Wimmer Sam P, Bent Melissa A, Wren Tishya A L, Kay Robert M
Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.
Keck School of Medicine, University of Southern California, Los Angeles, CA.
J Pediatr Orthop. 2025 Feb 1;45(2):e138-e142. doi: 10.1097/BPO.0000000000002837. Epub 2024 Oct 1.
Socioeconomic disadvantage has been shown to limit timely access to pediatric orthopaedic care and can result in poor surgical outcomes. Insurance coverage has often served as a proxy for socioeconomic status; however, area deprivation index (ADI) and child opportunity index (COI) are more comprehensive measures of social determinants of health (SDOH). The treatment of hip displacement in children with cerebral palsy (CP) requires early radiographic identification and continuous surveillance, which may be impacted by SDOH. This study seeks to evaluate the influence of insurance, ADI, and COI on preoperative Reimer migration percentage and need for pelvic osteotomy during varus derotation osteotomy (VDRO) in children with CP.
This retrospective cohort study examined 219 patients with CP who underwent VDRO surgery for hip subluxation or dislocation at a tertiary referral center (135 male, mean age 7.9 y, SD: 2.9, range: 2.4 to 17.2; 17 GMFCS II, 21 GMFCS III, 89 GMFCS IV, 92 GMFCS V) from 2004 to 2022. Imaging and clinical documentation for patients with CP and hip displacement, age <18 years with ≥1 year of follow-up, treated with VDRO were reviewed. GMFCS level, preoperative Reimer migration percentages (MP), surgical details, and demographic and socioeconomic data were collected, and addresses were used to determine ADI (2018 version) and COI (2.0 database). The relationship of ADI, COI, and insurance type to preoperative Reimer MP of the more displaced hip and the need for pelvic osteotomy were analyzed with linear regressions and logistic regressions.
The mean preoperative Reimer MP was 64.4% (SD: 25.0, range: 0 to 100). As expected, patients functioning at higher GMFCS levels presented with greater Reimer MPs. The average Reimer MP was 34.0 for GMFCS II, 44.2 for GMFCS III, 64.6 for GMFCS IV, and 74.5 for GMFCS V ( P <0.01). The mean ADI state decile (1 to 10 scale) and COI (1 to 100 scale) for the cohort were 5.6 (SD: 2.2, range: 1 to 10) and 37.2 (SD: 28.1, range: 4 to 100), respectively. ADI ( P =0.77), COI ( P =0.30), and insurance type ( P =0.78) were not related to preoperative Reimer MP. However, patients with lower ADIs (OR 0.83, 95% CI [0.70, 0.99], P =0.04) and higher COIs (OR 1.01, 95% CI [1.00, 1.03], P =0.03) underwent pelvic osteotomies at a higher rate.
ADI, COI, and insurance type were not related to preoperative Reimer MP. Interestingly, greater social disadvantage was associated with a lower frequency of pelvic osteotomy at the time of VDRO. Our data demonstrate that at our institution, greater social disadvantage does not result in limited access to timely orthopaedic care for children with CP. This is likely due to adequate governmental insurance coverage for children with neuromuscular disorders in this state and the active involvement of pediatric orthopaedic surgeons in government-sponsored clinics, including ongoing hip screening programs for children with CP. These results provide hope that healthcare disparities can potentially be mitigated.
社会经济劣势已被证明会限制及时获得小儿骨科护理，并可能导致手术效果不佳。保险覆盖范围常常被用作社会经济地位的替代指标；然而，地区贫困指数（ADI）和儿童机会指数（COI）是衡量健康社会决定因素（SDOH）的更全面指标。脑瘫（CP）患儿髋关节移位的治疗需要早期影像学识别和持续监测，这可能会受到SDOH的影响。本研究旨在评估保险、ADI和COI对CP患儿内翻旋转截骨术（VDRO）期间术前赖默移位百分比以及骨盆截骨需求的影响。
这项回顾性队列研究检查了2004年至2022年期间在一家三级转诊中心接受VDRO手术治疗髋关节半脱位或脱位的219例CP患儿（135例男性，平均年龄7.9岁，标准差：2.9，范围：2.4至17.2岁；17例GMFCS II级，21例GMFCS III级，89例GMFCS IV级，92例GMFCS V级）。对年龄<18岁、接受VDRO治疗且有≥1年随访的CP和髋关节移位患儿的影像学和临床记录进行了回顾。收集了GMFCS水平、术前赖默移位百分比（MP）、手术细节以及人口统计学和社会经济数据，并使用地址确定ADI（2018版）和COI（2.0数据库）。采用线性回归和逻辑回归分析ADI、COI和保险类型与术前移位更明显髋关节的赖默MP以及骨盆截骨需求之间的关系。
术前平均赖默MP为64.4%（标准差：25.0，范围：0至100）。正如预期的那样，GMFCS水平较高的患儿表现出更高的赖默MP。GMFCS II级的平均赖默MP为34.0，GMFCS III级为44.2，GMFCS IV级为64.6，GMFCS V级为74.5（P<0.01）。该队列的平均ADI州十分位数（1至10分制）和COI（1至100分制）分别为5.6（标准差：2.2，范围：1至10）和37.2（标准差：28.1，范围：4至100）。ADI（P = 0.77）、COI（P = 0.30）和保险类型（P = 0.78）与术前赖默MP无关。然而，ADI较低的患儿（比值比0.83，95%置信区间[0.70，0.99]，P = 0.04）和COI较高的患儿（比值比1.01，95%置信区间[1.00，1.03]，P = 0.03）接受骨盆截骨术的比例更高。
ADI、COI和保险类型与术前赖默MP无关。有趣的是，更大的社会劣势与VDRO时骨盆截骨术的较低频率相关。我们的数据表明，在我们的机构中，更大的社会劣势并不会导致CP患儿难以及时获得骨科护理。这可能是由于该州对神经肌肉疾病患儿有足够的政府保险覆盖，以及小儿骨科医生积极参与政府资助的诊所，包括正在进行的CP患儿髋关节筛查项目。这些结果为减轻医疗保健差距带来了希望。
