified into before January 2012, when medicinal marijuana was legalized in the institution’s state, 13 between January 2012 and January 2016, and after January 2016, when recreational marijuana was legalized. 14 Intraoperative details, defined from surgical incision to closure, were recorded, including duration of surgery and anesthesia, estimated blood loss (measured in mL), intraoperative complications, and intraoperative narcotics (measured in morphine milligram equivalents [MME]). Perioperative outcomes, defined from the end of surgery until discharge from the hospital, were recorded, including maximum heart rate, maximum systolic blood pressure (measured in mmHg), level of pain in the postoperative recovery unit (recorded on a patient-reported scale of 0 being no pain, and 10 being severe pain), and length of stay. Reasons for overnight admission were categorized as pain or postoperative observation, defined as standard monitoring without pain-related concerns. Discharge analgesia (measured in MME) and antiemetics (measured in mg) were recorded. Analgesic prescriptions were at the discretion of the treating physicians. Postoperative outcomes were recorded after discharge—including 90-day readmission rate, time to return to sport (RTS), complications, retear rate, and further surgeries on the ipsilateral knee. RTS was determined based on documented clearance for athletic participation by the treating surgeon. Complications included tissue healing (documented delay or impaired remodeling of the implanted tendon tissue), wound issues (superficial), infection (requiring antibiotics or surgical intervention), arthrofibrosis (documented decreased range of motion requiring intervention), retear (confirmed ACL graft failure), ipsilateral non-ACL injury (new injury to operative knee not involving ACL), and contralateral non-ACL injury (new injury to opposite knee).
Statistical Analysis
Descriptive data of the patient cohorts were summarized using descriptive statistics. Continuous variables were reported as means and standard deviations, or medians and ranges. Categorical variables were reported as frequencies and percentages. Perioperative outcomes between the cohort who self-reported positive marijuana attestation and the matched cohort who did not self-report positive marijuana attestation were compared using Wilcoxon rank sum tests, the Fisher exact tests, and Pearson chi-square tests as appropriate. To further evaluate associations, univariate negative binomial regression for count outcomes, logistic regression for binary outcomes, and simple linear regression for continuous outcomes were performed with the appropriate method based on the distribution of each outcome variable.
To estimate the overall prevalence of self-reported positive marijuana attestation in the whole study cohort, the proportion of patients who self-reported positive marijuana attestation was calculated, and the corresponding 95% CI was determined using the Clopper-Pearson method. To evaluate the association between marijuana attestation and neighborhood COI 2.0, the raw COI scores were categorized into 5 groups: very low (0 to <20), low (20 to <40), moderate (40 to <60), high (60 to <80), and very high (>80). An unadjusted logistic regression model was conducted to examine the relationship between marijuana attestation and the neighborhood COI. A multivariable logistic regression model was performed, adjusting for race and ethnicity to account for potential confounding. All statistical analyses were conducted using R Version 4.1.2 (R Foundation for Statistical Computing), and all statistical tests were assessed at the 5% significance level.
Results
Of the 4358 patients who were screened according to the eligibility criteria, 42 self-identified on the surgical intake patient attestation form to have used marijuana. Utilizing the matching process, 126 patients were identified who did not attest to having used marijuana. The mean follow-up for study participants was 25.26 months (SD, 27.17; range, 1-125 months). The estimated prevalence of self-reported positive marijuana attestation in this cohort was 0.96% (95% CI, 0.70%-1.30%). Among the self-reported positive marijuana attestation cohort, the median number of days between last marijuana use and the day of surgery was 30 days (range, 1-791 days). Eleven patients (26%) reported using marijuana before January 2012, when medicinal marijuana was legalized in the institution’s state; 8 patients (19%) reported marijuana use between January 2012 and January 2016; and 23 patients (55%) reported marijuana use after January 2016, when recreational marijuana was legalized.
A post-hoc power analysis revealed varying levels of statistical power: >90% power to detect differences in RTS, 84% power for heart rate differences, 41% power for complications, and 22% power for length of stay.
The descriptive data for the total patient cohort (n = 168), positive self-reported marijuana attestation (n = 42), and matched cohort (n = 126) are demonstrated in Table 1. There was a higher percentage of patients who identified as races other than White (67% vs 26%) and a higher proportion of Hispanic patients (33% vs 6.9%) within the cohort who attested to marijuana use compared with those who did not attest to marijuana. Patients who attested to marijuana use lived in lower COI score (60 ± 33) areas than patients who did not report marijuana use (75 ± 26).
Table 1.
Patient Characteristics a
| Characteristic | Total Cohort (N = 168) | SR MJ Users (n = 42) |
Non-SR MJ Users (n = 126) |
|---|---|---|---|
| Age at surgery, years | 18.1 (1.8) | 18.1 (1.9) | 18.1 (1.8) |
| Sex | |||
| Male | 126 (75) | 32 (76) | 94 (75) |
| Female | 42 (25) | 10 (24) | 32 (25) |
| Race, n = 151 | |||
| White | 97 (64) | 12 (33) | 85 (74) |
| Races other than White | 54 (36) | 24 (67) | 30 (26) |
| Ethnicity, n = 152 | |||
| Hispanic | 20 (13) | 12 (33) | 8 (6.9) |
| Non-Hispanic | 132 (87) | 24 (67) | 108 (93) |
| COI | 70.9 (28.2) | 59.8 (32.5) | 74.6 (25.6) |
| COI Category | |||
| Very low | 16 (10) | 7 (17) | 9 (7) |
| Low | 14 (8) | 7 (17) | 7 (6) |
| Moderate | 13 (8) | 5 (12) | 8 (6) |
| High | 39 (23) | 6 (14) | 33 (26) |
| Very high | 86 (51) | 17 (40) | 69 (55) |
Data are presented as mean (SD) or n (%). COI, Child Opportunity Index; Non-SR MJ users: patients who did not self-report marijuana use; SR MJ users: self-reporting marijuana users.
The intraoperative, perioperative, and postoperative outcomes are demonstrated in Table 2. Intraoperatively, patients with positive marijuana attestation had greater median estimated blood loss (10 vs 3 mL; P < .001) compared with those who did not report marijuana use. In the postanesthetic care unit, patients with positive marijuana attestation had a lower maximum heart rate (74.3 ± 12.8 beats per min) compared with those who did not report marijuana use (80.2 ± 14.8 beats per min) (P = .04). Among those admitted overnight, patients who self-reported marijuana use had a higher rate of pain as the primary reason for admission (90% vs 29%; P = .004). Postoperatively, patients who reported positive marijuana attestation had a longer time to RTS (median 286 vs 210 days; P < .001). Regression analyses demonstrated that marijuana attestation was associated with time to RTS, with those patients with positive marijuana attestation taking 76 days longer to RTS than the no marijuana attestation group (95% CI, 1.1-1.5; P < .001).
Table 2.
