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Howard RA, Morales JA, Ordaz A, Bryan TP, Edmonds EW. Postoperative Access and Compliance Following Medial Patellofemoral Ligament Reconstruction in Hispanic Adolescents Mirrors the Non-Hispanic Adolescent Population. J Pediatr Orthop 2024:01241398-990000000-00595. [PMID: 38907588 DOI: 10.1097/bpo.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
BACKGROUND Disparity in surgical care of patellar instability patients has not been fully investigated in the adolescent Hispanic population. This demographic has been shown to have differences in their care, including a lower rate of surgical treatment for patellar instability. Socioeconomic factors have been cited as a factor that influences patient outcomes and its relationship with ethnicity in context of patellar instability has not been evaluated. METHODS Review performed of patients <19 years of age who underwent MPFL reconstruction between September 2008 and December 2015. Demographics, patient median household income data, and clinical variables were collected. Generalized linear mixed model (GLMM) with subject as random effects factor was utilized to evaluate differences between ethnicity groups due to nonindependence of data. It was then expanded to incorporate interactions between ethnicity and income. RESULTS Ninety-five patellar dislocation events met criteria in 85 adolescents (mean age: 15.5 y). Thirty-four (40%) adolescents identified as Hispanic. In univariate analysis no differences were found between Hispanic and non-Hispanic patients. The multivariate GLMM demonstrated a significant interaction between ethnicity and income. The Hispanic group in the >100% State median income category had the highest rate of postoperative clinic appointments attended (P=0.019). The Hispanic group in the <100% State median income category had the lowest rate of physical therapy appointments attended (P=0.044). No differences were observed for duration of follow-up (P=0.57) or final Kujala score (P=0.75). CONCLUSIONS Hispanic ethnicity alone is not associated with inferior postoperative management after MPFL reconstruction in adolescents. However, when socioeconomic status is considered, Hispanic patients of lower-income backgrounds are found to have lower compliance with postoperative rehab recommendations. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Roland A Howard
- Department of Orthopedic Surgery, University of California San Diego
| | - Jose A Morales
- School of Medicine, University of California Riverside, Riverside, CA
| | - Angel Ordaz
- Department of Orthopedic Surgery, University of California San Diego
| | - Tracey P Bryan
- Division of Orthopaedic Surgery, Rady Children's Hospital-San Diego, San Diego
| | - Eric W Edmonds
- Department of Orthopedic Surgery, University of California San Diego
- Division of Orthopaedic Surgery, Rady Children's Hospital-San Diego, San Diego
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Lau J, Garcia-Lopez E, Feeley BT, Pandya NK. Association of Spanish as a Primary Language With Retear Rates After Pediatric ACL Reconstruction. Orthop J Sports Med 2024; 12:23259671241252936. [PMID: 38881856 PMCID: PMC11179484 DOI: 10.1177/23259671241252936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 11/13/2023] [Indexed: 06/18/2024] Open
Abstract
Background Anterior cruciate ligament (ACL) injuries are one of the most common knee injuries in pediatric patients in the United States. The patient's primary spoken language may affect outcomes after ACL reconstruction (ACLR). Purpose/Hypothesis The purpose of this study was to identify differences in ACLR outcomes between patients whose primary, preferred spoken language was either English or Spanish. It was hypothesized that there would be a difference in retear rates between patients preferring English versus Spanish. Study Design Cohort study; Level of evidence, 3. Methods A retrospective cohort study was performed on pediatric and adolescent patients who underwent ACLR at a single institution. Patients were divided into 2 cohorts based on their preferred spoken language: English or Spanish. All patients underwent either hamstring tendon or bone-patellar tendon-bone autograft ACLR performed by the same surgeon with the same postoperative rehabilitation protocols. Linear regression, chi-square tests, and multivariate logistic regression were used to determine if outcomes, graft tear, revision surgery, and contralateral injury differed between groups. Results A total of 68 patients were identified: 33 patients whose preferred language was English and 35 patients whose preferred language was Spanish. The overall mean age of the patients was 16.4 ± 1.4 years (range, 13.2-20.5 years), and the mean follow-up time was 3.26 ± 1.98 years (range, 0.53-8.13 years). Patients who preferred Spanish were more likely than those who preferred English to experience graft tears requiring revision surgery after ACLR (P = .02; odds ratio [OR] = 5.81; adjusted OR = 1.94), at a tear rate of 14.3%. Conclusion Patients who preferred to speak Spanish experienced higher graft tear rates when compared with patients who preferred speaking English, even after adjusting for sex, sport played, graft type, type of insurance, and time to surgery.
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Affiliation(s)
- Justin Lau
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Edgar Garcia-Lopez
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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Dadoo S, Keeling LE, Engler ID, Chang AY, Runer A, Kaarre J, Irrgang JJ, Hughes JD, Musahl V. Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage. Br J Sports Med 2024; 58:649-654. [PMID: 38760154 DOI: 10.1136/bjsports-2023-107409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume. METHODS Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups. RESULTS The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair. CONCLUSION Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons. LEVEL OF EVIDENCE Retrospective cohort study, level III.
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Affiliation(s)
- Sahil Dadoo
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura E Keeling
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ian D Engler
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Central Maine Medical Center, Lewiston, Maine, USA
| | - Audrey Y Chang
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Armin Runer
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Sports Orthopaedics, Technical University of Munich, Munchen, Germany
| | - Janina Kaarre
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedics, Sahlgrenska Academy, Goteborg, Sweden
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedics, Sahlgrenska Academy, Goteborg, Sweden
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Nacier CM, Vutescu ES, Bergen MA, Quinn MS, Albright JA, Cruz AI. Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics. PHYSICIAN SPORTSMED 2024:1-6. [PMID: 38618689 DOI: 10.1080/00913847.2024.2342235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation. METHODS A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture). RESULTS In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001). CONCLUSION Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.
