Abstract
Objectives:
The primary aim of this study was to evaluate the influence of socioeconomic status (SES), assessed by child opportunity index (COI) and insurance type, on the access to orthopedic care after pediatric ACL rupture. The secondary aim was to determine whether delays in access to care were associated with additional knee ligament injury or influenced any characteristics of the surgery. We hypothesize that patients with lower COI and public insurance will have greater delays to care and that delays in access to care will result in greater risk of additional knee ligament injury and concomitant procedures such as meniscus repair or meniscectomy.
Methods:
An IRB-approved retrospective study was conducted reviewing 238 patients aged 10-21 who underwent a primary ACLR between 2013 and 2021 at a tertiary care center. Demographic and clinical data were obtained via chart review. The time intervals of interest were date of injury to date of initial orthopedic visit, date of initial orthopedic visit to date of MRI exam, and date of MRI exam to date of surgery. Patients were grouped by those who had ≤ 30 days and > 30 days between each time interval. Statewide COI scores (total and 3 domains: education, SES, health) were collected based on each patient’s zip code and assigned quintile-ranking scores (very low or low, and moderate, high, or very high). Chi-square or fischer’s exact tests were used to compare the characteristics of patients with prompt versus delayed orthopedic care.
Results:
A total of 238 patients were included in this study. The mean age was 16.51 ± 1.73, and 66.0% were male and identified themselves as: 60.3% Asian/Other Race, 28.2% Black/African American, and 11.5% White. 54.1% of patients identified as Spanish/Hispanic/Latino and 63.1% had public insurance. 87.4% had very low or low total COI scores. There were no significant differences in insurance type or demographic factors between patients who received prompt or delayed care (Table 1). There were no significant differences total-COI, nor with any of its three domains; education-COI, socioeconomic-COI, and health-COI between patients who received care promptly or after 30 days (Table 2). Patients with ligamentous injuries were more prevalent in the group who had their initial orthopedic visit > 30 days after injury (82.8% vs 65.2%, p=0.004) (Table 3). Patients who ultimately underwent meniscus repair (56.7% vs 38.9%, p=0.004) and meniscectomy (24.7% vs 22.9%, p=0.004) were also significantly more prevalent in the group with > 30 days from injury to their initial orthopedic visit (Table 3). All patients with an initial orthopedic visit within 30 days of injury had autograft, while patients seen > 30 days after injury had a greater number of allografts and hybrid grafts (p=0.028) (Table 3).
Conclusions:
Lower SES, as measured by COI and public insurance, did not adversely affect time to orthopedic care after pediatric ACL injury. Patients with their initial orthopedic visit > 30 days after injury had a greater chance of additional ligamentous injury, undergoing additional meniscus repair or meniscectomy, and receiving allograft or hybrid graft over autograft. In a predominantly minority population with low COI, the influence of COI on access to care may not be as severe when compared to care delivered to minorities in a white majority population. Future studies should assess the impact of hospital and community-based interventions to help recognize telltale signs and symptoms of ACL injury and ensure an orthopedic visit within 30 days.
