Pediatric and Adolescent Shoulder Instability: Does Insurance Status Predict Delays in Care, Outcomes, and Complication Rate?

Children and adolescents with all forms of shoulder instability demonstrate differences in their movement and muscle activity patterns when compared to age- and sex-matched controls

HYPOTHESIS AND BACKGROUND

Shoulder instability (SI) is a complex impairment, and identifying biomarkers that differentiate subgroups is challenging. Children and adolescents with SI (irrespective of etiology) have differences in their movement and muscle activity profiles compared to age- and sex-matched controls (2-tailed). There are limited fundamental movement and muscle activity data for identifying different mechanisms for SI in children and adolescents that can inform subgrouping and treatment allocation.

METHODS

Young people between 8 and 18 years were recruited into 2 groups of SI and age- and sex-matched controls (CG). All forms of SI were included, and young people with coexisting neurologic pathologies or deficits were excluded. Participants attended a single session and carried out 4 unweighted and 3 weighted tasks in which their movements and muscle activity was measured using 3-dimensional (3D) movement analysis and surface electromyography (sEMG). Statistical parametric mapping was used to identify between-group differences.

RESULTS

Data were collected for 30 young people (15 SI [6 male, 9 female] and 15 CG [8 male, 7 female]). The mean (standard deviation) age of the participants was 13.6 years (3.0). The SI group demonstrated consistently more protracted and elevated sternoclavicular joint positions during all movements. Normalized muscle activity in latissimus dorsi was lower in the SI group and had the most statistically significant differences across all movements. Where differences were identified, the SI group also had increased normalized activity of their middle trapezius, posterior deltoid, and biceps muscles but decreased activity of their latissimus dorsi, triceps and anterior deltoid muscles compared with the CG group. No statistically significant differences were found for the pectoralis major across any movements. Weighted tasks produced fewer differences in muscle activity patterns compared with unweighted tasks.

DISCUSSION AND CONCLUSION

Young people with SI may adapt their movements to minimize glenohumeral joint instability. This was demonstrated by reduced variability in acromioclavicular and sternoclavicular joint angles, adoption of different movement strategies across the same joints, and increased activity of the scapular stabilizing muscles, despite achieving similar arm positions to the CG. Young people with SI demonstrated consistent differences in their muscle activity and movement patterns. Consistently observed differences at the shoulder girdle included increased sternoclavicular protraction and elevation accompanied by increased normalized activity of the posterior scapula-stabilizing muscles. Existing methods of measurement may be used to inform clinical decision making; however, further work is needed to evaluate the prognostic and clinical utility of derived 3D and sEMG data for informing decision making within SI.

Incidence of arthroscopic and open pediatric shoulder stabilization procedures across the United States: a Pediatric Health Information System database study

Background

Shoulder instability in pediatric and adolescent patients can be treated operatively via arthroscopic or open procedures, but there a paucity of evidence to support the incidence of these treatment modalities over time. It is hypothesized that the overall rate of arthroscopic shoulder stabilization procedures will increase over time. Given advances in open stabilization techniques, we also hypothesized that the rate of open procedures may be increasing.

Methods

The Pediatric Health Information System database was queried for patients 19 years or younger who underwent arthroscopic or open surgery for shoulder instability and pediatric orthopedic surgeries between 2009 and 2019. Data from 37 of the 52 pediatric hospitals with Pediatric Health Information System data was included in the analysis. Annual and overall incidence rates were estimated for arthroscopic and open procedures, along with 95% confidence intervals. The yearly incidence for secondary (homolateral revisions) or primary contralateral arthroscopic and open procedures was also examined.

Results

4747 patients underwent primary arthroscopic procedures and 384 patients had primary open procedures. There were 8.2 primary open shoulder stabilization procedures per 10,000 orthopedic surgical patients in 2009, which decreased by 19% to 6.7 per 10,000 orthopedic surgical patients in 2019. There was an increase seen in both arthroscopic and open secondary stabilization procedures. In 2009, there were 0.97 secondary arthroscopic procedures per 10,000 orthopedic surgical patients. This increased by 672% to 7.5 per 10,000 orthopedic surgical patients in 2019. No secondary open procedures were recorded in 2009; however, an increase to 2.6 secondary open procedures per 10,000 orthopedic surgical patients was seen by 2019.

Conclusion

This study shows a rise in primary arthroscopic pediatric shoulder stabilization surgeries across the U.S. over the last decade. There was a slight decrease in the rate of primary open shoulder stabilization surgeries and an increase in both arthroscopic and open secondary (homolateral revisions or primary contralateral) shoulder stabilization surgeries, implying an increasing revision burden in this population.

Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics

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.

