Outcomes of open reduction and internal fixation (ORIF) of lower extremity fractures in homeless patients.

BACKGROUND

The rise of homelessness in the United States has resulted in an alarming burden of unmet medical need. Homeless patients are at higher risk for orthopedic trauma yet there is limited literature investigating it. This study aims to investigate open reduction and internal fixation outcomes of lower extremity fractures in homeless patients.

METHODS

This retrospective database analysis evaluated homeless patients who underwent open reduction and internal fixation of the lower extremities. Patients were categorized based on the housing status preoperatively, resulting in 3596 homeless and 436,540 housed patients. A 1:1 propensity score matching analysis was performed, adjusting for age, sex, race, ethnicity, body mass index and comorbid conditions (diabetes, hypertension, chronic kidney disease, tobacco use, obesity, heart failure, liver diseases, substance abuse and opioid dependence). Postoperative complications were assessed at 90 days, and both surgical and medical related complications were evaluated at 1 year.

RESULTS

At 90 days, homeless patients had significantly higher rates of emergency department (ED) visits (RR 2.47, p < 0.0001), readmissions (RR 2.49, p < 0.0001), opioid dependence (RR 2.48, p = 0.001), substance abuse (RR 2.96, p < 0.0001), surgical site infections (RR 2.54, p < 0.0001), postoperative infections (RR 1.49, p < 0.0001), and blood transfusions (RR 2.12, p < 0.0001) compared to controls. At 1 year, homeless patients continued to demonstrate higher rates of ED visits (RR 2.62, p < 0.0001), admissions (RR 2.35, p < 0.0001), opioid dependence (RR 1.62, p = 0.011), and substance abuse (RR 4.00, p < 0.0001). Implant removal (RR 0.75, p = 0.001) and malunion/nonunion repair (RR 0.63, p = 0.018) were less frequent in homeless patients, while amputation was more common (RR 1.87, p = 0.018).

CONCLUSION

Homeless patients experience significantly higher rates of medical complications, fracture-related complications and increased opioid dependence following surgical fixation of lower extremity fractures. Further investigation into these findings and potential for perioperative medical optimization is indicated.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort.