Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis

Abstract

Background: Few studies have investigated the outcomes of surgical fracture care among socially deprived patients despite the increased incidence of fractures and the inequality of care received in this group. We evaluated whether socioeconomic deprivation affected the complications and subsequent management of marginalized/homeless patients following surgery for ankle fracture. Methods:In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45 444 patients who underwent open reduction and internal fixation (ORIF) for ankle fracture performed by 710 different surgeons between Jan. 1, 1994, and Dec. 31, 2011. Multivariable logistic regression models were used to assess the association between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and débridement owing to infection, and amputation). Multivariable Cox proportional hazards models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty). Results:A higher level of deprivation was associated with an increased risk of irrigation and débridement (quintile 5 v. quintile 1: odds ratio [OR] 2.14, 95% confidence interval [CI] 1.25-3.67, p = 0.0054) and amputation (quintile 4 v. quintile 1: OR 3.56, 95% CI 1.01-12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed (quintile 5 v. quintile 1: OR 0.822, 95% CI 0.76-0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty. Conclusion:Marginalized patients are at a significantly increased risk of infection and amputation following surgical treatment of ankle fractures. However, these complications are still extremely uncommon among this group. Socioeconomic deprivation should not prohibit marginalized patients from receiving surgery for unstable ankle fractures.

Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation

“…Conversely, homeless patients were significantly less likely to have their hardware removed in isolation, potentially resulting from unequal provision of care at the patient level or a lack of follow-up. 14,25 These findings contribute to the growing body of evidence that demonstrates the significant impact of social determinants of health disparities on ankle fracture surgery, 7,8 and surgical fracture care more broadly. 9–14 However, it should be noted that rates of amputation, irrigation and debridement, and repeat ORIF were still quite low even in the homeless cohort.…”

“…Recent findings highlight the considerable impact of social determinants of health disparities on orthopedic trauma surgery. [7][8][9][10][11][12][13] However, to our knowledge, only one study has directly explored surgical outcomes in homeless patients with orthopedic trauma. 14 Given that musculoskeletal injury is a substantial cause of disability, understanding disparities in outcomes for homeless patients following surgical fracture care may help develop interventions that promote health equity.…”

Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework

“…26,38 With respect to complications, two studies reported high rates of treatment failure and amputation for orthopedic injuries, including open reduction and internal fixation for ankle fracture and foot osteomyelitis. 40,47 A study by Titan et. al.…”

Traumatic soft tissue defects: a perspective review on reconstruction and communication priorities from the orthopaedic trauma surgeon as a partner in care

“…The assessment of limb salvage vs. amputation begins with early, thoughtful, and, when possible, shared decision making with the patient and/or family to either amputate a threatened limb or begin a pathway of limb salvage. The possibility of a failed limb salvage resulting in delayed amputation due to infection, compartment syndrome, flap failure, nonunion, unsatisfactory function, or pain must be discussed to set treatment expectations [15][16][17] . Access to post-operative care, a stable living situation, self-efficacy and engagement in care, and social support should be considered [18] .…”