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Affiliation(s)
| | - Emil Stefan Vutescu
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael A Bergen
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Matthew S Quinn
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - J Alex Albright
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Jo J, Williams KL, Wallace J, Anand M, Anesi T, Brewer C, Burns C, Hefley WF, St Julien Z, Tang AR, Zuckerman SL, Terry DP, Yengo-Kahn AM. Systematic Review Examining the Reporting of Race and Ethnicity in Sport-Related Concussion Studies. J Athl Train 2024; 59:354-362. [PMID: 37347141 PMCID: PMC11064120 DOI: 10.4085/1062-6050-0072.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Sport-related concussion (SRC) is an evolving public health concern among youth athletes. Despite emerging evidence that race and ethnicity are important factors in determining concussion outcomes, studies examining race and ethnicity are limited. We conducted a systematic review to (1) determine the prevalence of SRC studies in which participants' race or ethnicity is reported, (2) describe how race and ethnicity are used within each study, and (3) assess predictive factors for the reporting of race and ethnicity. DATA SOURCES PubMed, Embase, PsycINFO, and CINAHL databases. STUDY SELECTION Study inclusion criteria were (1) primary and peer-reviewed research; (2) related to the diagnosis, treatment, or recovery of SRC; (3) involving school-aged athletes (ages 5 to 25); and (4) with 25 or more participants. The search was performed in March 2021 and included only studies published after March 2013. DATA EXTRACTION For each article, we looked at whether race and ethnicity were reported, and if so, which races or ethnicities were mentioned. For each race or ethnicity mentioned, we extracted the corresponding sample size and how they were used as variables in the study. DATA SYNTHESIS Of 4583 studies screened, 854 articles met inclusion criteria. Of the included articles, 132 (15.5%) reported race, and 65 (7.6%) reported ethnicity, whereas 721 (84.4%) reported neither. When examining the demographic characteristics of the 132 studies that reported race, 69.8% of athletes were White. Additionally, 79.5% of these studies used race solely as a demographic descriptor as opposed to a main exposure or covariate of interest. Studies published more recently were more likely to report race. Further, studies in specific study or journal topics and specific geographic locations of the authors were more likely to report race. CONCLUSIONS Reporting of race and ethnicity is limited in current SRC literature. Future authors should improve the reporting of race and ethnicity, diversify study samples by focusing on enrolling athletes from underrepresented groups, and consider the potential effect of race and ethnicity as social determinants of health on risk factors, recovery, and long-term sequelae after SRC.
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Affiliation(s)
- Jacob Jo
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, TN
| | - Kristen L Williams
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica Wallace
- Department of Health Science, Athletic Training Program, University of Alabama, Tuscaloosa
| | - Malini Anand
- Vanderbilt University School of Medicine, Nashville, TN
| | - Trevor Anesi
- Vanderbilt University School of Medicine, Nashville, TN
| | - Claire Brewer
- Department of Health Science, Athletic Training Program, University of Alabama, Tuscaloosa
| | | | | | | | - Alan R Tang
- Vanderbilt University School of Medicine, Nashville, TN
| | - Scott L Zuckerman
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, TN
| | - Douglas P Terry
- Vanderbilt Sport Concussion Center, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Yengo-Kahn
- Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
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Dewidar O, McHale G, Al Zubaidi A, Bondok M, Abdelrazeq L, Huang J, Jearvis A, Aliyeva K, Alghamyan A, Jahel F, Greer-Smith R, Tufte J, Barker LC, Elmestekawy N, Sharp MK, Horsley T, Prats CJ, Jull J, Wolfenden L, Cuervo LG, Hardy BJ, Roberts JH, Ghogomu E, Obuku E, Owusu-Addo E, Nicholls SG, Mbuagbaw L, Funnell S, Shea B, Rizvi A, Tugwell P, Bhutta Z, Welch V, Melendez-Torres GJ. Motivations for investigating health inequities in observational epidemiology: a content analysis of 320 studies. J Clin Epidemiol 2024; 168:111283. [PMID: 38369078 DOI: 10.1016/j.jclinepi.2024.111283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES To enhance equity in clinical and epidemiological research, it is crucial to understand researcher motivations for conducting equity-relevant studies. Therefore, we evaluated author motivations in a randomly selected sample of equity-relevant observational studies published during the COVID-19 pandemic. STUDY DESIGN AND SETTING We searched MEDLINE for studies from 2020 to 2022, resulting in 16,828 references. We randomly selected 320 studies purposefully sampled across income setting (high vs low-middle-income), COVID-19 topic (vs non-COVID-19), and focus on populations experiencing inequities. Of those, 206 explicitly mentioned motivations which we analyzed thematically. We used discourse analysis to investigate the reasons behind emerging motivations. RESULTS We identified the following motivations: (1) examining health disparities, (2) tackling social determinants to improve access, and (3) addressing knowledge gaps in health equity. Discourse analysis showed motivations stem from commitments to social justice and recognizing the importance of highlighting it in research. Other discourses included aspiring to improve health-care efficiency, wanting to understand cause-effect relationships, and seeking to contribute to an equitable evidence base. CONCLUSION Understanding researchers' motivations for assessing health equity can aid in developing guidance that tailors to their needs. We will consider these motivations in developing and sharing equity guidance to better meet researchers' needs.
