Background 

Markers of a patient’s social determinants of health, including healthcare insurance and median household income based on ZIP Code, have been associated with the interval between injury and ACL reconstruction (ACLR) as well as the presence of concomitant meniscus tears in children and adolescents. However, the aforementioned surrogate indicators of a patient’s social determinants of health may not reflect all socioeconomic and healthcare resources affecting the care of ACL injuries in children and adolescents. The use of multivariate indices such as the Child Opportunity Index (COI) may help to better identify patients at risk for increased risk for delay between ACL injury and surgery, as well as the incidence of meniscus tears at the time of surgery. The COI is a summative measure of 29 indicators that reflect neighborhood opportunities across three domains: education, health and environment, and social and economic factors. COI scores range from 0 to 100 (100 being the highest possible score), as well as five categorical scores (very low, low, moderate, high, and very high) based on quintile rankings.

Questions/purposes 

To investigate the relationship between neighborhood conditions and the treatment of ACL injuries in children and adolescents via the COI, we asked: (1) Is a lower COI score associated with a longer delay between ACL injury and surgery? (2) Does a higher proportion of patients with lower COI scores have meniscus tears at the time of ACLR?

Methods 

In this retrospective, comparative study, we considered data from 565 patients, 18 years or younger, who underwent primary ACLR at an urban, tertiary children’s hospital between 2011 and 2021. Of these patients, 5% (31 of 565) did not have a clearly documented date of injury, 2% (11 of 565) underwent revision reconstructions, and 1% (5 of 565) underwent intentionally delayed or staged procedures. Because we specifically sought to compare patients who had low or very low COI scores (lowest two quintiles) with those who had high or very high scores (highest two quintiles), we excluded 18% (103 of 565) of patients with moderate scores. Ultimately, 73% (415 of 565) of patients with COI scores in either the top or bottom two quintiles were included. Patient addresses at the time of surgery were used to determine the COI score. There were no differences between the groups in terms of gender. However, patients with high or very high COI scores had a lower median (IQR) age (15 years [2.6] versus 17 years [1.8]; p < 0.001) and BMI (23 kg/m² [6.1] versus 25 kg/m² [8.8]; p < 0.001), were more commonly privately insured (62% [117 of 188] versus 22% [51 of 227]; p < 0.001), and had a higher proportion of patients identifying as White (67% [126 of 188] versus 6.2% [14 of 227]; p < 0.001) compared with patients with low or very low COI scores. Medical records were reviewed for demographic, preoperative, and intraoperative data. Univariate analyses focused on the relationship of the COI and interval between injury and surgery, frequency of concomitant meniscus tears, and frequency of irreparable meniscus tears treated with partial meniscectomy. Multivariable regression analyses were used to determine factors that were independently associated with delayed surgery (longer than 60 and 90 days after injury), presence of concomitant meniscal injuries, and performance of meniscectomy. Multivariable models included insurance and race or ethnicity to determine whether COI was independently associative after accounting for these variables.

Results 

Patients with a high or very high COI score had surgery earlier than those with a low or very low COI score (median [IQR] 53 days [53] versus 97 days [104]; p < 0.001). After adjusting for insurance and race/ethnicity, we found that patients with a low or very low COI score were more likely than patients with a high or very high COI score to have surgery more than 60 days after injury (OR 2.1 [95% CI 1.1 to 4.0]; p = 0.02) or more than 90 days after injury (OR 1.8 [95% CI 1.1 to 3.4]; p = 0.04). Furthermore, patients with low or very low COI scores were more likely to have concomitant meniscus tears (OR 1.6 [95% CI 1.1 to 2.5]; p = 0.04) compared with patients with high or very high COI scores. After controlling for insurance, race/ethnicity, time to surgery, and other variables, there was no association between COI and meniscectomy (OR 1.6 [95% CI 0.9 to 2.8]; p = 0.12) or presence of a chondral injury (OR 1.7 [95% CI 0.7 to 3.9]; p = 0.20).

Conclusion 

As the COI score is independently associated with a delay between ACL injury and surgery as well as the incidence of meniscus tears at the time of surgery, this score can be useful in identifying patients and communities at risk for disparate care after ACL injury. The COI score or similar metrics can be incorporated into medical records to identify at-risk patients and dedicate appropriate resources for efficient care. Additionally, neighborhoods with a low COI score may benefit from improvements in the availability of additional and/or improved resources. Future studies should focus on the relationship between the COI score and long-term patient-reported functional outcomes after ACL injury, identification of the specific timepoints in care that lead to delayed surgery for those with lower COI scores, and the impact of community-based interventions in improving health equity in children with ACL injury.

Level of Evidence 

Level III, therapeutic study.

