Operative Fixation for Clavicle Fractures-Socioeconomic Differences Persist Despite Overall Population Increases in Utilization

Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study

BACKGROUND

Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States.

MATERIALS AND METHODS

The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported.

RESULTS

A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery.

CONCLUSION

These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 202x;4x(x):xx-xx.].

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes

BACKGROUND

Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.

RESULTS

Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.

CONCLUSION

Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

Racial and Ethnic Disparities in Sports Medicine and the Importance of Diversity

Within orthopedics surgery as a specialty, sports medicine is one of the least diverse surgical subspecialties. Differences in minority representation between patient and provider populations are thought to contribute to disparities in care, access, and outcomes.

Trends in and Factors Associated With Surgical Management for Closed Clavicle Fractures

INTRODUCTION

Clavicle fractures are common and have historically been managed nonsurgically. Over time, there are increasing surgical considerations for such injuries. Nonetheless, trends over the past decade are not well characterized.

METHODS

Adult patients presenting for first diagnosis of clavicle fractures were identified from the 2010 to 2020 PearlDiver M151 database. Patients were defined to have undergone surgical management if they received clavicular open reduction and internal fixation within 90 days after fracture diagnosis. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance coverage, fracture anatomic location, and polytraumatic diagnoses were extracted. Factors independently associated with surgical management versus nonsurgical management were assessed with multivariable analysis.

RESULTS

Overall, 50,980 patients with clavicle fractures were identified of whom 6,193 (12.1%) were managed surgically. This proportion increased significantly over the study period (7.4% in 2015 to 13.9% in 2020, P < 0.001). Independent predictors of surgical management included fracture diagnosis in 2020 (versus 2015, odds ratio [OR] 2.36), anatomic location (relative to lateral end, shaft OR 1.84 and sternal OR 3.35), and Midwest region of service (OR 1.26, relative to South) (P < 0.001 for all).

DISCUSSION

A small but increasing minority of patients with clavicle fractures are managed surgically. Clinical factors and nonclinical factors were associated with surgical management.

Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures.

METHODS

A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed.

RESULTS

In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025).

CONCLUSIONS

Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.

Treatment of Severe Blunt Splenic Injury Varies Across Race and Insurance Type of Pediatric Patients

INTRODUCTION

Racial and ethnic disparities in the management of adult patients with blunt splenic injuries (BSIs) have been previously demonstrated. It is unknown if similar disparities exist in pediatric patients with BSIs. Management of BSIs can include operative management, but nonoperative management (NOM) is preferred. This study assesses the association of race and insurance status on use of NOM among pediatric (aged < 18 y) patients following BSI.

MATERIALS AND METHODS

Data were abstracted from the American College of Surgeons Trauma Quality Improvement Program Participant Use Files for calendar years 2013-2017. Multivariate logistic regression was used to evaluate the associations between race or insurance status and NOM while controlling for injury severity, age, and facility type. Secondary outcomes included blood transfusion within 24 h and hospital length of stay.

RESULTS

We analyzed 1436 pediatric BSI patients. Black, non-Hispanic patients were less likely (odds ratio: 0.45, 95% confidence interval: 0.21-1.02, P = 0.043) to undergo NOM and stayed 0.6 d longer (P = 0.010) than White, non-Hispanic patients. Uninsured patients were less likely (odds ratio: 0.52, 95% CI: 0.25-1.11, P = 0.080) to undergo NOM and publicly insured patients stayed 0.24 d (P = 0.048) longer than privately insured patients.

CONCLUSIONS

We found disparities in use of NOM for Black patients and uninsured patients as well as differences in length of stay. These results extend the literature on racial and socioeconomic disparities in care of trauma patients to pediatric BSI patients. Addressing these disparities requires additional studies aimed at identifying the underlying causes.

Midshaft Clavicle Fractures: When Is Surgical Management Indicated and Which Fixation Method Should Be Used?

For displaced midshaft clavicle fractures, operative treatment either with open reduction and plate fixation or with intramedullary fixation has been shown to provide earlier return to work and sport, improved functional outcomes, greater patient-reported satisfaction with appearance, and significantly decreased incidence of nonunion and malunion when compared with conservative treatment. Operative intervention is not without risks associated with surgery. Shared decision-making with the patient and understanding patient goals allows surgeons to recommend a management option that the patient will be comfortable with and will follow to achieve a satisfactory outcome.

Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis

Background

End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis.

Methods

TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA.

Results

In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA.

Conclusion

Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis.

Level of Evidence

Level III, retrospective cohort study.

The fifty most-cited articles regarding midshaft clavicle fractures

Introduction

The clavicle is the most frequently fractured bone in the human body, and up to 80% of clavicle fractures occur in the middle third diaphyseal region of the clavicle (midshaft). We conducted a bibliometric analysis to identify and evaluate the 50 most-cited publications pertaining to midshaft clavicle fractures (MCF).

Materials and methods

Two independent reviewers conducted separate queries on Web of Science in December 2021 for "midshaft clavicle fractures". The publications yielded were organized from highest to lowest number of citations. We included articles, review articles, and editorial materials and excluded other document types. Both reviewers independently reviewed all abstracts until 50 studies pertaining to MCF were included.

Theory

We hypothesized that most articles would be published between 2000 and 2019, pertain to outcomes, and those with a greater (lower numeric) level of evidence would correlate with number of citations.

Results

The most prolific decade was from 2010 to 2019, with 50% (25/50) of articles published. Average citation density was 6.3 ± 5.5 (range, 1.3-33.1), defined as the average number of citations per year since publication. The median level of evidence (LOE) was 3.5 (IQR: 3). One-way ANOVA tests were used to compare the effects of LOE on total citations and citation density. There were statistically significant differences in total citations (F value = 12.07, p = 0.001) and citation density (F value = 21.14, p < 0.001) between LOE groups. The median number of total citations, grouped by LOE of 1 through 5, were as follows: 110, 66, 66, 51, 52.

Conclusions

This review provides an overview of the 50 most cited papers regarding MCF. This should be used as a reference for physicians and other providers who treat patients with MCF for treatment guidance and for those in teaching roles as a student and resident/fellow educational resource.

Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures: Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice

In 2007, a randomized controlled trial (RCT) by the Canadian Orthopaedic Trauma Society (COTS) demonstrated better functional outcomes and a lower proportion of patients who developed malunion or nonunion following operative, compared with nonoperative, treatment of midshaft clavicle fractures. The primary aim of the present study was to compare the proportion of midshaft clavicle fractures treated operatively prior to and following the publication of the COTS RCT. An additional exploratory aim was to assess whether the proportion of midshaft clavicle fractures that were treated with surgery for malunion or nonunion decreased.

Methods

This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (≥18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts.

Results

A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male). More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001). Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation. The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001).

Conclusions

We found a significant change in surgeon practice regarding operative management of clavicle fractures following the publication of a Level-I RCT. With limited high-quality trials comparing operative and nonoperative management, it is important that clinicians, health-care institutions, and health-authority administrations determine what steps can be taken to increase responsiveness to new clinical studies and evidence-based guidelines.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of clavicle fractures in Australia: an analysis of Australian Medicare Benefits Schedule database from 2001 to 2020

BACKGROUND

There is no consensus on the optimal management of clavicle fractures, with advocates of both operative and non-operative management. The objective of this study is to assess the trends in the management of clavicle fractures in Australia over the past two decades.

METHODS

The incidence of surgical fixation of clavicle fractures from 2001 to 2020 was analysed using the Australian Medicare Benefits Schedule database, reflective of operations performed on privately insured patients, thus excluding public patients and compensable cases. An offset term was utilized with data from the Australian Bureau of Statistics to account for population changes over the study period.

RESULTS

A total of 17 089 procedures for the management of clavicle fractures were performed from 2001 to 2020. The incidence of operative intervention increased from 1.87 per 100 000 in 2001 to a peak of 6.63 per 100 000 in 2016. An overall increase was seen in males (310%) and females (347%) over the study period, as well as across all age groups. A greater proportion of operative interventions was performed on males (n = 14 075, 82%) than females (n = 3014, 18%, P < 0.001). The greatest increase in intervention was noted in those aged 65 or older (14% increase per year, 95% CI 11%-17%, P < 0.05). In 2020, the incidence of operative intervention decreased to a level last seen in 2013.

