Changing Dynamics of Ankle Fracture Care Across Emergency, Inpatient, and Ambulatory Settings.

BACKGROUND: Ankle fracture care is increasingly delivered outside inpatient settings, but whether this transition is uniform across patient, fracture, payer, and geographic groups remains unclear. PURPOSE: To evaluate national trends in ankle fracture care across emergency department, inpatient, and ambulatory surgery settings from 2016 to 2022 and identify factors associated with inpatient admission after emergency department presentation. STUDY DESIGN: Retrospective serial cross-sectional study. METHODS: Healthcare Cost and Utilization Project data from the Nationwide Emergency Department Sample, National Inpatient Sample, and Nationwide Ambulatory Surgery Sample were used to estimate annual ankle fracture volumes. Fractures were classified as unimalleolar, bimalleolar, or trimalleolar. Cochran-Armitage tests assessed temporal trends, and survey-weighted multivariable logistic regression evaluated 2022 admission factors. RESULTS: Emergency department visits increased 12.0% (219,601 to 246,042), ambulatory surgery encounters increased 33.6% (75,571 to 101,000), and inpatient admissions decreased 1.7% (82,065 to 80,635). In 2022, admission odds were higher for patients aged 65 years or older, bimalleolar and trimalleolar fractures, Medicare coverage, and nonmetropolitan location (all p < 0.001). The nonmetropolitan association varied by fracture subtype (p = 0.023) and attenuated after the coronavirus disease 2019 pandemic (odds ratio, 0.89; p = 0.006). CONCLUSIONS: National ankle fracture care shifted toward ambulatory surgery without a parallel increase in inpatient admissions. Admission remained associated with fracture complexity, age, payer, and geography. LEVEL OF CLINICAL EVIDENCE: Level III, retrospective comparative study.