Comparison of Inpatient and Outpatient Ankle Fracture Surgery

Category: Ankle Introduction/Purpose: One of the emerging trends in contemporary healthcare is the shift in surgical resources to the outpatient setting coupled with reductions in the inpatient length of stay. Through a multi-center retrospective review of surgically treated ankle fractures, we sought to determine whether the selection for outpatient surgery or inpatient admission was dependent upon specific patient demographics, associated medical co-morbidities, or surgeon practice management. Methods: A multi-center retrospective cohort study of 240 surgically treated ankle fractures over a two-year period was performed. Two tertiary care hospitals and their affiliated ambulatory surgery centers were included in the study. Patient selection criteria was based on CPT codes while exclusion criteria included pediatric patient, open trauma, pilon fracture, or history of prior ankle fracture. Patient age, presence of poly-trauma, medical co-morbidities (syncope, hypertension, diabetes, as well as coronary artery, pulmonary, renal or hepatic disease), and ordering of CT-scan were evaluated in the study. Surgeons were divided into three groups according to fellowship training: foot and ankle (Group 1), trauma (Group 2, and general / other (Group 3). There were 2 foot and ankle fellowship trained orthopedists, 5 trauma fellowship trained orthopedists, and 9 generalists whose fellowships included sports, hand, and spine. Results: 142 inpatient surgeries were performed with 5 days median length of stay and 98 surgeries were performed in the outpatient ambulatory care setting. The chi-square test or Fisher's exact test was used to compare inpatients and outpatients for each variable. Statistically significant higher percentages were recorded among inpatients in the following categories: age 65+ years (p < 0.0003), hypertension (p < 0.0230), presence of poly-trauma (p < 0.0149), and ordering of CT-scan (p < 0.0001). The majority of ankle fracture surgeries performed by Group 1 surgeons (84%) and Group 3 surgeons (61%) were outpatient cases compared with only 29% for Group 2 surgeons. There were no statistically significant differences in demographics and medical risk factors among patients in the three groups. Conclusion: Our data shows that age (65+ years-old) and specific medical co-morbidities are statistically linked with inpatient admission for ankle fracture surgery. In this multi-center review, trauma fellowship trained surgeons on-call were more likely to hospitalize their patients in preparation for surgery. With a 5 day median length of stay for these inpatient admissions, the health care institution may realize substantial practice management cost savings by shifting cases to the outpatient setting using the ambulatory care model of foot and ankle fellowship trained surgeons