Do Social Determinants of Health Impact the Initial Evaluation and Management of Pediatric Patients With First-Time Patellofemoral Dislocation?

Abstract

Background: Under-resourced communities face greater barriers to care. However, this relationship is not well-defined in the management of patellofemoral instability. We hypothesized that pediatric patients from under-resourced neighborhoods and those with public insurance would experience delays in care for first-time patellofemoral dislocation.

Methods: A retrospective cohort study was performed of patients younger than or equal to 18 years evaluated at a single institution after a first-time patellofemoral dislocation between 2011 and 2022. Demographic, clinical, and radiographic characteristics were collected. Neighborhood conditions were categorized using the Child Opportunity Index (COI). Time from injury to presentation, magnetic resonance imaging (MRI), and physical therapy (PT) initiation were compared across COI categories and insurance types.

Results: Three hundred seventy-five patients with first-time patellofemoral dislocation met inclusion criteria. Injuries occurred at a mean age of 14.2±2.1 years, with a majority occurring in female patients (55%). Time to evaluation by orthopaedic provider was longer in patients with very low COI (8.4 vs. 5.6 d for very high COI patients, P <0.001) and those with public insurance (7.4 vs. 6.1 d in those with private insurance, P =0.001). Time to MRI was also longer in patients with very low COI (mean 18.6 vs. 11.2 d in the very high group, P <0.001) and those with public insurance (mean 17.4 d vs. 12.5 d in those with private insurance, P <0.001). Time to initial PT evaluation was longer in patients of very low COI (67.0 d vs 39.4 in the very high group, P =0.02) and in patients with public insurance (49.5 vs 47.5 d in those with private insurance, P =0.03).

Conclusion: Neighborhood resources and insurance are associated with statistically significant delays across multiple phases of care for pediatric patients with first-time patellar dislocation. The specific mechanisms underlying these disparities and the clinical significance of these delays require further evaluation. Efforts should be made to develop interventions that address these barriers and providers should be aware of these inequities.

Levels of evidence: Level III (retrospective comparative study).