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Affiliation(s)
- Omar Dewidar
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Bruyère Research Institute, University of Ottawa, Ottawa, Canada.
| | - Georgia McHale
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Ali Al Zubaidi
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada; School of Medicine, University College Cork, Cork, Ireland
| | - Mostafa Bondok
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada; Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Leenah Abdelrazeq
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada; Department of Health Sciences, Carelton University, Ottawa, Canada
| | - Jimmy Huang
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Alyssa Jearvis
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Khadija Aliyeva
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Amjad Alghamyan
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Fatima Jahel
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | | | | | - Lucy C Barker
- Department of Psychiatry, University of Toronto, Toronto, Canada; Women's College Hospital, Toronto, Canada
| | - Nour Elmestekawy
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada
| | - Melissa K Sharp
- Department of General Practice, Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tanya Horsley
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | - Clara Juandro Prats
- Applied Health Research Center, St. Michael's Hospital, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Luke Wolfenden
- Cochrane Public Health, School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia
| | - Luis Gabriel Cuervo
- Department of Evidence and Intelligence for Action in Health, Pan American Health Organization (PAHO/WHO), Washington, DC, USA; Department of Paediatrics, Obstetrics & Gynaecology, and Preventive Medicine, Doctoral School, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Billie-Jo Hardy
- Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Janet Hatchet Roberts
- WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Ottawa, Canada
| | | | - Ekwaro Obuku
- Africa Centre for Systematic Reviews & Knowledge Translation, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ebenezer Owusu-Addo
- Bureau of Integrated Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sarah Funnell
- Department of Family Medicine, Queen's University, Kingston, Canada; Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Bev Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anita Rizvi
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Peter Tugwell
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Zulfiqar Bhutta
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Centre for Excellence in Women and Child Health and Institute of Global Health and Development, The Aga Khan University, Karachi, Pakistan
| | - Vivian Welch
- Bruyère Research Institute, University of Ottawa, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Middleton KK, Turner A. Racial and Ethnic Disparities in Sports Medicine and the Importance of Diversity. Clin Sports Med 2024; 43:233-244. [PMID: 38383106 DOI: 10.1016/j.csm.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
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.
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Affiliation(s)
| | - Alex Turner
- University of Texas Southwestern Medical School, Dallas, TX, USA
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Abed V, Kapp S, Bradley T, Homen DT, Landy DC, Dasa V, Conley C, Stone AV. Orthopaedic Sports Medicine Randomized Controlled Trials Infrequently Report on the Social Determinants of Health Factors of Their Patient Cohorts. Arthroscopy 2024; 40:922-927. [PMID: 37879516 DOI: 10.1016/j.arthro.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE To describe the prevalence of randomized controlled trials (RCTs) in orthopaedic sports medicine-related journals reporting on the social determinants of health (SDOH) of their patient cohorts, including factors receiving less attention, such as education level, employment status, insurance status, and socioeconomic status. METHODS The PubMed/MEDLINE database was used to search for RCTs between 2020 and 2022 from 3 high-impact orthopaedic sports medicine-related journals: American Journal of Sports Medicine, Arthroscopy, and Journal of Shoulder and Elbow Surgery. The following information was extracted from each article: age, sex/gender, body mass index, year published, corresponding author country, and self-reported SDOH factors (race, ethnicity, education level, employment status, insurance status, and socioeconomic status). RESULTS A total of 189 articles were analyzed. Articles originated from 34 different countries, with the United States (n = 66) producing the greatest number of articles. Overall, age (n = 186; 98.4%) and sex/gender (n = 184; 97.4%) were the factors most commonly reported, followed by body mass index (n = 112; 59.3%), race (n = 17; 9.0%), ethnicity (n = 10; 5.3%), employment status (n = 9; 4.8%), insurance status (n = 7; 3.7%), and education level (n = 5; 2.6%). Socioeconomic status was not reported in any of the articles analyzed. Articles from the United States report on SDOH factors more frequently than international articles, most notably race (24.2% vs 0.8%, respectively) and ethnicity (15.2% and 0%, respectively). CONCLUSIONS RCTs from 3 high-impact orthopaedic sports medicine journals infrequently report on SDOH. CLINICAL RELEVANCE Better understanding patient SDOH factors in RCTs is important to help orthopaedic surgeons and other practitioners best apply study results to their patients, as well as help researchers and our field ensure that research is being done transparently with relevance to as many patients as possible.
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Affiliation(s)
- Varag Abed
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Sabryn Kapp
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Taylor Bradley
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Dylan T Homen
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - David C Landy
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A
| | - Caitlin Conley
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Austin V Stone
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, U.S.A..
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9
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Kliethermes SA, Asif IM, Blauwet C, Christensen L, Coleman N, Lavallee ME, Moeller JL, Phillips SF, Rao A, Rizzone KH, Sund S, Tanji JL, Tuakli-Wosornu YA, Stafford CD. Focus areas and methodological characteristics of North American-based health disparity research in sports medicine: a scoping review. Br J Sports Med 2024; 58:164-171. [PMID: 38216322 PMCID: PMC10961938 DOI: 10.1136/bjsports-2023-107607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE Health disparities are widely prevalent; however, little has been done to examine and address their causes and effects in sports and exercise medicine (SEM). We aimed to summarise the focus areas and methodology used for existing North American health disparity research in SEM and to identify gaps in the evidence base. DESIGN Scoping review. DATA SOURCES Systematic literature search of PubMed, Scopus, SPORTDiscus, CINAHL Plus with Full Text, Web of Science Core Collection and Cochrane Central Register of Controlled Trials. ELIGIBILITY CRITERIA Full-text, peer-reviewed manuscripts of primary research, conducted in North America; published in the year 2000 or after, in English; and focusing on organised sports were included. RESULTS 103 articles met inclusion criteria. Articles were classified into five focus areas: access to and participation in sports (n=45), access to SEM care (n=28), health-related outcomes in SEM (n=24), provider representation in SEM (n=5) and methodology (n=1). Race/ethnicity (n=39), socioeconomic status (n=28) and sex (n=27) were the most studied potential causes of health disparities, whereas sexual orientation (n=5), location (rural/urban/suburban, n=5), education level (n=5), body composition (n=5), gender identity (n=4) and language (n=2) were the least studied. Most articles (n=74) were cross-sectional, conducted on youth (n=55) and originated in the USA (n=90). CONCLUSION Health disparity research relevant to SEM in North America is limited. The overall volume and breadth of research required to identify patterns in a heterogeneous sports landscape, which can then be used to inform positive change, need expansion. Intentional research focused on assessing the intersectionality, causes and consequences of health disparities in SEM is necessary.
