Safety and Outcomes of Inpatient Compared with Outpatient Surgical Procedures for Ankle Fractures

J Bone Joint Surg Am. 2016 Oct 19;98(20):1699-1705. doi: 10.2106/JBJS.15.01465.


Background: As the cost of health-care delivery rises in the era of bundled payments for care, there is an impetus toward minimizing hospitalization. Evidence to support the safety of open reduction and internal fixation (ORIF) of ankle fractures in the outpatient setting is largely anecdotal.

Methods: Patients who underwent ORIF from 2005 to 2013 were identified via postoperative diagnoses of ankle fracture and Current Procedural Terminology codes; patients with open fractures and patients who were emergency cases were excluded. Patients undergoing inpatient and outpatient surgical procedures were propensity score-matched to reduce differences in the baseline characteristics. Primary tracked outcomes included medical and surgical complications, readmission, and reoperation within 30 days of the procedure. Binary logistic regression models were created that determined the risk-adjusted relationship between admission status and primary outcomes.

Results: Outpatient surgical procedures were associated with lower rates of urinary tract infection (0.4% compared with 0.9%; p = 0.041), pneumonia (0.0% compared with 0.5%; p = 0.002), venous thromboembolic events (0.3% compared with 0.8%; p = 0.049), and bleeding requiring transfusion (0.1% compared with 0.6%; p = 0.012). Outpatient status was independently associated with reduced 30-day medical morbidity (odds ratio, 0.344 [95% confidence interval, 0.201 to 0.589]). No significant differences were uncovered with respect to surgical complications (p = 0.076), unplanned reoperations (p = 0.301), and unplanned readmissions (p = 0.358).

Conclusions: In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Ambulatory Surgical Procedures / adverse effects*
  • Ankle Fractures / surgery*
  • Female
  • Fracture Fixation, Internal / adverse effects*
  • Hospitalization
  • Humans
  • Incidence
  • Inpatients
  • Male
  • Middle Aged
  • Outpatients
  • Pneumonia / epidemiology*
  • Pneumonia / etiology
  • Postoperative Complications / epidemiology
  • Reoperation
  • Retrospective Studies
  • Treatment Outcome
  • Urinary Tract Infections / epidemiology*
  • Urinary Tract Infections / etiology