Intraoperative, Perioperative, and Postoperative Outcomes for the Total Cohort a
| Measures | Total Cohort (N = 168) |
SR MJ Users (n = 42) |
Non-SR MJ Users (n = 126) | P b |
|---|---|---|---|---|
| Intraoperative: from surgical incision to closure | ||||
| Type of graft | >.9 | |||
| Patellar tendon | 24 (14) | 6 (14) | 18 (14) | |
| Hamstring | 124 (74) | 31 (74) | 93 (74) | |
| Quadriceps tendon | 8 (5) | 2 (5) | 6 (5) | |
| Allograft | 8 (5) | 2 (5) | 6 (5) | |
| ITB | 4 (2) | 1 (2) | 3 (2) | |
| Anesthetic time, min | 141 (75, 294) | 142 (76-240) | 139 (75- 294) | .632 |
| Surgical time in minutes, n = 158 | 88 (54- 225) | 103 (59-215) | 98 (54- 225) | .576 |
| Estimated blood loss, mL, n = 142 | 5 (0.300) | 10 (0-300) | 3 (0-40) | <.001 |
| Total intraoperative analgesia in morphine milligram equivalents, n = 164 | 17 (1.6-52) | 16 (1.6-52) | 17 (4-42.3) | .224 |
| Perioperative: from the end of surgery until discharge | ||||
| Length of stay | .115 | |||
| 0 days | 141 (84) | 32 (76) | 109 (87) | |
| ≥1 day | 27 (16) | 10 (24) | 17 (13) | |
| Reasons for overnight admissions, n = 27 | .004 | |||
| Pain | 14 (52) | 9 (90) | 5 (29) | |
| Postoperative observation | 13 (48) | 1 (10) | 12 (71) | |
| Maximum heart rate in beats per minute, n = 163 | 78.6 (14.5) | 74.3 (12.8) | 80.2 (14.8) | .016 |
| Maximum systolic blood pressure, mmHg, n =163 | 125.2 (17.8) | 124.2 (19.8) | 125.5 (17.1) | .696 |
| Maximum pain score on NRS, n = 164 | 3.2 (1.8) | 3.6 (2.1) | 3 (1.7) | .104 |
| Postoperative: from hospital discharge to the final follow-up | ||||
| Discharge analgesia, mmHg, n = 143 | 30 (0-60) | 30 (0-60) | 30 (0-60) | .657 |
| Time to RTS, days, n = 154 | 222 (60-540) | 286 (150- 417) | 210 (60-540) | <.001 |
| Occurrence of perioperative complications | 56 (33) | 11 (26) | 45 (36) | .257 |
| Readmission within 90 days | 5 (3) | 3 (7) | 2 (2) | .100 |
| Further surgery required on the ipsilateral knee, n = 40 | 1 (1-3) | 1 (1-3) | 1 (1-2) | .590 |
Data are presented as mean (SD), median (range), or n (%). ITB, iliotibial band; Non-SR MJ users: patients who did not self-report marijuana use; NRS, numerical rating scale; RTS, return to sports; SR MJ users: self-reporting marijuana users.
The Wilcoxon rank sum test, the Fisher exact test, and the Pearson chi-square test.
The complication rate within the positive marijuana attestation cohort was 26.2% (11/42 patients) and 35.7% (45/126 patients) in the no attestation to marijuana group. Among recorded complications, ipsilateral ACL retear rates were 36% in the marijuana attestation group compared with 29% in the no attestation to marijuana group, while contralateral ACL injury rates were 0% versus 22%, respectively. However, no statistically significant difference was observed in the complications between the groups (Table 3).
Table 3.
Complication Types for the Total Cohort a
| Complication | Total (N = 56) | SR MJ Users (n = 11) |
Non-SR MJ Users (n = 45) | P b |
|---|---|---|---|---|
| Retear | 17 (30) | 4 (36) | 13 (29) | .719 |
| Arthrofibrosis before RTS | 13 (23) | 4 (36) | 9 (20) | .259 |
| Ipsilateral non-ACL injury | 13 (23) | 1 (9) | 12 (27) | .426 |
| Contralateral non-ACL injury | 10 (18) | 0 (0) | 10 (22) | .183 |
| Wound issues | 5 (9) | 2 (18) | 3 (7) | .251 |
| Lack of tissue healing | 4 (7) | 3 (27) | 1 (2) | .021 |
| Removal of hardware | 4 (7) | 1 (9) | 3 (7) | >.9 |
| Other complications | 4 (7) | 0 (0) | 4 (9) | .575 |
| Infection | 3 (5) | 2 (18) | 1 (2) | .095 |
| Postop fever | 2 (4) | 1 (9) | 1 (2) | .357 |
| Lack of graft incorporation | 1 (2) | 0 (0) | 1 (2) | >.9 |
ACL, anterior cruciate ligament; RTS, return to sports; Non-SR MJ users: patients who did not self-report marijuana use; Postop, postoperative; SR MJ users: self-reporting marijuana users.
The Fisher exact test.