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Affiliation(s)
- Stephanie A Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
- The American Medical Society For Sports Medicine, Leawood, Kansas, USA
| | - Irfan M Asif
- Family and Community Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Cheri Blauwet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation; Spaulding Hospital/Brigham and Women's Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
- Kelley Adaptive Sports Research Institute, Boston, Massachusetts, USA
| | - Leslie Christensen
- Department of Library Science, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nailah Coleman
- Pediatric Primary Care, Children's National Hospital, Washington, District of Columbia, USA
| | - Mark E Lavallee
- Department of Orthopedics, UPMC, Harrisburg, Pennsylvania, USA
| | - James L Moeller
- Orthopaedic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Shawn F Phillips
- Department of Family and Community Medicine, Penn State Health, Mount Joy, Pennsylvania, USA
| | - Ashwin Rao
- Family Medicine, University of Washington, Seattle, Washington, USA
| | - Katherine H Rizzone
- Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
| | - Sarah Sund
- The American Medical Society For Sports Medicine, Leawood, Kansas, USA
| | - Jeffrey L Tanji
- Orthopedics, UC Davis Sports Medicine, Sacramento, California, USA
| | - Yetsa A Tuakli-Wosornu
- Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Cleo D Stafford
- Department of Orthopaedics and Rehabilitations Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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10
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Vazquez S, Dominguez JF, Jacoby M, Rahimi M, Grant C, DelBello D, Salik I. Poor socioeconomic status is associated with delayed femoral fracture fixation in adolescent patients. Injury 2023; 54:111128. [PMID: 37875032 DOI: 10.1016/j.injury.2023.111128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Healthcare disparities continue to exist in pediatric orthopedic care. Femur fractures are the most common diaphyseal fracture and the leading cause of pediatric orthopedic hospitalization. Prompt time to surgical fixation of femur fractures is associated with improved outcomes. OBJECTIVE The objective of this study was to evaluate associations between socioeconomic status and timing of femoral fixation in adolescents on a nationwide level. METHODS The 2016-2020 National Inpatient Sample (NIS) database was queried using International Classification of Disease, 10th edition (ICD-10) codes for repair of femur fractures. Patients between the ages of 10 and 19 years of age with a principal diagnosis of femur fracture were selected. Patients transferred from outside hospitals were excluded. Baseline demographics and characteristics were described. Patients were categorized as poor socioeconomic status (PSES) if they were classified in the Healthcare Cost and Utilization Project's (HCUP) lowest 50th percentile median income household categories and on Medicaid insurance. The primary outcome studied was timing to femur fixation. Delayed fixation was defined as fixation occurring after 24 h of admission. Secondary outcomes included length of stay (LOS) and discharge disposition. RESULTS From 2016-2020, 10,715 adolescent patients underwent femur fracture repair throughout the United States. Of those, 765 (7.1 %) underwent late fixation. PSES and non-white race were consistently associated with late fixation, even when controlling for injury severity. Late fixation was associated with decreased rate of routine discharge (p < 0.01), increased LOS (p < 0.01) and increased total charges (p < 0.01). CONCLUSION Patients of PSES or non-white race were more likely to experience delayed femoral fracture fixation. Delayed fixation led to worse outcomes and increased healthcare resource utilization. Research studying healthcare disparities may provide insight for improved provider education, implicit bias training, and comprehensive standardization of care.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA.
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Jacoby
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Rahimi
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Christa Grant
- Department of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Damon DelBello
- Department of Orthopaedic Pediatric Surgery, Maria Fareri Children's Hospita, Westchester Medical Center, Valhalla, NY, USA
| | - Irim Salik
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
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11
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Zhu AS, Morrissey P, Byrne RA, Albright JA, Lemme NJ, Cruz AI, Owens BD. Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury. Orthop J Sports Med 2023; 11:23259671231212241. [PMID: 38021303 PMCID: PMC10666816 DOI: 10.1177/23259671231212241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 12/01/2023] Open
Abstract
Background Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability. Hypothesis Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment. Study Design Cohort study; Level of evidence, 3. Methods Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables. Results While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049). Conclusion In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.
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Affiliation(s)
- Angela S. Zhu
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
| | - Patrick Morrissey
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
| | - Rory A. Byrne
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
| | - J. Alex Albright
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
| | - Nicholas J. Lemme
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
| | - Aristides I. Cruz
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
| | - Brett D. Owens
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Rhode Island, USA
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12
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Kay J, Liotta ES, Sugimoto D, Heyworth BE. Assessment of Return to Sport After ACL Reconstruction With Soft Tissue Autograft in Adolescent Athletes: Quadriceps Versus Hamstring Tendon. Orthop J Sports Med 2023; 11:23259671231207113. [PMID: 38021299 PMCID: PMC10676070 DOI: 10.1177/23259671231207113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Quadriceps tendon soft tissue autograft represents an increasingly popular graft option for anterior cruciate ligament reconstruction (ACLR), particularly for adolescents, some of whom have an open physis, precluding use of graft options with bone plugs. Purpose/Hypothesis The purpose of this study was to quantify return-to-sport performance assessments in adolescents at 6 months after ACLR with all-soft tissue quadriceps tendon autograft (ACLR-Q) versus hamstring tendon autograft (ACLR-HS). It was hypothesized that ACLR-Q would be associated with improved hamstring strength and hamstring-to-quadriceps (HS:Q) ratios compared with ACLR-HS, albeit with decreased quadriceps strength. Study Design Cross-sectional study; Level of evidence, 3. Methods Included were patients aged 12 to 19 years who underwent primary ACLR by a single surgeon and who completed a return-to-sport performance assessment between 5 and 9 months postoperatively. The performance assessment included manual muscle strength tests (hamstring, quadriceps, hip abductor and adductor), dynamic balance test (Y-balance), and functional hop tests (single hop, triple hop, crossover hop, 6-m timed hop). Data were converted to limb symmetry indices, and limb symmetry index deficits were compared between the ACLR-Q and ACLR-HS cohorts using the Student t test or Wilcoxon-Mann-Whitney test. Results An initial cohort of 90 ACLR-Q patients was compared with 54 ACLR-HS patients, with no significant differences in patient characteristics. Differences in meniscal repair rates, however, prompted use of propensity score matching on age, sex, body mass index, meniscectomy, and meniscal repair to produce comparable subcohorts. The matching resulted in 67 ACLR-Q and 52 ACLR-HS patients. Hamstring strength deficits were significantly greater in ACLR-HS versus ACLR-Q patients (-40.5% vs -5.7%; P < .001). Quadriceps strength deficits were significantly greater in ACLR-Q versus ACLR-HS patients (-12.8% vs -0.4%; P < .001). ACLR-Q patients had a significantly greater HS:Q ratio on the operative knee (P < .001) and significantly higher Y-balance composite score deficits (-2.9% vs -0.4%; P = .01) than ACLR-HS patients. There were no significant differences in hop test performance between groups. Conclusion Adolescent athletes who underwent ACLR-Q showed significantly greater quadriceps strength deficits but significantly smaller hamstring strength deficits than those who underwent ACLR-HS, leading to more favorable HS:Q ratios in ACLR-Q patients at 6 months postoperatively.
