Fate of the Uninsured Ankle Fracture: Significant Delays in Treatment Result in an Increased Risk of Surgical Site Infection

SLR - April 2022 - Steven Cooperman

Reference: Zelle, Boris A. MDa; Johnson, Taylor R. BSa; Ryan, James C. MDa; Martin, Case W. MDa; Cabot, John H. BBAa; Griffin, Leah P. MSb; Bullock, Travis S. BSa; Ahmad, Farhan BSa; Brady, Christina I. MDa; Shah, Kush PhDa Fate of the Uninsured Ankle Fracture: Significant Delays in Treatment Result in an Increased Risk of Surgical Site Infection, Journal of Orthopaedic Trauma: March 2021 - Volume 35 - Issue 3 - p 154-159 doi: 10.1097/BOT.0000000000001907

Level of Evidence: III – Prognostic

Scientific Literature Review

Reviewed By: Steven Cooperman, DPM
Residency Program: Highlands/Presbyterian St. Luke’s Medical Center – Denver, Colorado

Podiatric Relevance: Uninsured and underinsured patient populations have been shown to face significant barriers to accessing healthcare delivered by specialists. Insurance status has also been shown in prior literature to correlate with clinical outcomes for various types of elective orthopedic procedures. This correlation has yet to be demonstrated for the treatment of unstable ankle fractures, which is the author’s purpose in this paper. The authors hypothesize that uninsured patients will have significant delays in surgical management of their ankle fractures, will experience higher rates of loss to follow-up, and will experience higher rates of postoperative surgical site complications.

Methods: This was a retrospective chart review of all adult patients with isolated, closed ankle fractures undergoing ORIF between 2014 and 2016, performed at a single level-1 trauma center. Open fractures, closed fractures with polytrauma, and tibial pilon fractures were excluded from the study. Information collected included: demographic information, clinical information, overall health status as categorized by the American Society of Anesthesiologists (ASA) score, fracture classification according to the OTA/AO system, insurance status, access to orthopedic care measured in days between injury and hospital presentation/injury and fracture fixation, and clinical outcomes.

Results: Six hundred nineteen ankle fractures underwent ORIF during the study period, with 489 patients included in the final analysis after exclusion of polytrauma and open fracture cases. According to the OTA fracture classification system, the most common fracture pattern was a B2 type (n =169 – 34.6 percent), followed by B3 (n = 145 – 29.7 percent). 70.5 percent (n = 345) in the study were uninsured, with the remaining 29.5 percent (n = 144) insured. Insured patients were found to be significantly older, more commonly female, and have a higher ASA. Uninsured patients were found to more commonly use tobacco products and have a history of diabetes mellitus and hypertension. Looking at the access to orthopedic care, uninsured patients experienced significantly longer time from injury to presentation (7.6 days vs 2.3 days), time from injury to surgery (9.4 days vs 7.3 days), and lower rate of three-month follow-up completion (39.7 percent lost to follow up vs 23.6 percent). Increasing time from injury to surgery had a statistically significant effect on the rate of superficial surgical site infection. A similar trend was identified for deep infections, but did not reach significance. With the use of regression models, older age and time from injury to surgery were identified as independent predictors of increased postoperative surgical site infections.

Conclusions: Based on their findings, the authors of this paper concluded that uninsured patients not only experience barriers to obtaining and maintaining health care for acute ankle fractures, but they also experience significant delays in treatment which leads to an increased risk of adverse outcomes. This article is valuable in demonstrating the need for increased awareness regarding the treatment of acute injuries for the uninsured community. By identifying that there is discrepancy in the care provided to this community, we can attempt to identify opportunities for further interventions within this vulnerable patient population, which ultimately can reduce patient morbidity and health care costs.