CONCLUSIONS

The incidence of operative interventions for clavicle fractures has increased in Australia over the 20-year study period. This increase is in keeping with recent evidence suggesting several advantages when displaced mid-shaft clavicle fractures are operatively managed.

Inclusive Mentorship and Sponsorship

Mentorship and sponsorship are part of academia because they are vital for professional and personal development. Inclusive mentorship is defined as mentoring across differences. It highlights the need of all mentors to be well-versed culturally and to recognize and circumvent bias and microaggressions. Inclusive mentorship can also elevate underrepresented populations in medicine and create intercultural relationships that also benefit the relationships we have with our diversifying patient populations. There are still several barriers prohibiting inclusive mentorship from being widely understood and employed. This article discusses the importance of and techniques for improving inclusive mentorship.

Socioeconomic status does not change decision-making in the treatment of distal radius fractures at a level 1 trauma center

Objectives

To compare operative rates, total hospital charges, and length of stay between different socioeconomic cohorts in treating distal radius fractures (DRFs).

Design

A retrospective cohort study.

Setting

Large public level 1 trauma center.

Patients

A retrospective search of all trauma activations over a 7-year period (2013-2020) yielded 816 adult patients diagnosed with DRF. Patients were separated into cohorts of socioeconomic status based on 2010 US Census data and insurance status.

Intervention

DRFs were treated either nonoperatively using closed reduction and splinting or operatively using open reduction and internal fixation, closed reduction percutaneous pinning, or external fixator application.

Main Outcome Measurements

Operative rates of DRF, total hospital charges, and length of stay.

Results

Patients who were uninsured or in the low-income socioeconomic cohort had no significant difference in operative rates, total hospital costs, or length of stay when compared with their respective insured or standard income groups. Younger patients and those with OTA/AO type C, bilateral, or open DRFs were more likely to undergo operative intervention.

Conclusions

This study demonstrates that low socioeconomic status based on annual household income and insurance status was not associated with differences in operative rates on DRFs, length of stay, or total hospital charges. These results suggest that outcome disparities between groups may be caused by postoperative differences rather than treatment decision-making. Although this study investigates access to surgical care at a publicly funded level 1 trauma center, disparities may still exist in other models of care.

Level of Evidence

Prognostic Level III.

Bucket-Handle Meniscus Tear Management With Meniscectomy Versus Repair Correlates With Patient, Socioeconomic, and Hospital Factors

INTRODUCTION

Bucket-handle meniscus tears are common knee injuries that are often treated surgically with meniscectomy or meniscal repair. Although clinical factors may influence the choice of one treatment approach over the other, the influence of patient, socioeconomic, and hospital factors remains poorly characterized. This study aimed to estimate the relative nationwide utilization of these two procedures and delineate a variety of factors that are associated with the selection of one treatment approach over the other.

METHODS

Meniscal repair and meniscectomy procedures conducted for isolated bucket-handle meniscus tears in 2016 and 2017 were identified in the Nationwide Ambulatory Surgery Sample database. Cases were weighted using nationally representative discharge weights. Univariate analyses and a multivariable logistic regression model were used to compare patient, socioeconomic, and hospital factors associated with meniscal repair versus meniscectomy.

RESULTS

In total, 12,239 cases were identified, which represented 17,236 cases after weighting. Of these, meniscal repair was conducted for 4,138 (24.0%). Based on the logistic regression model, meniscal repair was less likely for older and sicker patients. By contrast, several factors were associated with markedly higher odds of undergoing meniscal repair compared with meniscectomy. These included urban teaching hospitals; geographic location in the midwest, south, and west; and higher median household income.

DISCUSSION

Using a large nationally representative cohort, the current data revealed that only 24.0% of surgically treated bucket-handle meniscus tears were treated using repair. Identification of patient, socioeconomic, and hospital factors differentially associated with meniscal repair suggest that other factors may systematically influence surgical decision-making for this patient population. Surgeons should be conscious of these potential healthcare disparities when determining the optimal treatment for their patients.

LEVEL OF EVIDENCE

Level III.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005-2007 vs 2012-2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability

Purpose

To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors.

Methods

Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type.

