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

Abstract

Objective: To examine the impact of insurance status on access to orthopaedic care and incidence of surgical site complications in patients with closed unstable ankle fractures. Design: Retrospective chart review. Setting: Certified Level-1 urban trauma center and county facility. Participants: Four hundred eighty-nine patients with closed unstable ankle fractures undergoing open reduction and internal fixation between 2014 and 2016. Intervention: Open reduction and internal fixation of unstable ankle fracture. Main Outcome Measures: Time from injury to presentation, time from injury to surgery, rate of surgical site infections, and loss to follow-up. Results: A total of 489 patients (70.5% uninsured vs. 29.5% insured) were enrolled. Uninsured patients were more likely to be present to an outside hospital first (P = 0.004). Time from injury to presentation at our hospital was significantly longer in uninsured patients (4.5 ± 7.6 days vs. 2.3 ± 5.5 days, P < 0.001). Time from injury to surgery was significantly longer in uninsured patient (9.4 ± 8.5 days vs. 7.3 ± 9.1 days, P < 0.001). Uninsured patients were more likely to be lost to postoperative follow-up care (P = 0.002). A logistic regression analysis demonstrated that delayed surgical timing was directly associated with an increased risk of postoperative surgical site infection (P = 0.002). Conclusions: Uninsured patients with ankle fractures requiring surgery experience significant barriers regarding access to health care. Delay of surgical management significantly increases the risk of surgical site infections in closed unstable ankle fractures. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development of a nomogram to predict surgical site infection after open reduction and internal fixation for closed pilon fracture: a prospective single-center study

“…Our data suggested that delayed ORIF for closed pilon fracture was associated with an increased risk of SSI, which was consistent with previous reports [ 19 ]. A better understanding of psychosocial and socioeconomic factors was critical to identifying opportunities for further intervention to reduce patient morbidity and healthcare costs [ 12 ]. In addition to increasing the financial burden by prolonging hospital stays or treatment periods, there was also the concern that delaying surgery may increase the risk of complications such as infection or ankle stiffness.…”

No delay in care of ambulatory orthopaedic fractures observed during the early Coronavirus-2019 pandemic: a retrospective cohort study

“…Given the various fracture types analyzed, there is no standard surgical delay known to cause complications so the authors used data from ambulatory ankle fracture literature to guide the analysis. 5 They initially hypothesized that the pandemic would delay care for several weeks beyond the usual time from injury to surgery. If 14 days of additional delay to care were considered to be clinically significant, then a sample size of 12 operative patients would be needed to power the study adequately.…”

“…Delays in treatment can result in changes to management, malunion, and increased complications. [5][6][7][8][9] The goals of this study were to characterize the volume of ambulatory orthopaedic fractures that presented to a clinic and the emergency room immediately after the initial implementation of social distancing practices. The authors hypothesized that there would be an overall increased delay in care for ambulatory orthopaedic fracture patients during the early COVID-19 pandemic.…”

“…The treatment of many orthopaedic fractures, both operatively and nonoperatively, requires timeliness to allow for appropriate reduction and maintenance of alignment to allow for healing. Delays in treatment can result in changes to management, malunion, and increased complications 5–9…”

Providing Orthopaedic Care to Vulnerably Underserved Patients

“…This limited access to health care for Medicaid patients often delays timely care, even for acute injuries 7,8 . This associated delay in care often leads to worse clinical outcomes 9 .…”