Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures

SLR - June 2022 - Sean Kipp, DPM

Reference: Pasic N, Akindolire J, Churchill L, Ndoja S, Del Balso C, Lawendy AR, Lanting B, Degen RM. Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures. Can J Surg. 2022. Apr 8;65(2):E259-63.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Sean Kipp, DPM
Residency Program: McLaren Oakland Hospital (Pontiac, MI)

Podiatric Relevance: Ankle fractures are common fractures that often require surgical planning to optimize the patient's outcome. One factor that needs attention is value-based medicine in balancing cost effectiveness with patient outcomes. The purpose of this article was to compare cost and safety associated with in-patient versus out-patient open reduction and internal fixation (ORIF) of isolated closed ankle fractures. 

Methods: Electronic chart review was performed for ORIF of acute ankle fractures between two affiliated hospitals. Inclusion criteria included all isolated closed ankle fractures that underwent ORIF of lateral malleolus, bimalleolar, or trimalleolar fractures. Exclusion criteria included open fractures, polytrauma, bilateral ankle fractures, fractures requiring external fixation or staged-procedures. Surgically treated patients were then grouped into if they had the surgery as an in-patient or out-patient. Length of stay, pre-operative comorbidities, operative time, post-operative complications, 30-day readmissions, and emergency department (ED) visits within 30 days were noted. Case cost was determined for all patients and analyzed using multivariate regression analysis.

Results: 196 patients met criteria with 125 being in-patient and 71 being out-patient. Between the two groups, there was no difference between age, body mass index, or American Society of Anesthesiologist (ASA) score. Post-operative complications, 30-day readmissions, and ED visits within 30 days were not significant in the two groups. The in-patient cohort had a higher proportion of females (75 versus 31, p = 0.03). Out-patient cases had a greater proportion of isolated unimalleolar injuries (p < 0.001). Out-patient cases waited longer for surgery (9.6d versus 2.0d, p < 0.001). Mean operating time was shorter by nine minutes in the out-patient group (p < 0.001). In-patient group had significantly longer mean length of stay (54.3hrs versus 7.5hrs p < 0.001). The mean cost associated with in-patient surgery was significantly greater than that for out- patient surgery ($4137 versus $1834, p < 0.001). 

Conclusions: In summary, financial implications with increased focus on cost-effectiveness favor out-patient surgery for isolated closed ankle fractures with a slight delay in time to surgery. Cost effectiveness is increased in the out-patient setting largely from reduced hospital stay with an added benefit of a slightly lower operating time. It should also be noted that there was no difference in post-operative complications, readmissions within 30 days, or ED visits between the two groups.  Thus, one can reasonably balance cost effectiveness with patient outcomes by doing surgery in an out-patient setting. One should still weigh in medical comorbidities, but in medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.