Results

In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery.

Conclusions

Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation.

Clinical Relevance

Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Achilles Injury and Access to Care in South Florida

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

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Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care.

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Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States.

»

Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes.

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Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

BACKGROUND

The national rates of readmission and reoperation after open reduction internal fixation (ORIF) of midshaft clavicle fractures in adolescents is unknown.

AIM

To determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.

METHODS

This retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012. Readmissions within ninety days, reoperations within two years, and differences in patient demographic factors were determined through descriptive, univariate, and multivariate analyses.

RESULTS

In total, 3.29% (n = 11) of patients were readmitted within 90 d to a hospital at an average of 18.91 ± 18 d after discharge, while 15.87% (n = 53) of patients underwent a reoperation within two years at an average of 209.53 ± 151 d since the index surgery. The most common reason for readmission was a postoperative infection (n < 10). Reasons for reoperation included implant removal (n = 49) at an average time of 202.39 ± 138 d after surgery, and revision ORIF (n < 10) with an average time of 297 ± 289 d after index surgery. The odds of reoperation were higher for females (P < 0.01) and outpatients (P < 0.01), while the odds of reoperation were lower for patients who underwent surgery in California (P = 0.02).

CONCLUSION

There is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents. There are significant differences for reoperation based on patient sex, location, and hospital type.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center

Objectives:

Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic.

Design:

Retrospective chart review.

Setting:

Outpatient visits (in-person, telephone, virtual—Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic.

Intervention:

Virtual visits utilizing the Doxy.me platform.

Main Outcome Measures:

Accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Methods:

All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Results:

Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028).

Conclusion:

A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Factors Associated With Surgical Treatment of Isolated, Displaced Midshaft Clavicle Fractures

Given the current available evidence, surgical treatment of isolated, displaced midshaft clavicle fractures is discretionary. The aim of this study was to determine whether there are identifiable factors associated with the surgical treatment of isolated, displaced midshaft clavicle fractures. A retrospective cohort study of 150 patients who underwent nonoperative treatment and 290 patients who underwent surgical treatment of isolated, displaced midshaft clavicle fractures from January 2010 to March 2019 at 2 level I trauma centers was performed. Multivariable regression analysis demonstrated that younger age (odds ratio [OR], 0.97; 95% CI, 0.95-0.99), absence of diabetes mellitus (OR, 0.045; 95% CI, 0.003-0.79), nonsmoking status (OR, 0.31; 95% CI, 0.13-0.75), higher American Society of Anesthesiologists classification (OR, 5.0; 95% CI, 2.7-9.2), fracture comminution (OR, 2.3; 95% CI, 1.3-3.9), and fracture displacement (OR, 1.1; 95% CI, 1.0-1.1) were associated with surgical treatment of an isolated, displaced midshaft clavicle fracture. Furthermore, lower social deprivation (OR, 0.99; 95% CI, 0.97-0.99) and private insurance compared with Medicare (OR, 6.6; 95% CI, 1.6-27) were associated with surgical treatment. The authors conclude that surgical treatment of discretionary midshaft clavicle fractures is influenced by patient factors, fracture characteristics, and socioeconomic factors. Further study is needed to understand the etiology of social disparities in clavicle surgery and rectify unintended trends in treatment. [Orthopedics. 2021;44(4):e515-e520.].

Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study

Background

The impact of associated chest wall injuries (CWI) on the complications of clavicle fracture repair is unclear to date. This study aimed to investigate the complications after surgical clavicle fracture fixation in patients with and without different degrees of associated CWI.

Methods

A retrospective review over a four-year period of patients who underwent clavicle fracture repair was conducted. A CWI and no-CWI group were distinguished, and the CWI group was subdivided into the minor-CWI (three or fewer rib fractures without flail chest) and complex-CWI (flail chest, four or more rib fractures) subgroup. Demographic data, classification of the clavicle fracture, number of rib fractures, and associated injuries were recorded. Overall complications included surgery-related complications and unplanned hospital readmissions. Univariate analysis and stepwise backward multivariate logistic regression were used to identify potential risk factors for complications.