Effect of Age and Body Mass Index on Time to Advanced Imaging and Surgery in Young Athletes With Anterior Cruciate Ligament Injury

Background

In young athletes with anterior cruciate ligament (ACL) injury, increased times from injury to magnetic resonance imaging (MRI) and injury to surgery can lead to the accrual of new injuries over time.

Purpose

To determine the patient characteristics associated with differences in timing between injury, MRI, and surgery in young athletes with ACL tears.

Study Design

Case-control study; Level of evidence, 3.

Methods

We reviewed the electronic medical records of patients aged 13 to 25 years who underwent isolated primary ACL reconstruction between January 2017 and June 2020 at a single orthopaedic surgery department. The times from injury to MRI, MRI to surgery, and injury to surgery were documented. Patient demographic data (age, sex, body mass index [BMI], race and ethnicity, and insurance type) were recorded. Multivariable analysis was used to determine if any patient characteristic had a significant association with increased time to MRI or surgery.

Results

A total of 369 patients (mean age, 18.0 years; 56% female) were included. Both age and BMI were found to be significantly associated with timing of care while holding all other predictors constant. For every 1-year increase in patient age, time from injury to MRI increased by 9.6 days (95% CI, 1.8-17.4 days; P = .02), time from MRI to surgery increased by 7.4 days (95% CI, 4.4-10.5 days; P < .001), and time from injury to surgery increased by 17.0 days (95% CI, 8.4-25.6 days; P < .001). Compared with patients with normal BMI, overweight patients (BMI range, 25-29.9 kg/m2) had an MRI-to-surgery time that was on average 37.2 days (95% CI, 11.7-62.7 days; P < .004) longer and an injury to surgery time that was on average 71.8 days (95% CI, 0.5-143.0 days; P = .048) longer. Obese patients (BMI ≥30 kg/m2) did not demonstrate a significant relationship with the studied time intervals.

Conclusion

Increasing age and elevated BMI were found to be associated with increased time to MRI and surgical care in young athletes with ACL injuries.

Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF).

METHODS

Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes.

RESULTS

A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories.

CONCLUSIONS

In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.

Public Insurance Is Associated With Decreased Rates of Surgical Management for Glenohumeral Instability: An Analysis of the Rhode Island All-Payers Claims Database

Background

Socioeconomic status has been shown to influence patients' ability to access health care.

Purpose

To evaluate the socioeconomic status and/or insurance provider of patients and to determine whether these differences influence the management of shoulder instability.

Study Design

Descriptive epidemiology study.

Methods

The Rhode Island All-Payers Claims Database (APCD) was used to identify all patients between the ages of 5 and 64 years who made an insurance claim related to a shoulder instability event between January 1, 2011, and December 31, 2019. Chi-square analysis and multivariate logistic regression were utilized to determine whether insurance status, social deprivation index (SDI), or median income by zip code were significant predictors of treatment methodology and recurrent instability. Kaplan-Meier failure analysis and Cox regression were used to assess for variation in the cumulative rates of surgical intervention and recurrent instability over 20-year age groups (5-24, 25-44, and 45-64 years).

Results

There were 3310 patients from the APCD query included in the analysis. Bivariate analysis demonstrated significant variation in the rates of surgical stabilization between patients with public and commercial insurance providers (P < .001). Patients with public insurance received surgery 1.8% of the time compared with 5.8% of the time in patients with commercial insurance. After controlling for recurrent instability, age, instability type (subluxation or dislocation) and directionality, and sex, patients with public insurance were 79% less likely to receive surgery within 30 days (P = .035) and 64% less likely to receive surgery within 1 year (P = .002). This disparity was most notable in the 5- to 24-year (hazard ratio [HR] = 0.28; 95% CI, 0.13-0.61) and 25- to 44-year (HR = 0.26; 95% CI, 0.08-0.89) age groups. Neither SDI quartile nor income quartile based on patient primary zip code had a clinically significant influence on rates of surgery or recurrent instability.

Conclusion

These data demonstrate that patients with public insurance have a decreased likelihood of undergoing surgical stabilization to address glenohumeral instability compared with patients with commercial insurance.

Insurance status is not a predictor of rotator cuff tear magnitude

Background

Rotator cuff tear (RCT) chronicity is an important factor in considering treatment options and outcomes for surgical repair. Many factors may contribute to delayed treatment, including timely access to care due to insurance status. The purpose of this study was to evaluate the relationship between the magnitude of RCT on presentation and insurance status. We hypothesize that publicly insured patients will have a greater incidence of chronic RCTs and shoulder pathology on initial presentation.