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Affiliation(s)
- Jeffrey Kay
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Elizabeth S. Liotta
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Faculty of Sport Sciences, Waseda University, Tokyo, Japan
| | - Benton E. Heyworth
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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13
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Amen TB, Chatterjee A, Rudisill SS, Joseph GP, Nwachukwu BU, Ode GE, Williams RJ. National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States. Orthop J Sports Med 2023; 11:23259671231187447. [PMID: 37655237 PMCID: PMC10467402 DOI: 10.1177/23259671231187447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy. Purpose To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region. Study Design Descriptive epidemiology study. Methods The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables. Results During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]). Conclusion Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.
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Affiliation(s)
- Troy B. Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Abhinaba Chatterjee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Samuel S. Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Gabriel P. Joseph
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Benedict U. Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Gabriella E. Ode
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Riley J. Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
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14
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Jacobs CA, Stone AV, Johnson DL, Landy DC, Conley CE. Comparison of Physical Therapy Utilization and Motion-Related Re-operations Between Isolated Anterior Cruciate Ligament and Multi-Ligament Knee Injuries. Cureus 2023; 15:e40681. [PMID: 37485093 PMCID: PMC10357971 DOI: 10.7759/cureus.40681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
The increased prevalence of postoperative arthrofibrosis after multi-ligament knee injuries (MLKI) compared to isolated anterior cruciate ligament (ACL) injuries has been proposed to be due, in part, to patient factors limiting physical therapy utilization. The purpose of this study was to compare demographic factors, pre- and postoperative physical therapy utilization, and the need for motion-restoring surgery between MLKI and ACL-injured patients. Using the PearlDiver Mariner 151 database, two cohorts matched by age and sex were identified using current procedural terminology (CPT) codes and included those age 16 or greater that underwent isolated ACL (n=3801) vs. MLKI reconstruction (n=3801). The number of pre- and postoperative physical therapy visits was recorded, as was the need for motion-restoring surgery (arthroscopic lysis of adhesions or manipulation under anesthesia). Demographic factors, physical therapy utilization, and the prevalence of motion-restoring surgery were compared between the MLKI and ACL groups using t-tests or chi-square tests, as appropriate. A significantly greater proportion of those with MLKI underwent subsequent motion-restoring surgery (MLKI=412/3081 (13.4%) vs. ACL=84/3081 (2.7%), p<0.001; odds ratio = 5.5 (95% CI: 4.3, 7.0), p<0.0001). Following surgery, less than half of those with MLKI that underwent subsequent motion-restoring surgery attended physical therapy, which was significantly lower than those who did not require motion-restoring surgery (p<0.0001). The prevalence of motion-restoring surgery was significantly greater after MLKI when compared to an isolated ACL injury. While the etiology of arthrofibrosis after MLKI is likely complex, the current results suggest that demographic factors and physical therapy utilization are not solely responsible for the increased risk of arthrofibrosis after MLKI.
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Affiliation(s)
- Cale A Jacobs
- Orthopedic Surgery, Brigham and Women's Hospital, Boston, USA
| | - Austin V Stone
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
| | - Darren L Johnson
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
| | - David C Landy
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
| | - Caitlin E Conley
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
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15
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Migliorini F, Torsiello E, Trivellas A, Eschweiler J, Hildebrand F, Maffulli N. Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis. Sci Rep 2023; 13:6883. [PMID: 37106008 PMCID: PMC10140035 DOI: 10.1038/s41598-023-33899-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Andromahi Trivellas
- Department of Orthopaedic and Trauma Surgery, Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, 90095, USA
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
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16
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Ziedas A, Castle JP, Abed V, Swantek A, Chaides S, Elhage K, Fife J, Moutzouros V, Makhni EC. Associating Social Determinants of Health With PROMIS CAT Scores and Health Care Utilization After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671221139350. [PMID: 36683912 PMCID: PMC9850131 DOI: 10.1177/23259671221139350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 01/18/2023] Open
Abstract
Background The term "social determinants of health" (SDOH) refers to social and economic factors that influence a patient's health status. The effect of SDOH on the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) scores and postoperative resource utilization in patients with anterior cruciate ligament reconstruction (ACLR) have yet to be thoroughly studied. Purpose To investigate the impact SDOH have on PROMIS CAT outcomes and postoperative resource utilization in patients with ACLR. Study Design Cohort study; Level of evidence, 3. Methods The electronic medical record was used to identify the SDOH for patients who underwent ACLR by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons between July 2017 and April 2020. PROMIS CAT measures of Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), and Depression (PROMIS-D) were completed at the preoperative, 6-month postoperative, and 12-month postoperative time points. Postoperative health care utilization was recorded as well. Independent 2-group t tests and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH. Results Two-hundred and thirty patients who underwent ACLR were included (mean age, 27 years; 59% male). Compared with White patients, Black patients were represented more frequently in the lowest median household income (MHI) quartile (63% vs 23%, respectively; P < .001). White patients were represented more frequently in the highest area deprivation index (ADI) quartile when compared with Black patients (67% vs 12%, respectively; P = .006). Significantly worse PROMIS-PF, PROMIS-PI, and PROMIS-D scores at all 3 time points were found among patients who were Black, female, smokers, and in the lower MHI quartiles, with higher ADI and public health care coverage. In terms of resource utilization, Black patients attended significantly fewer postoperative physical therapy visits when compared with their respective counterparts. Those in the lower MHI quartiles attended significantly fewer postoperative imaging encounters, and female patients attended significantly more postoperative virtual encounters than male patients. Conclusion Specific SDOH variables, particularly those that reflect racial and socioeconomic disparities, were associated with differences in postoperative health care utilization and ACLR outcomes as measured by PROMIS CAT domains.