Results

A total of 314 patients undergoing 316 clavicle fracture operations were studied; 28.7% of patients (90/314) occurred with associated CWI. Patients with associated CWI showed a significantly higher age, body mass index, and number of rib fractures. The overall and surgical-related complication rate were similar between groups. Unplanned 30-day hospital readmission rates were significantly higher in the complex-CWI group (p = 0.02). Complex CWI and number of rib fractures were both independent factor for 30-day unplanned hospital readmission (OR 1.59, 95% CI: 1.00–2.54 and OR 1.33, 95% CI: 1.06–1.68, respectively).

Conclusion

CWI did not affect surgery-related complications after clavicle fracture repair. However, complex-CWI may increase 30-day unplanned hospital readmission rates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04148-1.

Socioeconomic and Demographic Disparities in Early Surgical Stabilization Following Emergency Department Presentation for Shoulder Instability

Purpose

To describe which patients are the most likely to undergo surgical management within the same calendar year as their emergency department visit for anterior shoulder instability.

Methods

The State Emergency Department Databases and State Ambulatory Surgery and Services Databases from Florida were used. All patients presenting to the emergency department for anterior shoulder subluxation or dislocation between January 1 and September 30, 2017, were selected. Bivariate analysis was performed for associations with demographic variables. A binary logistic regression was performed with all significant factors to assess which were predictors of undergoing surgery the same calendar year.

Results

While controlling for all significant factors, we found that patients with recurrent dislocations were 3.14 times more likely to have surgery within the same year (P = .037). Patients younger than 40 years were also 2.04 times more likely to have surgery than those aged 40 years or older (P < .001). White patients were 2.47 times more likely to have surgery than black patients (P < .001). On bivariate analysis, there was an association between greater income quartile and higher odds of undergoing surgery within 30 days.

Conclusions

Following an emergency department visit for acute shoulder instability, the following variables were associated with undergoing surgical stabilization within the same calendar year: previous dislocation, age younger than 40, and white race. Patients living in the greatest income quartile of patients had a significantly greater percentage of patients having surgery within 30 days. This demonstrates that disparities and barriers to care may exist for patients with shoulder instability.

Level of Evidence

Level III, Retrospective Comparative Study.

Predictors of Loss to Follow-up in Hip Fracture Trials: A Secondary Analysis of the FAITH and HEALTH Trials

BACKGROUND

Hip fracture trials often suffer substantial loss to follow-up due to difficulties locating and communicating with participants or when participants, or their family members, withdraw their consent. We aimed to determine which factors were associated with being unable to contact FAITH and HEALTH participants for their 24-month follow-up and to also determine which factors were associated with their withdrawal of consent.

METHODS

We conducted 2 multivariable logistic regression analyses to determine which factors were predictive of being unable to contact participants at 24 months postfracture and withdrawal of consent within 24 months of their fracture. Results were reported as odds ratios, 95% confidence intervals, and associated P-values. All tests were 2-tailed with alpha = 0.05.

RESULTS

We were unable to contact 123 of 2520 participants (4.9%) for their 24-month follow-up visits and 124 (4.9%) withdrew their consent from the trial. Being non-White (P = 0.003), enrolled from a non-European hospital (P < 0.001), and treated with arthroplasty (P < 0.001) were associated with an increased odds of not completing the 24-month follow-up visit. Being enrolled from a hospital in the United States (P = 0.02), from a hospital in Oceania, India, or South Africa (P < 0.001) as compared to a European hospital, and treated with arthroplasty (P < 0.001) were associated with an increased odds of consent withdrawal.

DISCUSSION

Certain factors may be predictive of loss to follow-up in hip fracture trials. We suggest that the identification of such factors may be used to inform and improve retention strategies in future orthopaedic hip fracture trials.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis

OBJECTIVES

Middle third clavicle fractures have long been managed conservatively with immobilization. Some patients, especially those with completely displaced or shortened clavicle fractures are now thought to have increased risk of nonunion or symptomatic malunion. The authors performed a meta-analysis to study the incidence of nonunion and symptomatic malunion and test the hypothesis that surgical fixation of these fractures significantly lowers the risk of these complications.

