Access to care for the adolescent anterior cruciate ligament patient with Medicaid versus private insurance.

PURPOSE: To determine the potential impact of type of health insurance on access to outpatient orthopaedic care for an adolescent patient with an acute anterior cruciate ligament (ACL) tear. METHODS: The offices of 42 orthopaedic surgeons in the Greater Cincinnati area, to include Ohio, Indiana, and Kentucky were contacted on 2 separate occasions describing a fictitious 14-year-old male with an acute ACL tear. The 2 calls were separated by a period of 2 to 4 weeks. The independent variable was the patient's insurance status, reported as either Medicaid or private insurance. Statistical comparison of the rates of successful appointment scheduling was performed through the Fisher exact test. RESULTS: Thirty-eight of 42 Orthopaedic surgery practices (90%) offered the privately insured 14-year-old ACL patient an appointment within 2 weeks, while only 6 of 42 (14%) offered the Medicaid patient such an appointment. The difference in these rates was statistically significant (P<0.0001) with the odds of getting an appointment with private insurance being 57 times higher than that with Medicaid (95% confidence interval: 12.87, 288.62). CONCLUSIONS: Access to orthopaedic care for children on Medicaid continues to be a problem in the United States. Previous pediatric studies have documented that the reason for these discrepancies in access are related primarily to Medicaid reimbursement rates (approximately 23% of private insurance). Ours is the first study to show that these same limitations exist for teenagers with acute knee injuries likely to require surgery.

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs.

BACKGROUND: The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum. METHODS: On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum. RESULTS: Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P < 0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P < 0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P = 0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P < 0.001). The angle between the neck and shaft lines correlated positively with LCD (P < 0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (κ = 0.40-0.75). CONCLUSIONS: The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment. LEVEL OF EVIDENCE: Diagnostic Level 3.