Methods

Retrospective chart review of patients undergoing RCT repair at an academic tertiary care institution from 2005 to 2019. Demographic data, including age, race, sex, and insurance carrier, were collected. Insurance carriers were categorized into public (Medicare and Medicaid) or private insurance coverage. Individual magnetic resonance imagings were then reviewed by a board-certified musculoskeletal radiologist for supraspinatus (SS), infraspinatus (IS), subscapularis, and biceps tendon tears, as well as acromioclavicular arthritis. In addition, rotator cuff atrophy was evaluated by the scapular ratio. Univariate analysis of variance and logistic regression analyses were used to compare demographics and rotator cuff pathology between those with Medicaid and Medicare, as well as between publicly and privately insured patients.

Results

Of the 492 patients in this study, 192 had private insurance, and 300 had public insurance (Medicaid: 50 and Medicare: 250). Insurance status was not found to be associated with differences in RCTs between Medicare and Medicaid patients. Those with Medicaid or Medicare (public), presented more frequently with SS or IS atrophy (SS atrophy, P = .002; IS atrophy, P = .039) than those with private insurance. However, after adjusting for age, no significant differences in rotator cuff tendon tear or atrophy frequencies were found between insurance groups.

Conclusions

Patients with private and public insurance tend to present with similar chronicity and magnitude of RCTs. Insurance status does not appear to influence timely access to surgical care for patients with RCTs at an academic medical center.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical Relevance

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

Common Upper Extremity Injuries in Pediatric Athletes

PURPOSE OF REVIEW

The aim of this study is to review the most recent literature on common upper extremity injuries in pediatric athletes and discuss their diagnosis, management, and outcomes. We also highlight ultrasound as a tool in their evaluation.

RECENT FINDINGS

Shoulder conditions presented include little league shoulder, glenohumeral rotation deficit, acute traumatic shoulder dislocation, and multidirectional shoulder instability. Elbow conditions include capitellar OCD, medial epicondyle avulsion fracture, and medial epicondylitis. We also review scaphoid fractures and gymnast wrist. Not all physeal injuries lead to long-term growth disruption. Ultrasound has been shown to be useful in the diagnosis of scaphoid fracture, medial epicondyle avulsion fractures, and capitellar OCD. It can also be helpful in assessing risk for shoulder and elbow injuries in overhead athletes. There is a rising burden of upper extremity injuries among pediatric athletes. Knowledge of their sport specific mechanics can be helpful in diagnosis. As long-term outcome data become available for these conditions, it is clear, proper diagnosis and management are critical to preventing adverse outcomes. We highlight many of these injuries, best practice in care, and controversies in care in hopes of improving outcomes and preventing injury for pediatric athletes.

Association of Insurance Status With Treatment Delays for Pediatric and Adolescent Patients Undergoing Surgery for Patellar Instability

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.

Epidemiology and Revision Rates of Pediatric ACL Reconstruction in New York State

BACKGROUND

There are limited epidemiologic data examining the incidence of pediatric anterior cruciate ligament reconstruction (ACLR) over the past decade.

PURPOSE

To examine statewide population trends in the incidence of ACLR in a pediatric population.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Inpatient and outpatient claims for pediatric patients who underwent ACLR between 2009 and 2017 were identified in the New York Statewide Planning and Research Cooperative System database via International Classification of Diseases (ICD), Revision 9, Clinical Modification; ICD, Revision 10, Clinical Modification and Procedural Classification System; or Current Procedural Terminology codes. New York population data for each year between 2009 and 2017 were used from the New York State Department of Health to calculate the rates of ACLR per 100,000 people aged 3 to 19 years and determine the 95% confidence limits. The rates were then stratified by age, sex, and insurance. Two-year rates of revision and contralateral ACLR were also analyzed by sex.

RESULTS

Between 2009 and 2017, 20,170 pediatric ACLRs were identified. The rates of pediatric ACLR increased steadily from 49.3 per 100,000 in 2009 (95% CI, 47.2-51.4) to a peak of 61.0 (95% CI, 58.6-63.4) in 2014 and decreased to 51.8 (95% CI, 49.6-54.1) by 2017. The age group 15 to 17 years had the highest rates of ACLR of all age groups, peaking at 198.5 (95% CI, 188.3-208.7) per 100,000. Analysis by sex showed that ACLR rates between males and females were not different. Males had a 2-year ipsilateral revision rate of 4.3%, while females had a rate of 3.3% (P = .0001). Females had a contralateral ACLR rate of 4.0%, while males had a rate of 2.6% (P = .0002).

CONCLUSION

Pediatric ACLR rates continued to rise until 2014, but there was a demonstrable decrease in rates after 2014. This decline in pediatric ACLR may point to the efficacy of injury prevention programs or changes in practice management. The high revision rate in males and high contralateral surgery rate in females can help guide patient counseling for return to play and complication risk.

CLINICAL RELEVANCE

This study showed that ACLR in pediatric patients may be decreasing in recent years. There were differences in revision and contralateral ACLR by sex.

Disparities in Youth Sports and Barriers to Participation

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.