METHODS

A search was performed in the PubMed, Embase, and Cochrane Library databases for randomized clinical trials and quasi-experimental trials that compare outcomes of operative and nonoperative management for clavicle fractures that are fully (100%) displaced or have greater than 2 cm of shortening. Pooled patient data were used to construct forest plots for the meta-analysis.

RESULTS

Eleven studies including 497 patients who were treated and 457 patients treated conservatively were analyzed. Patients managed operatively had significantly lower relative risk of developing nonunion [0.17 (95% confidence interval 0.08-0.33)] and symptomatic malunion [0.13 (95% confidence interval 0.05-0.37)]. Plate fixation significantly reduced the risk of nonunion, but intramedullary nail fixation did not. There was no difference in Constant-Murley or DASH scores between the 2 treatment groups or in the rate of secondary operative procedures.

CONCLUSIONS

Patients who undergo operative fixation of displaced middle-third clavicle fractures have a lower incidence of nonunion and symptomatic malunion. The clinical significance of this effect is uncertain, as functional scores were similar in both groups. Further research into the risk factors for nonunion and symptomatic malunion will be necessary to determine which patients benefit from operative fixation.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The willingness of orthopaedic trauma patients in Uganda to accept financial loans following injury

Background:

Early access to a monetary loan may mitigate some of the socioeconomic burden associated with surgical treatment and lost wages following injury. The primary objective of this study was to determine the willingness of orthopaedic trauma patients in Uganda to accept a formal financial loan shortly after their time of injury.

Methods:

A consecutive sample of adult orthopaedic trauma patients admitted to Uganda's national referral hospital was included in the survey. The primary outcome was the self-reported willingness to accept a financial loan. Secondary outcomes included the preferred loan terms, fracture treatment costs, and the factors associated with loan willingness.

Results:

Of the 40 respondents (mean age, 40 years; 58% male), the median annual income was $582 United States dollars (USD) (range: $0–$6720). Around 50% reported a willingness to accept a loan with any terms. Patients requested loans with a median principal of $500 USD and a median interest rate of 5% with 12 months to pay back. Patients had received loans with a median principal of $142 USD, an interest rate of 10%, and payback of 6 months. These received loans covered a mean of 63% of the treatment costs. Patients with higher median incomes ($857 USD vs $342 USD) were more willing to accept a loan.

Conclusion:

This study demonstrated a limited interest of orthopaedic trauma patients in Uganda to procure loans through formalized lending. This observed resistance must be overcome in future programs that rely on mechanisms such as conditional cash transfers or microfinancing to improve clinical and socioeconomic outcomes after injury.

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

BACKGROUND

Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate.

QUESTIONS/PURPOSES

(1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?

METHODS

A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios.

RESULTS

After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001).

CONCLUSIONS

We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures

Background

Socio-demographic factors have been suggested to contribute to differences in healthcare utilization for several elective orthopedic procedures. Reports on disparities in utilization of orthopedic trauma procedures remain limited. The purpose of our study is to assess the roles of clinical and socio-demographic variables in utilization of operative fixation of calcaneus fractures in the USA.

Methods

The National Inpatient Sample (NIS) dataset was used to analyze all patients from 2005 to 2014 with closed calcaneal fractures. Multivariate logistic regression analyses were performed to evaluate the impact of clinical and socio-demographic variables on the utilization of surgical versus non-surgical treatment.

Results

A total of 17,156 patients with closed calcaneus fractures were identified. Operative treatment was rendered in 7039 patients (41.03%). A multivariate logistic regression demonstrated multiple clinical and socio-demographic factors to significantly influence the utilization of surgical treatment including age, gender, insurance status, race/ethnicity, income, diabetes, peripheral vascular disease, psychosis, drug abuse, and alcohol abuse (p <  0.05). In addition, hospital size and hospital type (teaching versus non-teaching) showed a statistically significant difference (p <  0.05).

Conclusions

Besides different clinical variables, we identified several socio-demographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Further studies need to identify the specific patient-related, provider-related, and system-related factors leading to these disparities.

The Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injury

BACKGROUND

Racial, ethnic, and socioeconomic disparities have been shown to exist in trauma patients. Management of blunt splenic injuries (BSIs) can include splenectomy, embolization, or nonoperative management. This study assesses the effect of race and insurance status on outcomes in patients after blunt splenic trauma.

