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. 2025 Sep 27;19(6):483-491.
doi: 10.1177/18632521251367969. eCollection 2025 Dec.

Lower Child Opportunity Index and public insurance are associated with decreased prenatal orthopedic evaluation and minor treatment delays for idiopathic clubfoot

Joshua T Bram  1 , Patrick P Nian  1 , Christopher J Williams  1 , Olivia C Tracey  1 , David M Scher  1 , John S Blanco  1 , Emily R Dodwell  1 , Shevaun M Doyle  1
Affiliations

Lower Child Opportunity Index and public insurance are associated with decreased prenatal orthopedic evaluation and minor treatment delays for idiopathic clubfoot

Joshua T Bram et al. J Child Orthop. .

Abstract

Background: Idiopathic clubfoot is a congenital disorder necessitating time-sensitive treatment. Delayed application of the Ponseti method may result in poorer outcomes. Adverse social determinants of health, as measured with the Childhood Opportunity Index version 3.0, hinder access to care. This study aimed to determine the association between Childhood Opportunity Index, insurance status, and treatment disparities for patients with idiopathic clubfoot.

Methods: This retrospective cohort study included patients with idiopathic clubfoot who underwent Ponseti treatment at an urban tertiary care orthopedic hospital between October 2004 and September 2022. Patients presenting for care before 6 months of age and with a minimum 2-year follow-up were included. A threshold Childhood Opportunity Index value of 60.0 categorized patients into low (<60.0) and high (≥60.0) cohorts. Clinical and treatment/outcome variables were compared.

Results: A total of 156 patients (mean follow-up 5.1 ± 2.5 years) merited inclusion: 31 (20%) with Childhood Opportunity Index <60 and 125 (80%) with Childhood Opportunity Index ≥60. Patients with low Childhood Opportunity Index presented at older ages (18 ± 23 versus 11 ± 10 days, p = 0.03) and had fewer prenatal orthopedic evaluations (42% versus 64%, p = 0.03). Recurrence and necessity for further treatment were similar (p > 0.05). Patients with public insurance presented at older ages (28 ± 31 versus 10 ± 9 days, p < 0.01) and were less likely to undergo prenatal consultation (13% versus 65%, p < 0.01). Black/Hispanic patients were more likely to experience a recurrence (odds ratio 6.4, 95% confidence interval 1.2-35.4, p = 0.03), whereas patients who had a prenatal orthopedic evaluation were less likely to experience a recurrence (odds ratio 0.3, 95% confidence interval 0.1-0.9, p = 0.03).

Conclusions: Patients with idiopathic clubfoot and low Childhood Opportunity Index/public insurance experienced delayed presentation to care and fewer prenatal orthopedic consultations. However, low Childhood Opportunity Index and public insurance status were not associated with adverse treatment outcomes. Clubfoot specialists remain a critical component of the multidisciplinary prenatal team, as orthopedic consultations served as a protective factor against recurrence. These findings contribute to the existing literature by highlighting discrepancies in the care for patients with adverse social determinants of health.

Level of evidence: Level III.

Keywords: Child Opportunity Index; Idiopathic clubfoot; social determinants of health; talipes equinovarus.

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Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Flowchart of patient exclusions with exclusion criteria and patient count at each step.
Figure 1.
Flowchart of patient exclusions.
flowchart of clubfoot treatment protocol
Figure 2.
Flowchart of clubfoot treatment algorithm.
See this image and copyright information in PMC

References

    1. Meacock SS, Khan IA, Hohmann AL, et al. What are social determinants of health and why should they matter to an orthopaedic surgeon? J Bone Joint Surg Am 2024; 106: 1731–1737. - PubMed
    1. Baidya J, Gordon AM, Nian PP, et al. Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care? Arch Orthop Trauma Surg 2023; 143: 7073–7080. - PubMed
    1. Gordon AM, Ng MK, Elali F, et al. A nationwide analysis of the impact of socioeconomic status on complications and health care utilizations after total knee arthroplasty using the Area Deprivation Index: consideration of the disadvantaged patient. J Arthroplasty 2024; 39: 2166–2172. - PubMed
    1. Amen TB, Varady NH, Rajaee S, et al. Persistent racial disparities in utilization rates and perioperative metrics in total joint arthroplasty in the U.S. J Bone Joint Surg Am 2020; 102: 811–820. - PubMed
    1. Orellana KJ, Lee J, Yang D, et al. Impact of social determinants of health on adolescent idiopathic scoliosis curve severity. J Pediatr Orthop 2024; 44: e168–e173. - PubMed

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