JBJS Editor’s Choice: Ankle Fractures—Is Hospitalization Ever Needed?

The practice of orthopaedic surgery is moving fairly rapidly to the outpatient environment. Advances in less invasive surgical procedures, regional anesthesia, and postoperative pain management have provided the foundation for this transition. The migration to outpatient surgery centers enables surgeons to use surgical teams more focused on orthopaedic technology and practice parameters. The concern that arises in everyone’s mind, though, is the issue of safety.

In the October 19, 2016 issue of JBJS, Qin et al. analyzed the NSQIP database and found that the outpatient surgical treatment of patients with a closed ankle fracture and minimal comorbidities resulted in lower risk of pneumonia and no difference in surgical morbidity, reoperations, and readmissions when compared with inpatient surgery.

The NSQIP dataset is voluntary and, as with any database, confounding variables are unavoidable. But these authors used propensity score matching and Bonferroni correction to minimize selection bias and manage multiple comparisons.

The study excluded emergency cases, cases with preoperative sepsis, and cases of open ankle fracture, and I can still foresee that patients with more severe fracture patterns, soft tissue compromise, and unstable medical comorbidities would be better off treated as inpatients. Nevertheless, it is reassuring that this study found no differences in complication or readmission rates. These findings reinforce the movement of orthopaedic surgical practice to the outpatient setting, and in my experience that movement is wholly welcomed by patients and their families.

Marc Swiontkowski, MD
JBJS Editor-in-Chief