METHODS

The National Trauma Data Bank was used to study patients aged 15-89 y with BSIs from 2013 to 2015. Patients with abbreviated injury scores greater than two in nonabdominal areas, excluding extremities, were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using chi-square tests, and those with significant associations were used in multivariate regression models for each outcome.

RESULTS

We analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality, more splenic operations, and were less likely to have nonoperative management (P < 0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave against medical advice (P < 0.001). African Americans and Hispanics had higher mortality (odds ratio [OR] 2.03, CI 1.34-3.08; OR 1.58, CI 1.03-2.44, respectively). African Americans had more splenic operations (OR 1.33, CI 1.08-1.64) and were 60% less likely to receive angioembolization (CI 0.41-0.84). Hispanics had fewer splenic operations (OR 0.79, CI 0.63-0.98).

CONCLUSIONS

Noteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race likely affect surgical treatment plans and mortality, particularly for uninsured, black, and Hispanic patients, but further research is needed to identify the root cause of these disparities.

Identifying Risk Factors for 30-Day Readmissions After Triple Arthrodesis Surgery

Rigid flatfoot deformity is a debilitating condition that can be managed by triple arthrodesis surgery. Triple arthrodesis has the potential to restore health-related quality of life, but it is also associated with several complications. Few studies have examined the 30-day readmission rates after triple arthrodesis. The objective of this study was to investigate risk factors for 30-day all-cause readmissions after triple arthrodesis. The nationwide readmission database was queried from 2013. By using International Classification of Disease, Ninth Revision, procedure codes, all triple arthrodesis procedures were identified. Demographic factors, comorbidities, insurance status, and hospital characteristics were statistically compared between patients who experienced a 30-day readmission and those who did not. Multivariable logistic regression was used to identify independent risk factors for 30-day readmission. Overall, 1916 triple arthrodesis cases were identified. The overall 30-day readmission rate after triple arthrodesis was 4.6%. Univariate analysis revealed a statistically higher proportion of patients with electrolyte abnormalities (13.8% vs 4.6%; p < .01) in the patients who were readmitted within 30 days compared with those who were not. Multivariable analysis demonstrated Medicaid insurance, relative to private insurance, as the only statistically significant predictor of 30-day readmission with an odds ratio of 4.43 (p < .05). These results suggest that patients of lower socioeconomic status may be at a greater risk for development of a short-term readmission after triple arthrodesis surgery. These findings are important for surgeon and patient communication, counseling, and postoperative care when choosing to pursue triple arthrodesis surgery.

Race and Insurance Status Are Associated With Surgical Management of Isolated Meniscus Tears

PURPOSE

The purpose of this study was to perform a population-level analysis to evaluate the effect of socioeconomic markers on the use of meniscus surgery in patients with meniscus tears.

METHODS

We queried all hospital-based clinic visits from 2011 to 2014 in the Statewide Planning and Research Cooperative System database, which also contains all New York inpatient/outpatient visits. Patients with known prior knee surgery, meniscus tear before 2011, or other ligament injuries were excluded. The primary outcome was a meniscus procedure (meniscectomy or meniscus repair). Survival analysis was used to calculate the rate of meniscus surgery within 6 months. A multivariate model identified patient factors (age, sex, race, and payer) associated with surgical intervention.

RESULTS

There were 32,012 patients identified who met the inclusion criteria. The rate of meniscus procedure within 6 months of diagnosis was 49.6%. Meniscectomy was performed in 98.8% of cases compared with 1.2% for meniscus repair. Rates of meniscus procedures were higher in patients who were older, male, and white, as well as those first diagnosed by a surgeon. The highest rates of meniscus procedures were in those with private, worker's compensation, or other insurance types. Multivariable analysis showed that female sex, non-white race, and public or self-pay insurance were independently associated with lower rates of meniscus surgery.

CONCLUSIONS

These results suggest both insurance-based and race-based disparities regarding surgical treatment. Additionally, the strongest variable for surgical management was a meniscus tear being first diagnosed by a surgeon.

LEVEL OF EVIDENCE

Level of Evidence IV, retrospective case-control study.

Midshaft clavicle fractures: Current concepts

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.

Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.

However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033