中文翻译：

---

社区条件是否与接受 ACL 重建的儿童和青少年的手术延误和半月板撕裂有关？

背景 

患者健康社会决定因素的标志，包括医疗保险和基于邮政编码的家庭收入中位数，与受伤和 ACL 重建 (ACLR) 之间的间隔以及儿童和青少年伴随的半月板撕裂的存在有关。然而，上述患者健康社会决定因素的替代指标可能无法反映影响儿童和青少年 ACL 损伤护理的所有社会经济和医疗保健资源。使用儿童机会指数 (COI) 等多变量指数可能有助于更好地识别 ACL 损伤和手术之间延迟风险增加的风险患者，以及手术时半月板撕裂的发生率。COI 是 29 个指标的综合衡量指标，反映了三个领域的邻里机会：教育、健康和环境，以及社会和经济因素。COI 分数范围从 0 到 100（100 是可能的最高分数），以及基于五分位数排名的五个分类分数（非常低、低、中等、高和非常高）。

问题/目的 

为了通过 COI 调查邻里条件与儿童和青少年 ACL 损伤治疗之间的关系，我们询问：(1) 较低的 COI 评分是否与 ACL 损伤和手术之间的较长延迟相关？(2) 是否有较高比例的 COI 评分较低的患者在 ACLR 时有半月板撕裂？

方法 

在这项回顾性比较研究中，我们考虑了 565 名年龄在 18 岁或以下的患者的数据，这些患者在 2011 年至 2021 年间在城市三级儿童医院接受了初级 ACLR。在这些患者中，5%（565 名中的 31 名）没有明确记录受伤日期，2%（565 人中的 11 人）接受了翻修重建，1%（565 人中的 5 人）接受了故意延迟或分期手术。因为我们专门试图比较 COI 评分低或非常低（最低的两个五分位数）的患者与评分高或非常高（最高的两个五分位数）的患者，我们排除了 18%（565 名中的 103 名）的中等评分患者。最终，73%（565 名中的 415 名）的 COI 评分在前两个五分位数或后五分位数中的患者被纳入。手术时的患者地址用于确定 COI 评分。就性别而言，各组之间没有差异。然而，COI 评分高或非常高的患者的中位 (IQR) 年龄（15 岁 [2.6] 对比 17 岁 [1.8]；p < 0.001）和 BMI（23 kg/m² [6.1] 对比 25 kg/m ²[8.8]；p < 0.001），更常见的是私人保险（62% [188 人中的 117 人] 对比 22% [227 人中的 51 人]；p < 0.001），并且有更高比例的白人患者（67% [188 人中的 126 人]与 6.2% [227 人中的 14 人]；p < 0.001）与 COI 评分低或非常低的患者相比。审查医疗记录的人口统计学、术前和术中数据。单变量分析侧重于 COI 与损伤和手术之间的间隔、伴随半月板撕裂的频率以及部分半月板切除术治疗的无法修复的半月板撕裂的频率之间的关系。多变量回归分析用于确定与延迟手术（受伤后超过 60 天和 90 天）、是否存在伴随半月板损伤和半月板切除术独立相关的因素。

结果 

COI 评分高或非常高的患者比 COI 评分低或非常低的患者更早接受手术（中位 [IQR] 53 天 [53] 对比 97 天 [104]；p < 0.001）。在针对保险和种族/族裔进行调整后，我们发现 COI 评分低或非常低的患者比 COI 评分高或非常高的患者更有可能在受伤后 60 天以上接受手术（OR 2.1 [95% CI 1.1 至 4.0]；p = 0.02）或受伤后超过 90 天（OR 1.8 [95% CI 1.1 至 3.4]；p = 0.04）。此外，与 COI 评分高或非常高的患者相比，COI 评分低或非常低的患者更可能伴有半月板撕裂 (OR 1.6 [95% CI 1.1 至 2.5]；p = 0.04)。在控制保险、种族/民族、手术时间和其他变量后，COI 与半月板切除术之间没有关联 (OR 1. 6 [95% CI 0.9 至 2.8]；p = 0.12) 或存在软骨损伤（OR 1.7 [95% CI 0.7 至 3.9]；p = 0.20）。

结论 

由于 COI 评分与 ACL 损伤和手术之间的延迟以及手术时半月板撕裂的发生率独立相关，因此该评分可用于识别 ACL 损伤后面临不同护理风险的患者和社区。可以将 COI 评分或类似指标纳入医疗记录中，以识别处于危险中的患者并为有效护理分配适当的资源。此外，COI 得分较低的社区可能会受益于额外和/或改进资源可用性的改善。未来的研究应侧重于 COI 评分与 ACL 损伤后患者报告的长期功能结果之间的关系，确定导致 COI 评分较低的患者延迟手术的特定护理时间点，

证据等级 

III 级，治疗研究。