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Affiliation(s)
| | | | - Varag Abed
- Henry Ford Health System, Detroit, Michigan, USA
| | | | | | | | | | | | - Eric C. Makhni
- Henry Ford Health System, Detroit, Michigan, USA.,Eric C. Makhni, MD, MBA, Henry Ford Health System, 2799 W Grand
Boulevard, Detroit, MI 48202, USA (
)
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17
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Stafford CD, Keitt F, Irvin L. Health disparities in the management of ACL injuries: How socioeconomic status, insurance, and race influence care. PM R 2022; 14:669-677. [PMID: 35488488 DOI: 10.1002/pmrj.12831] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/06/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
Health care disparities and racial health inequities significantly influence health care delivery and patient outcomes, including for people with injuries of the anterior cruciate ligament (ACL). This narrative review explores factors that may influence the management of ACL injuries. Studies that have discussed potential social barriers to treatment such as socioeconomic status (SES), insurance status, educational level, and cost of treatment were identified by searching databases such as EBSCO Host, PubMed, and Galileo for the index years from 2008 to 2020. The influence of health care inequities on ACL injury management was explored. Twelve studies met inclusion criteria and described a total of 219,708 participants. Barriers to surgical management of ACL injury were higher cost of surgery, greater time to evaluation and treatment, lower SES, lack of private insurance, and being identified as a racial minority. In addition, surgical environment, whether within a private or community-based health care system, and access to care affected post-surgical complication rates. Finally, risk of revision, lack of physical therapy access, and odds of additional injuries to include chondral and meniscal derangement were higher in racial minority, lower SES, and government insurance populations. These findings suggest health disparity and inequity exist in the care of ACL injury for patients with lower SES and without commercial insurance, and in minority populations. These patients appear to have a significantly reduced ability to access timely care, which can impact healing and ability to return to preferred activities of daily life or sport.
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Affiliation(s)
- Cleo D Stafford
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Frazier Keitt
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Landon Irvin
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
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18
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Allahabadi S, Halvorson RT, Pandya NK. Association of Insurance Status With Treatment Delays for Pediatric and Adolescent Patients Undergoing Surgery for Patellar Instability. Orthop J Sports Med 2022; 10:23259671221094799. [PMID: 35601736 PMCID: PMC9118478 DOI: 10.1177/23259671221094799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Health care disparities have been highlighted in pediatric sports medicine, but the association between insurance status and delayed care for patients undergoing surgery for patellar instability has not been defined. Purpose: To determine whether there is an association between insurance status and delays in care in pediatric and adolescent patients undergoing surgery for patellar instability. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective case series at a safety-net tertiary referral center of pediatric and adolescent patients undergoing surgical treatment for patellar instability. Insurance status was classified as public or private. We calculated the times from injury to clinical evaluation, injury to magnetic resonance imaging (MRI), injury to surgery, clinical evaluation to MRI, and clinical evaluation to surgery. Comparisons were made between insurance groups. Results: Included were 78 patients (38 public, 40 private insurance) who underwent surgery for patellar instability. The public insurance group was older (P = .019), with a lower proportion of White patients (15.8% vs 52.5%; P = .0005), higher proportion with Hispanic ethnicity (55.3% vs 15.0%; P = .0001), and higher proportion of Spanish-speaking patients (21.1% vs 2.5%; P = .007). Publicly insured patients had longer times from initial injury to clinical evaluation (466 vs 77 days; P = .002), MRI (466 vs 82 days; P = .003), and surgery (695 vs 153 days; P = .0003), as well as a longer time from clinical evaluation to surgery (226 vs 73 days; P = .002). Multivariable models confirmed insurance status as an independent predictor in each of the identified delays. Conclusion: Significant delays were seen for pediatric and adolescent patients with patellar instability and public insurance (approximately 6 times longer to clinical evaluation, more than 5.5 times longer to obtain MRI, and 4.5 times longer to surgery) relative to injured patients with private insurance. Even after adjusting for delays to clinical evaluation, publicly insured patients had a delay from clinic to surgery that was triple that of privately insured patients.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ryan T Halvorson
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
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19
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Smith HE, Cruz AI, Mistovich RJ, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes JT, Sachleben BC, Schmale GA, Patel NM. What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study. Orthop J Sports Med 2022; 10:23259671221078333. [PMID: 35284586 PMCID: PMC8905066 DOI: 10.1177/23259671221078333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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Affiliation(s)
- Haley E. Smith
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I. Cruz
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - R. Justin Mistovich
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M. Leska
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J. Ganley
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T. Aoyama
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B. Ellis
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J. Lee
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D. McKay
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Todd A. Milbrandt
