Abstract
Background:
Previous studies have reported on the impact of race and ethnicity on access to orthopaedic procedures in the United States. However, there are few studies evaluating racial disparities in elective foot and ankle surgeries. Recognizing and addressing disparities in the access of health resources are steps to improve care rationing. Our study specifically investigated potential racial disparities with utilization and perioperative metrics of lateral ankle ligament reconstruction.
Methods:
A retrospective study was performed using the National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology (CPT) code 27698 was used to identify patients who underwent LALR from 2011 to 2020. Sixty-one percent of these patients had available race/ethnicity data and were included in the study. Designations of race and ethnicity were standardized as White non-Hispanic, Black non-Hispanic, Hispanic, Asian American and Pacific Islander, and Other. Race/ethnicity stratifications of NSQIP patients were compared to 2010 and 2020 census data from the United States (US) Census Bureau. Thirty-day postoperative complications and total length of hospital stay, for all complications, were also compared between White patients and all other patients combined. Independent t tests, χ2, and Fisher exact tests were performed to compare differences including age, gender, and postoperative complications.
Results:
Overall, 1295 patients were included in the study. White non-Hispanic patients underwent 3.3 times more LALR than all other patients during the study period. This finding shows a higher prevalence of surgery on White non-Hispanic patients than all others reported in the US Census Bureau data for 2010 and 2020, where the ratio of White non-Hispanic vs all others were 1.9 and 1.5-fold, respectively. White patients were marginally older with a mean age of 38 years, compared with 36 years for Black patients (P < .05). There were no differences in 30-day complication rates or total length of hospital stay based on race and ethnicity.
Conclusion:
Our study found that there was increased utilization of LALR for White non-Hispanic patients compared with all other racial/ethnic groups. These numbers do not mimic the current population trends based on the national census data. Despite this discrepancy, no differences in postoperative complications and length of stay were found based on race and ethnicity. These results suggest that there may be barriers for patients who are not White non-Hispanic to undergo care for LALR.
Level of Evidence:
Level III, retrospective cohort study.
Introduction
Health disparities are defined by the Centers for Disease Control and Prevention (CDC) as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. 7 Recently, attention has been drawn to disparities in utilization of health care services. Within the field of orthopaedics, disparities have been documented in utilization of elective surgical procedures that are known to improve quality of life.3,4,12,30 For example, Adams et al 1 reported a 10-fold greater utilization of total ankle arthroplasty in White non-Hispanic patients compared with other racial/ethnic groups. Similarly, Amen et al 3 found that there were not only disparities in use of total hip and knee arthroplasties but also worse outcomes including longer length of stay in the hospital and an increase in the incidence of complications in Black patients compared with White patients.
Providers must understand the extent of disparities in health care to better address issues related to access and care. Presently, no studies have examined whether disparities exist among patients undergoing elective orthopaedic foot and ankle procedures other than total ankle arthroplasty. Although total ankle arthroplasty has become more common over time, not all foot and ankle surgeons perform this procedure, and this may confound the ability of patients to undergo this procedure even when indicated. However, lateral ankle ligament reconstruction (LALR) is a common and well-established procedure used to treat chronic ankle instability (CAI) that affects patients of all racial and ethnic backgrounds. Although most patients with ankle instability can be adequately managed with conservative treatment modalities, many opt for surgical management when symptoms are severe and limiting. The purpose of this study was to examine national trends in the utilization of lateral ankle ligament reconstruction with respect to race and ethnicity to identify any disparities.
Materials and Methods
The institutional review board granted this study a human subject research exemption. We retrospectively reviewed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 through 2020. Patients undergoing lateral ankle ligament reconstruction as their principal procedure were identified in NSQIP using the common procedural code 27698. Collected data included race, ethnicity, age, gender, smoking status, presence of diabetes, postoperative complications, and length of total hospital stay. Postoperative complications that occurred 30 days following LALR were documented including number of bleeding transfusion occurrences, reoperation, deep vein thrombosis, pulmonary embolism, deep wound infection, superficial wound infection, number of pneumonia occurrences, number of acute renal failure occurrences, number of urinary tract infection occurrences, number of stroke/cerebrovascular accident occurrences, and number of myocardial infarction occurrences. Patients were included if race and ethnicity data were available (1295/2109, 61%).
Designations of race and ethnicity were standardized with the following categories: White non-Hispanic (“White”), African American/Black non-Hispanic (“Black”), Hispanic/Latinx (“Hispanic”), Asian American and Pacific Islander (“Asian”), and “Other” (including American Indian, Alaska Native, other or mixed race/ethnicity). The mean age, gender, smoking status, and presence of diabetes were evaluated for patients in the study based on racial/ethnic group. The 30-day postoperative complications and the length of total hospital stay were compared between White patients and all other groups combined. Continuous variables were evaluated for normality, and differences were evaluated using t tests. Categorical variables were compared using χ2 or Fisher exact tests. Statistical significance was set to P <.05. Statistical analyses were performed using IBM SPSS Statistics (version 28.0.1.0). Post hoc power analysis demonstrated an ability to detect a difference in complication rate of 2.2% between White patients and all other groups combined (alpha 0.05, power 0.80). Additionally, we used the International Classification of Diseases, Ninth Revision (ICD-9) code 718.87 and International Classification of Diseases, Tenth Revision (ICD-10) code M25.37 to identify NSQIP patients with chronic ankle instability (CAI) and stratified them based on race/ethnicity. Thirty-three percent (224/673) of CAI patients were excluded because they did not have race or ethnicity designations. US Census Bureau data was used to put surgical utilization rates in the context of existing demographics during the study period. Descriptive statistics were used to describe differences in utilization rates between groups.
Results
In total, 1295 patients who underwent lateral ankle ligament reconstruction were included in the study. Cohort demographic data are present in Table 1. There was a 3.3-fold difference in LALR utilization rate between White patients and all other racial/ethnic groups (995 vs 300 patients; Figure 1A). This finding correlates with the 4.7-fold difference in CAI between White patients and all other racial/ethnic groups (371 patients vs 78 patients), although it is important to note that 33% (224/673) of CAI patients were excluded because of missing race or ethnicity. However, this finding does not reflect US Census Bureau data as represented by a 1.9-fold difference between White individuals and all other racial/ethnic groups in 2010 (63.8% vs 34.1%, Figure 1B) and a 1.5-fold difference in 2020 (57.9% vs 37.5%, Figure 1C).
Cohort Demographics.
814 patients were excluded because of missing race/ethnicity data.
American College of Surgeons National Surgical Quality Improvement Program.
Statistically significant value compared to all other patients (P < .05).
Pie chart demonstrating the race/ethnicity distribution (%) of patients from the: (
Regarding patient characteristics, White patients (Table 1) were older (38 ± 14 years, P = .003), more often female (575/995, 57.8%, P < .001) and more often smokers (173/995, 17.4%, P = .012) compared with all other racial/ethnic groups. In contrast, Black patients were younger (36 ± 11 years, P = .027), composed of fewer females (50/131, 41.3%, P = .002), and fewer smokers (11/121, 9.1%, P = .03) compared with all other racial/ethnic groups. Asian patients were also composed of fewer females (10/33, 30.3%, P = .005) compared with White patients. There were no significant differences in mean age, gender, smoking status, and presence of diabetes among Hispanic, Asian, and Other patients compared with all other racial/ethnic groups.
Our study found a low rate of overall postoperative complications among White patients (27/995, 2.7%) and all other racial/ethnic groups (8/300, 2.7%), and a similar length of total hospital stay regardless of race/ethnicity (P > .05). Similarly, there were no significant differences in the overall 30-day complication rate or individual types of complications based on race and ethnicity (Table 2).
Thirty-Day Postoperative Complications and Length of Hospital Stay.
Due to postoperative complications.
Discussion
In comparison to national data on race/ethnicity distribution, this study found a disproportionate number of White patients undergoing LALR compared with all other groups. Race-based differences in orthopaedic surgical care are well documented.3,28,33,34 In total hip and knee arthroplasty (THA, TKA), Nelson 28 found significantly lower rates of utilization of joint replacements among Black populations after accounting for socioeconomic, geographic region, insurance status, and medical comorbidities. The current literature also demonstrates a nearly 10-fold greater difference in the utilization of total ankle arthroplasty in White non-Hispanic patients compared with other racial/ethnic groups. 1 In the present study, we found a 3.3-fold difference in the utilization of LALR in White patients compared with all others, correlating with the 4.7-fold difference in CAI between White patients and all other racial/ethnic groups. To some extent, this finding suggests that the larger number of White patients undergoing LALR is proportional to the number of White patients with CAI. However, a study by Waterman et al 39 suggests that White and Black patients may experience more ankle instability than other racial/ethnic groups. Variations in risk factors of CAI, including decreased ankle dorsiflexion range of motion, increased waist size, and lack of participation in balance training exercises, may vary among different populations, which would contribute to differences in the incidence of CAI. 25 Further systematic research is needed to elucidate differences in CAI across racial/ethnic groups to analyze the correlation between CAI prevalence and LALR utilization. Nonetheless, the significant difference in CAI prevalence and LALR utilization between White patients and all other racial/ethnic groups does not reflect current population trends based on national census data, and this necessitates further analysis of potential factors contributing to this disparity.
In addition to disparities related to utilization/access to care within orthopaedic surgery, some studies have found that there are increased rates of postoperative complications among minority groups compared with the White non-Hispanic patient population.15,38 Yin et al 38 found a higher rate of postoperative complications and a higher mortality rate among Black patients compared with White patients undergoing total shoulder arthroplasty. Singh et al 33 reported that Black populations undergoing total joint arthroplasty experience higher complication and readmission rates than their White counterparts. Our study found very low rates of postoperative complications regardless of race/ethnicity. This may be related to the relative lower rate of postoperative complications for LALR compared with joint replacement procedures such as total ankle arthroplasty, which have been found to have a mean complication rate of 19.7%. 22 A similar length of stay was also found for all patients regardless of race/ethnicity, which reflects most of these procedures being performed on an outpatient basis.
Despite smoking being a well-documented modifiable risk factor associated with higher rates of perioperative complications, our study found that there was a larger proportion of smokers among White patients compared with all other racial/ethnic groups. One potential explanation is that White patients may have higher risk permissibility for surgical procedures; however, further systematic research is needed to investigate this. Alternatively, minority patients may be less likely to self-report smoking prior to surgery.5,10,26
Our study also found that the majority of White patients undergoing LALR were female. There is notable data on sex-based differences in CAI. The risk for developing CAI is multifactorial and a combination of biomechanical, anatomical, and functional factors may contribute to a higher prevalence of CAI among females compared to males. For example, some studies have found that females exhibit heightened plantarflexion and lower foot clearance heights, and both have been found to be risk factors for ankle instability.6,31 Anatomical differences, including variations in tibia, talus, calcaneus, fibula, and lower extremity alignment, may further exacerbate the risk of developing CAI among females.13,21 However, there are limited data on the intersection between sex and race/ethnicity in common foot and ankle procedures.
The underlying causes of racial disparities are complex. The factors involved can be categorized into systemic factors, physician factors, and patient factors. 16 On a systemic level, minority patients have a greater rate of being uninsured or recipients of Medicaid, 22 and insurance status has been found to affect access to care. Specifically, several studies have found that Medicaid patients experience more difficulty in obtaining an appointment for care,14,29 are surgically treated by low-volume surgeons and facilities that have been found to increase the risk of postoperative complications,11,14,20,24,37 and experience more difficulty in obtaining a physical therapy appointment. 9 On a physician level, disparities in access to care are potentially exacerbated by limited cultural awareness and subsequent difficulties in cross-cultural communication.2,23 Additionally, several studies have demonstrated bias in physician decision making regarding pain management and treatment options for minority patients compared to their White counterparts.8,17,27,35,36 Todd et al35,36 noted that Hispanic and Black patients were 7 times less likely to receive opioids than White patients following surgery. On a patient level, differences in cultural attitudes toward total joint arthroplasty and general distrust towards health care professions have been shown to contribute to racial disparities in utilization rates.18,19 Ibrahim et al18,19 found that Black patients were less likely to express “willingness” to consider joint replacement than White patients; this difference was attributed to Black patients being less familiar with joint replacement and perceiving poor postoperative outcomes. Such differences in treatment expectations emphasize the differences in physician-patient experiences between Black and White patients, including communication and quality of care. 32 No studies to date have evaluated the perception of patients of color regarding elective foot and ankle surgeries such as lateral ankle ligament reconstruction. These systemic, physician, and patient factors highlight the challenges that minority patients must navigate to obtain adequate surgical care. Recognizing and addressing disparities in the access of health resources are imperative in combating systemic care rationing.
The main strength of this study is the large population of patients undergoing lateral ankle ligament reconstruction (nearly 1300). Despite this, we found a relatively low rate of complications (2.7%), and this study was not powered to detect the extremely small differences found in individual complications among groups. Next, we recognize the inherent limitations associated with a database study. Our study variables were limited to those available in the ACS-NSQIP database, and some data are absent or not interpretable within the confines of ICD-9 and ICD-10 codes. Other limitations include a lack of socioeconomic data and long-term follow-up data beyond 30 days. Additionally, the ACS-NSQIP database has been noted to be primarily composed of academic institutions. The nonrandom selection methodology employed by NSQIP auditors potentially decreases the generalizability of our findings. Finally, studies using the same database have noted the presence of oversampling in cohorts (particularly, the elderly, Black, and Hispanic persons) to accrue large pools of data.
Conclusion
White patients were 3.3 times more likely to undergo lateral ankle ligament reconstruction than all other patients despite a 1.5-1.9 increase in self-identified race/ethnic identification difference in the US population at the time of treatment. We found no differences in postoperative complications based on race or ethnicity. Additional work is needed to address systemic factors and patient factors that may impact this disparity in utilization of elective orthopaedic surgery.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114241265112 – Supplemental material for Racial Disparities in the Utilization of Lateral Ankle Ligament Reconstruction for Chronic Ankle Instability in the United States
Supplemental material, sj-pdf-1-fao-10.1177_24730114241265112 for Racial Disparities in the Utilization of Lateral Ankle Ligament Reconstruction for Chronic Ankle Instability in the United States by Myra Chao, Britanny A. Hamama, Jason Bariteau, Rishin Kadakia and Michelle M. Coleman in Foot & Ankle Orthopaedics
Footnotes
Ethical Approval
Ethical approval for this study was waived by the institutional review board because it was granted a human subject research exemption.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
