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

Yaning Sun, MD, Huijuan Wang, MD, Yuchao Tang, MD, Haitao Zhao, MD, Shiji Qin, MD, Lihui Xu, MD, Zhiyong Xia, MD, and Fengqi Zhang, MD

Journal of Orthopaedic Trauma: March 2021 – Volume 35 – Issue 3 – p 154-159
doi: 10.1097/BOT.0000000000001907

Summary by Lorenzo Solon, B.A.

Ankle fractures are one of the most common orthopaedic injuries, occurring in about 169 out of every 100,000 people. For unstable fractures, open reduction and internal fixation (ORIF) has been the standard treatment, and the rate of ankle ORIF procedures has remained stable over the past 10 years.1 Although ankle ORIF procedures are not typically considered emergency procedures, it is still important for patients to receive timely consultations and surgical interventions to avoid postoperative complications. Underinsured and uninsured patients have been found to have significant barriers to receiving orthopaedic care as well as poorer postoperative outcomes.

Boris et al. sought to investigate how insurance status among ankle fracture patients undergoing an ORIF procedure impacts access to orthopaedic care and how variations in surgical timing affect postoperative complications such as surgical site infections (SSI). They retrospectively reviewed 489 patients from 2014-2016 from a Certified Level-1 trauma center who had closed, unstable ankle fractures that required an ORIF procedure. Basic demographic information was collected, and each patient was placed into either the insured or uninsured group. The primary outcomes measured were time from injury to hospital presentation, time from injury to surgical intervention, completion of 3-month follow-up appointments, and rate of surgical site infections.

In the study, 70.5% of the patients were placed into the uninsured group and 29.5% in the insured group. Uninsured patients demonstrated longer times between injury and presentation at the hospital (P < .001), as well as longer times between injury and surgical intervention (P < .001). Furthermore, uninsured patients were more likely to miss their 3-month follow-up appointment. The total rate of SSI was 7.6% and a univariate analysis found that the risk of SSI was increased among older patients (P = .009) and among patients with increased time delays between injury and surgery.

These findings demonstrate that uninsured patients with closed unstable ankle fractures experience significant barriers to accessing surgical care. Although insurance status was not determined as a direct predictor of increased rates of postoperative SSI, surgical delays were found to directly increase the risk of SSI. This study is limited by its retrospective nature at a single institution that could bias the results and impact its generalizability to other geographic regions and institutions. Future studies should seek to further our understanding of other psychosocial and socioeconomic factors which can lead to improved interventions for uninsured patient populations in orthopaedic care.


  1. Sun Y, Wang H, Tang Y, Zhao H, Qin S, Xu L, Xia Z, Zhang F. Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: A retrospective multicenter study. Medicine (Baltimore). 2018 Feb;97(7):e9901. doi: 10.1097/MD.0000000000009901. PMID: 29443762; PMCID: PMC5839807.

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