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T. Rhodes
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C. Sachleben
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A. Schmale
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M. Patel
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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20
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Ziedas A, Abed V, Swantek A, Cross A, Chaides S, Rahman T, Makhni EC. Social Determinants of Health Influence Access to Care and Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2022; 38:583-594.e4. [PMID: 34252555 DOI: 10.1016/j.arthro.2021.06.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the impact social determinants of health (SDOH) have on accessing orthopaedic treatment after an anterior cruciate ligament injury, as well as patient-reported and surgical outcomes after anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of the PubMed, MEDLINE, Epub Ahead of Print, Embase, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported at least 1 SDOH and its effect on patient-reported outcomes or surgical outcomes after anterior cruciate ligament reconstruction. Our search identified 937 studies. After eliminating 273 duplicates, 2 authors screened 664 articles on the basis of title and abstract. After this initial screening, 76 studies were evaluated for data extraction. Studies were categorized based on the social determinant(s) of health reported. RESULTS Twenty-two articles published between 2002 and 2020 were included in this study, encompassing 15 retrospective cohort studies, 3 prospective cohort studies, 3 cross-sectional studies, and 1 case-control study from 9 journals across 3 countries. Of these articles, 9 investigated race/ethnicity, 8 investigated insurance status, 4 investigated income, 5 investigated education level, 2 investigated employment status, and 5 investigated socioeconomic status. Reported outcomes included time to treatment, concomitant knee injury, patient-reported outcome measurement scores, postoperative complications, need for additional surgery, and postoperative healthcare utilization. CONCLUSIONS Certain SDOH, including black race, Hispanic ethnicity, public health insurance, and lower socioeconomic status contribute to a delay in access to care, which may result in increased severity of concomitant knee injuries encountered at the time of anterior cruciate ligament reconstruction and inferior outcomes. STUDY DESIGN Level III, systematic review of level I-III evidence.
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Affiliation(s)
| | - Varag Abed
- Henry Ford Health System, Detroit, Michigan, U.S.A
| | | | - Austin Cross
- Henry Ford Health System, Detroit, Michigan, U.S.A
| | | | | | - Eric C Makhni
- Henry Ford Health System, Detroit, Michigan, U.S.A..
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21
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Devana SK, Solorzano C, Nwachukwu B, Jones KJ. Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes. Curr Rev Musculoskelet Med 2022; 15:1-9. [PMID: 34970713 PMCID: PMC8804118 DOI: 10.1007/s12178-021-09736-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury. RECENT FINDINGS Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.
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Affiliation(s)
- Sai K. Devana
- Department of Orthopaedic Surgery, University of California, Los Angeles, USA
| | - Carlos Solorzano
- Department of Orthopaedic Surgery, University of California, Los Angeles, USA
| | - Benedict Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, University of California, Los Angeles, USA
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22
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Markiewitz ND, Swarup I, Talwar D, Muhly WT, Wells L, Williams BA. Perioperative Pain Management Practices Vary Across Time and Setting for Pediatric ACL Reconstruction: Trends From a National Database in the United States. Orthop J Sports Med 2022; 10:23259671211068831. [PMID: 35071660 PMCID: PMC8777349 DOI: 10.1177/23259671211068831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Surgical and anesthetic techniques have enabled a shift to the ambulatory
setting for the majority of patients with anterior cruciate ligament (ACL)
tears. While this change likely reflects improvements in acute pain
management, little is known about national trends in pediatric perioperative
pain management after ACL reconstruction (ACLR). Purpose: To describe recent trends in the United States in perioperative pain
management for pediatric ACLR. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Pediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve
blocks between January 2008 and December 2017 were identified in the
Pediatric Health Information System database. We modeled the use of oral and
intravenous analgesic medications over time using Bayesian logistic mixed
models. Models were adjusted for patient age, sex, race, primary payer, and
treatment setting (ambulatory, observation, or inpatient). Results: The study criteria produced a sample of 18,605 patients. Older children were
more likely to receive intravenous acetaminophen, intravenous ketorolac, and
oral and intravenous opioids. Younger children were more likely to receive
ibuprofen. In our adjusted logistic model, treatment setting was found to be
an independent predictor of the utilization of all medications. We found an
increase in the overall utilization of oral acetaminophen (adjusted odds
ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj
OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI,
1.06-1.28]) over the study period at a typical hospital. We found
significant heterogeneity in medication use across hospitals, with the most
heterogeneity in intravenous acetaminophen. Other studied descriptive
variables did not appear to predict practices. Conclusion: After adjusting for patient characteristics and treatment settings, pain
management strategies varied among hospitals and over time. Patient age and
treatment setting predicted practices. Regional anesthesia, opioid
medications, and intravenous ketorolac remained the mainstays of treatment,
while intravenous acetaminophen emerged in use over the course of the study
period. The variability in the pain management of pediatric patients
undergoing ACLR suggests that further study is necessary to establish the
most effective means of perioperative pain management in these patients.
