PEDIATRIC AND ADOLESCENT SHOULDER INSTABILITY: DOES INSURANCE STATUS PREDICT THE DEVELOPMENT OF BONY BANKART AND ENGAGING HILL-SACHS LESIONS?

Abstract

Background:

Pediatric and adolescent patients who undergo shoulder stabilization surgery have higher rates of failure than their adult counterparts. The impact of insurance status on intra-operative findings and outcomes is largely unknown.

Hypothesis/Purpose:

We hypothesized that patients with public insurance who undergo shoulder stabilization surgery would have greater degrees of bony pathology; leading to poor outcomes after stabilization.

Methods:

This was a retrospective cohort study of pediatric and adolescent patients with public and private insurance who were treated for recurrent shoulder instability from 2011-2017. Patients were treated at a tertiary care children’s hospital by a single orthopaedic surgeon. Patients 10 to 18 years of age were included in the study if they presented with recurrent shoulder instability and underwent surgical intervention for their injury. Time from injury to clinical consultation, imaging, and surgical intervention; incidences of labral pathology and secondary bony injury; and rates of repeat dislocation and repeat surgery were compared between the public and private insurance cohorts

Results:

Thirty-seven patients had public insurance while 18 patients had private insurance. Privately insured patients were evaluated by clinicians nearly five times faster than were publicly insured patients (p < 0.001), and they obtained MRIs over four times faster than did public insurance patients (p < 0.001). Publicly insured patients were twice as likely to have secondary bony injuries (p=0.043). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced re-dislocation versus the complete absence of re-dislocation in the privately insured patients (p=0.022).

Conclusion:

Public insurance status impacts access to care and correlates with both the development of secondary bony injury and an increased rate of clinical failure manifested as repeat post-operative dislocations.

Table 1.

Data Summary

	All (n=55)	Public Insurance (n=37)	Private Insurance (n=18)
Days from Injury to Clinic	298.71	402.38	85.61
Days from Injury to MRI	323.04	431.97	99.11
Days from Injury to Surgery	451.76	561.38	226.44
*Days from Clinic to MRI	24.33	29.59	13.50
*Days from MRI to Surgery	128.73	129.41	127.33
Number of prior dislocations		None = 3Single = 2Multiple = 32	None = 6Single = 0Multiple = 12
Incidence of anterior only vs. complex labral pathology	Anterior only = 81.8% (45/55)Complex = 18.2% (10/55)	Anterior only = 83.8% (31/37)Complex = 16.2% (6/37)	Anterior only = 77.8% (14/18)Complex = 22.2% (4/18)
Incidence of bony involvement (Y/N)	56.4% (31/55)	67.6% (25/37)	33% (6/18)
Incidence of repeat dislocations	16.4% (9/55)	24.3% (9/37)	0.00% (0/18)
*Incidence of repeat surgery	5.5% (3/55)	8% (3/37)	0.00% (0/18)

Table 1 shows the summary of results for public and private insurance cohorts for days from injury to clinic, injury to MRI, injury to surgery, clinic to MRI, MRI to surgery as well as number of prior dislocations, incidence of anterior only vs. complex labral pathology, incidence of bony involvement, incidence of repeat dislocations, and incidence of repeat surgery. * denotes that the difference between the two insurance cohorts was not statistically significant.