Univariate models demonstrated that living in very low COI neighborhoods was associated with 3.2 times higher odds of positive attestation to marijuana use (95% CI, 1-9.7; P = .04) and living in low COI neighborhoods was associated with 4.1 times higher odds of positive attestation to marijuana use (95% CI, 1.2-13.4; P = .02) when compared with patients in very high COI neighborhoods (Table 4). However, after adjusting for race and ethnicity in multivariable models, the COI was no longer significantly associated with self-reported positive marijuana attestation. Instead, the adjusted models demonstrated that being a racial minority was associated with 3.4 times higher odds of self-reported positive marijuana attestation (95% CI, 1.2-10.2; P = .03) and being Hispanic was associated with 4.2 times higher odds of positive marijuana attestation (95% CI, 1.2-16.9; P = .03).
Table 4.
Associations Between Child Opportunity Index, Race, and Ethnicity With Self-reported Positive Marijuana Attestation in a Matched Cohort a
| Univariate Model | Multivariable Model | |||
|---|---|---|---|---|
| OR (95% CI) | P | OR (95% CI) | P | |
| COI | ||||
| Very low vs very high | 3.2 (1-9.7) | .04 | 1.3 (0.3-5.2) | .71 |
| Low vs very high | 4.1 (1.2-13.4) | .02 | 1.2 (0.2-5.1) | .86 |
| Moderate vs very high | 2.5 (0.7-8.6) | .14 | 0.9 (0.2-4.2) | .87 |
| High vs very high | 0.7 (0.2-2) | .56 | 0.3 (0.1-1) | .07 |
| Races other than White vs White | - | - | 3.4 (1.2-10.2) | .03 |
| Hispanic vs non-Hispanic | - | - | 4.2 (1.2-16.9) | .03 |
Bold P values indicate statistical significance. COI, Child Opportunity Index; OR, odds ratio.
Discussion
As the first study to investigate the effect of self-reported positive marijuana attestation on perioperative outcomes in pediatric and adolescent patients undergoing ACLR, the key findings indicated that those who self-report marijuana use were more likely to have pain as the primary reason if overnight admission was required, and experienced a prolonged time to RTS by 76 days. Furthermore, the study highlighted the effect of sociodemographic factors—including COI, race, and ethnicity on the likelihood of self-reported positive marijuana attestation within the ACLR cohort.
Among patients requiring overnight admission, those who self-reported marijuana use had a higher rate of pain as the primary reason for admission (90% vs 29%; P = .004). These findings parallel those previously reported by Chiu et al, 6 demonstrating increased length of stay after elective spine surgery, and Bhashyam et al, 5 reporting that marijuana users required increased amounts of opioid prescription after musculoskeletal injury. Previous studies investigating the relationship between marijuana use and postoperative pain after spinal surgery have hypothesized the effect of marijuana on pain perception or tolerance in chronic marijuana use.8,19,21 This study is the first to report increased rates of overnight admission for pain within the pediatric population or those undergoing ACLR. However, as the prescribing patterns reflect discharge protocols and the number of postoperative analgesic doses is unknown, patient pain medication requirements could not be fully assessed in the study. Further evaluation is likely needed to fully elucidate the true relationship between marijuana use and the need for postoperative opioids.
A key finding of this study was the prolonged time to RTS in self-reporting marijuana users (286 vs 210 days; P < .001). Those who self-attested to marijuana use had higher rates of tissue healing complications (27% vs 2%; P = .021), which may be related to THC’s effect on mesenchymal stem cells—including inducing apoptosis and limiting differentiation. 10 In addition, THC stimulation of cannabinoid receptors 1 and 2 (CB1 and CB2) may alter the inflammatory response necessary for proper tissue healing. 7 This finding corroborates the findings by Heath et al, 10 who reported delayed radiographic union after surgical fixation in 21 pediatric patients with a positive toxicology screen for marijuana. Previous studies have proposed the pathomechanism of marijuana affecting bone health to be related to the stimulation of CB receptors influencing bone cell function, bone turnover, and bone mass.1,22 Other factors may contribute to this delay, including differential access to rehabilitation services between socioeconomic groups, varying levels of support for RTS, and differences in follow-up care. Further studies are required to elucidate the clinical consequences of reduced bone and tissue health in postoperative recovery, such as postoperative wound healing and infection risk.