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Affiliation(s)
- Nathan D. Markiewitz
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Divya Talwar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wallis T. Muhly
- Division of Anesthesia, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lawrence Wells
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brendan A. Williams
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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23
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Smith HE, Mistovich RJ, Cruz AI, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Fabricant PD, Green DW, Jagodzinski J, Johnson B, Kushare I, Lee RJ, McKay SD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Yen YM, Patel NM. Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures? Am J Sports Med 2021; 49:3842-3849. [PMID: 34652247 DOI: 10.1177/03635465211046928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
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Affiliation(s)
- Haley E Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - R Justin Mistovich
- Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I Cruz
- School of Medicine, Brown University, Providence, Rhode Island, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M Leska
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J Ganley
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T Aoyama
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | -
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Peter D Fabricant
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Daniel W Green
- Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason Jagodzinski
- UCSF Benioff Children's Hospital, San Francisco, California, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Benjamin Johnson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J Lee
- Johns Hopkins Children's Center, Baltimore, Maryland, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D McKay
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T Rhodes
- Children's Hospital Colorado, Aurora, Colorado, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C Sachleben
- Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - M Catherine Sargent
- Central Texas Pediatric Orthopaedics, Austin, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA].,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Abstract
Purpose of Review Youth sports participation has shifted from a school-based, seasonal activity to club-based, year-round activity over the past 10–15 years. Single sport specialization has become increasingly common with a concurrent increase in injury and burnout. Paralleling trends seen in other aspects of health care, disparities in regard to participation in youth sports, and subsequent injury treatment exist as well. Recognition of these disparities amongst coaches, parents, and athletes involved in youth sports are essential to promote the short- and long-term health of pediatric and adolescent athletes. Recent Findings Multiple barriers exist for youth in regard to sports participation. Youth who come from families without extensive financial means are increasingly finding it difficult to play organized sports, with this trend holding when broken down by insurance status (public versus private). This problem is further exacerbated by the lack of community-based programming in locations where organized (albeit expensive) options do not exist. The lack of athletic trainers increases the divide, as well as the care that injured athletes receive (particularly in public schools within communities of color) is not equivalent to schools with extensive financial resources. Thus, ability to quickly return to play after injury and/or access the health care system is limited. This is further exemplified by inferior outcomes in regard to care for anterior cruciate ligament, meniscus, shoulder instability, and concussions in this population. Summary Youth sports participation is laden with multiple disparities. This is unfortunately reflective of historical barriers to opportunities/advancements in multiple other areas of society. These disparities place certain groups of children at an uphill battle not only for participation when healthy, but also returning to participation when injured. Larger structural changes in youth sports are necessary to promote life-long, healthy physical activities for individuals most at risk.
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Affiliation(s)
- Nirav Kiritkumar Pandya
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA. .,Department of Pediatric Orthopedic Surgery, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA.
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25
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Robison HJ, Simon JE, Nelson EJ, Morris SN, Wasserman EB, Docherty CL. Secondary School Socioeconomic Status and Athletic Training Practice Characteristics. J Athl Train 2021; 57:418-424. [PMID: 34478545 DOI: 10.4085/1062-6050-0726.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Socioeconomic status (SES) is a significant predictor of morbidity and mortality across health outcomes. Limited information exists on how school SES impacts athletic training practice when a certified athletic trainer (AT) is present at secondary schools. OBJECTIVE To describe contact frequencies and service rates provided by ATs for injuries among secondary school student athletes and how these differ by school SES. DESIGN Cross-sectional study Setting: Athletic training room (ATR) visit days and AT services were collected from 77 secondary schools. Schools were separated into three school SES groups: affluent (n=31), average (n=29), and disadvantaged (n=17). PATIENTS OR OTHER PARTICIPANTS Secondary school student-athletes participating in 12 boys' and 11 girls' sports who visited the ATR during the 2014-2015 through 2018-2019 academic years and received athletic or non-athletic injury care. MAIN OUTCOME MEASURES Contact frequencies expressed as ATR visit days per injury, AT services per injury, and AT services per ATR visit day. Rates for service type utilized were expressed as the total count over reported athlete-exposures. RESULTS ATs documented 1,191 services. Affluent and average SES school communities provided greater contact frequencies for injury related care compared to disadvantaged school communities, particularly by AT services/injury (7.10±13.08 versus average: 9.30±11.60 and affluent: 9.40±12.20; p=0.020). Affluent school communities provided greater rates of services in five of the eleven service groups reported. No significant differences were observed among school SES groups in therapeutic exercises. CONCLUSIONS Our findings reflect that AT practice characteristics may differ by school SES, but these differences do not appear to result in less medical care. Given the complexity and widespread effects of SES, future investigations should utilize a complex method to determine SES as well as aim to identify how SES may impact secondary school student athletes outside of AT practice characteristics.
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Affiliation(s)
| | | | - Erik J Nelson
- Assistant Professor, Indiana University-Bloomington,
| | - Sarah N Morris
- Biostatistician, Datalys Center for Sports Injury Research and Prevention,
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26
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Patel NM, Helber AR, Gandhi JS, Shea KG, Ganley TJ. Race Predicts Unsuccessful Healing of Osteochondritis Dissecans in the Pediatric Knee. Orthopedics 2021; 44:e378-e384. [PMID: 34039200 DOI: 10.3928/01477447-20210414-09] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the effect of race, insurance status, and socioeconomic status on successful or unsuccessful healing of osteochondritis dissecans (OCD) lesions in the pediatric knee. The authors retrospectively reviewed patients younger than 18 years who were treated for a knee OCD lesion between 2006 and 2017. Patients were required to have at least 6 months of clinical and radiographic follow-up to be included, unless complete healing was achieved sooner. The primary outcome of interest was healing of the OCD lesion based on radiographic and clinical examination. A total of 204 OCD lesions in 196 patients with a mean follow-up of 15.8±6.4 months were included. The mean age at initial presentation was 12.4±2.8 years. At most recent follow-up, 28 (13.7%) lesions did not show radiographic or clinical evidence of healing. Nonhealing lesions were found in 25.0% of Black children compared with 9.4% of White children (P=.02). After controlling for age, sex, sports participation, lesion size and stability, skeletal maturity, and operative vs nonoperative treatment in a multivariate model, Black children had 6.7 times higher odds of unsuccessful healing compared with their White counterparts (95% CI, 1.1-41.7; P=.04). In this study, Black children with OCD of the knee were significantly less likely to heal than were White patients, even when controlling for numerous other factors in a multivariate model. Although the exact etiology of this finding is unclear, future work should focus on the social, economic, and cultural factors that may lead to disparate outcomes. [Orthopedics. 2021;44(3):e378-e384.].
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