Certain Social Determinants of Health Associated with Limited Access to Orthopaedic Care

Public Insurance is Associated with Delays to Surgery in Pediatric Patients with a First-Time Patellar Dislocation Involving a Loose Body 

First-time dislocated kneecaps (patellar dislocations) with detached cartilage (loose body) require that operations be performed promptly to restore joint function and prevent further damage. Disparities in access to orthopaedic care for pediatric and adolescent patients can delay evaluation, imaging, and surgical intervention for those with certain sports-related injuries, such as anterior cruciate ligament and meniscal tears, and affect long-term outcomes. This retrospective comparative study conducted by researchers at Lurie Children’s and Children’s Hospital of Philadelphia and published in the Journal of the Pediatric Orthopaedic Society of North America examined the association of social and demographic factors with time to surgery for 163 pediatric patients under 19 years of age with first-time patellar dislocations involving a loose body.  

Key Takeaways 

• The researchers collected demographic and clinical data from electronic medical records, including age at the time of surgery, sex, race, ethnicity, and insurance type. 
• Government insurance is associated with longer delays to surgery for children with a first-time kneecap dislocation involving a loose body in the joint. 
• Delayed treatment for these injuries is associated with a lower chance that the loose body can be repaired, resulting in missing cartilage. 
• Interventions are needed at many levels (community, healthcare system, policy) to address disparities in pediatric sports medicine. 

After ACL Injury in Children and Adolescents, Where in the Preoperative Timeline do Disparities in Timing and Clinical Course Originate? 

Factors such as insurance type, race, and ethnicity are associated with disparities in the timing of ACL reconstruction in pediatric patients, according to previously published research. However, research has not determined where in the pre-ACL reconstruction process these inequities first occur, and without this understanding it is difficult to design effective interventions to reduce delays. This retrospective comparative study published in the journal Clinical Orthopaedics and Related Research analyzed data from 534 youth and adolescent patients treated surgically for ACL injuries to identify differences in the course and timing of the preoperative timeline with respect to insurance and race or ethnicity. 

Key Takeaways 

• In children with ACL injuries, patients with public insurance and from racially minoritized communities experience delays to their first medical evaluation, MRI, evaluation by a surgeon, and surgery itself. 
• Hispanic children and those with public insurance are more likely to visit an emergency department for their first medical evaluation while those with private insurance are more likely to see an orthopaedic surgeon first. 
• Hispanic children and those with public insurance are more likely to have their injury misdiagnosed prior to MRI, which is associated with delays to MRI and surgery. 
• White children and those with private insurance are more likely to obtain multiple surgical opinions without any associated delay to surgery. 
• This study provides new details on exactly which points in the pre-surgical timeline are affected disparities, providing targets for future interventions. 

The next step following these two studies involves conducting a qualitative study to understand the mechanisms underlying the disparities they have identified in these and other quantitative studies, says Dr. Patel. After interviewing patients, parents, and coaches, researchers will establish a community advisory board and codesign interventions aimed at reducing disparities. 

Pediatric research at Ann & Robert H. Lurie Children’s Hospital of Chicago is conducted through Stanley Manne Children’s Research Institute.