The estimated prevalence of self-reported positive marijuana attestation was 0.96% (95% CI, 10.70-1.30). This is lower than the previously reported rate of 6.2% by Heath et al, 10 who identified patients who self-reported at the time of presentation or recorded a positive urine toxicology screen for marijuana—the latter of which we did not evaluate or record, potentially contributing to our lower observed rate. Tavabi et al 24 estimated 2% marijuana use documentation calculated through a natural language processing pipeline, which screened 370,087 patients over 21 years reviewed by the Orthopedic and Sports Medicine department. This discrepancy may be attributed to the nature of self-attestation, which is susceptible to underreporting due to social desirability bias or fear of potential consequences pertinent within the pediatric and adolescent population. This study identified an association between self-reported positive marijuana attestation and several sociodemographic factors—including those living in very low (odds ratio [OR], 3.2 [95% CI, 1.0-9.7]; P = .04) and low COI (OR, 4.1 [95% CI, 1.2-13.4]; P = .02) neighborhoods, those who identify as races other than White (OR, 3.4 [95% CI, 1.2-10.2]; P = .03), and Hispanic ethnicity (OR, 4.2 [95% CI, 1.2-16.9]; P = .03). Tavabi et al 24 supported higher odds of marijuana use in patients from Hispanic ethnicity (adjusted OR, 2.131; P < .001) and higher social vulnerability index (adjusted OR, 1.001; P < .001). These findings may assist in guiding further quantitative and qualitative research to explore disparities surrounding marijuana use in the pediatric and adolescent population, which may help in culturally appropriate preoperative screening, patient education on reducing perioperative marijuana use, and access to follow-up.
This study has several limitations. While adequately powered for outcomes such as RTS, the study was underpowered to detect small-to-moderate effects in other measures, such as complications. This should be considered when interpreting results where no significant differences were found. Furthermore, there is a high risk for statistical fragility with respect to the difference in tissue healing. The reliance on accurate self-reporting of marijuana use, particularly before legalization, may have led to an underestimation of true prevalence and potential recall or reporting bias. Limited data on consumption patterns precluded dose-response analysis, and the range of marijuana exposure before surgery may introduce temporal bias. The study did not account for concomitant substance abuse—including alcohol and tobacco. Previous literature has suggested an adverse synergistic effect between marijuana and tobacco 2 and alcohol use. 10 Analgesic requirements could not be fully assessed, as only prescription data were available, which may mask actual differences in analgesic requirements between groups. While propensity score matching enabled control of key confounding variables, a regression analysis may have accounted for additional variables. Future prospective studies should employ complete regression analyses to maximize statistical efficiency and identify additional factors associated with outcomes. Furthermore, standardized hourly or quarterly recording of pain scores may highlight temporal trends. We nonetheless believe that this is a strong foundation and an overview of the effects of marijuana on post-ACLR outcomes.
Conclusion
This study is the first to report the association between self-reported positive marijuana attestation and perioperative outcomes in pediatric and adolescent patients undergoing ACLR—including higher rates of overnight admission for pain and prolonged time to RTS by 76 days. This project may assist clinicians in better understanding and educating patients about the potential effects of marijuana use before pediatric orthopaedic interventions.
Footnotes
Final revision submitted May 5, 2025; accepted June 4, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: M.S.K. is a board or committee member of Harvard Medical School, Pediatric Orthopaedic Society of North America, and Pediatric Research in Sports Medicine. G.D.H. is a consultant for Medtronic and Orthopediatrics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from Boston Children’s Hospital (institutional review board [IRB] approval No: IRB-P00041987).
ORCID iD: Mininder S. Kocher 
https://orcid.org/0000-0002-7938-7820
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