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Foot and Ankle Surgery xxx (2019) xxx–xxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Is supplemental regional anesthesia associated with more

complications and readmissions after ankle fracture surgery
in the inpatient and outpatient setting?
Tanner N. Womblea , Shea M. Comadollb , Adam J. Duganc, Daniel L. Davenportd ,
Syed Z. Alie , Arjun Srinathb , Paul E. Matuszewskib , Arun Anejab,*
a
School of Medicine, University of Kentucky, Lexington, KY, USA
b
Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
c
Department of Biostatistics, University of Kentucky College of Public Health, Lexington, KY, USA
d
Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
e
Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA

A R T I C L E I N F O A B S T R A C T

Article history: Background: There is concern that regional anesthesia is associated with increased risk of complications,
Received 20 April 2020 including return to the hospital for uncontrolled pain once the regional anesthetic wears off.
Received in revised form 14 June 2020 Methods: Retrospective database review of patients who underwent open reduction and internal fixation
Accepted 31 July 2020
of a closed ankle fracture from 2014–16 who received general anesthesia alone (GA) or general anesthesia
Available online xxx
plus regional anesthesia (RA).
Results: 9459 patients met inclusion criteria. Patients in the RA group had significantly longer operative
Keywords:
duration in both inpatient (GAI = 71 min vs RAI = 79 min, p = 0.002) and outpatient setting (GAO = 66 min
Ankle fracture
Regional anesthesia
vs RAI = 72 min, p < 0.001), lower overall LOS (GA = 1.7 days vs RA = 1.1 days, p < 0.001), and higher
Local block readmission rate for pain (RAO = 4 [0.3%] vs GAO = 1 [0.0%], p = 0.007).
Readmissions Conclusions: Patients who received supplemental regional anesthesia had shorter hospital LOS, increased
Length of stay operative time, and increased readmission rates for rebound pain. However, the small number of patients
Hospital complications needing readmission are not clinically significant demonstrating that regional anesthesia is safe, effective
Rebound pain and readmission for rebound pain should not be a concern.
Level of Evidence: III.
Published by Elsevier Ltd on behalf of European Foot and Ankle Society.

1. Introduction valuable tool in helping with the management of acute postoper-

Ankle fractures, occurring at an annual rate of 187 per 100,000
person-years among United States residents, are one of the most
common injuries treated by orthopaedic surgeons [1–4]. This
occurrence is expected to increase as the population continues to
age [1–4]. As life expectancy and occurrence of geriatric ankle
fractures increases, it is likely that the rate of patients with
significant medical comorbidities undergoing open reduction and
internal fixation (ORIF) of unstable ankle fractures will also
increase [5,6].
Following injury and fixation of these fractures, providers seek
to optimally control pain. Regional anesthetic has become a
* Corresponding author at: University of Kentucky College of Medicine, Kentucky
Clinic, 740 South Limestone Street, Suite 400, Lexington, KY 40536, USA.
E-mail address: arun.aneja@uky.edu (A. Aneja).
ative pain in orthopaedic trauma patients, including those with
ankle fractures [7]. The use of regional anesthesia for pain
management in surgical treatment of foot and ankle fractures
improves quality of pain management within the first 24 h
following surgery [8–16]. This correlates with decreased opioid
consumption during the time when the block is active [8–16].
However, when the effects of the regional anesthesia dissipate
patients may experience a significant increase in pain at 12 and
24 h after the block was initiated. This phenomenon is referred to
as rebound pain, which may occur in 40% of patients who receive a
peripheral nerve block [17–25]. This severe pain outside of a
controlled healthcare setting is a clinically relevant problem with
the potential to translate into complications such as readmissions
and representations to the emergency department (ED) [26].
Previous studies have examined risk factors, complications, and
readmission rates related to ORIF of ankle fractures, but to our
knowledge no study has examined the effect of a supplemental

https://doi.org/10.1016/j.fas.2020.07.015
1268-7731/Published by Elsevier Ltd on behalf of European Foot and Ankle Society.

Please cite this article in press as: T.N. Womble, et al., Is supplemental regional anesthesia associated with more complications and
readmissions after ankle fracture surgery in the inpatient and outpatient setting?, Foot Ankle Surg (2020), https://doi.org/10.1016/j.
fas.2020.07.015
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2 T.N. Womble et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx
regional block on postoperative complications and readmission
rates [3,4,27–29]. The objective of this study is to determine the
effect of regional anesthesia on operative duration, length of
hospital stay, 30 day readmission rates (including readmission for
pain), and postoperative morbidity following ankle ORIF in both
inpatient and outpatient setting.
2. Materials and methods
2.1. Design and setting
A retrospective database review was done using the American
College of Surgeons (ACS) National Surgical Quality Improvement
Plan (NSQIP) Participant Use Files (PUF). The NSQIP PUF is
composed of both inpatient and outpatient data within a 30-day
period of the index procedure date from over 600 hospitals and
ambulatory surgery centers in 49 states. The PUF, which reflects
medical records from each reporting hospital, has associated
surgeons and medical teams involved in the patients’ care that
used their own judgment for the surgical and anesthetic
indications, preoperative workup, operative technique, and
postoperative care. The PUF was used to identify patients between
2014 and 2016 who underwent ORIF of a closed ankle fracture and
received either general anesthesia alone or in conjunction with
regional anesthesia.
2.2. Participants
Patients who underwent ORIF for an ankle fracture surgery
were identified using Current Procedural Terminology (CPT) codes.
Patients were included if their primary CPT code was for a medial
malleolus (27,766), lateral malleolus (27,792), bimalleolar (27,814),
or trimalleolar ankle fracture with (27,823) or without (27,822)
posterior lip fixation. To provide a stricter standard, patients were
excluded if they had secondary CPT codes indicative of polytrauma,
open ankle fractures, pathologic fractures, external fixator
placement, or fractures of the foot (hindfoot, midfoot, forefoot).
Primary and secondary anesthesia codes were used to determine
whether patients received general anesthesia with or without
supplemental regional anesthesia. Patients who received second-
ary anesthesia including spinal/epidural or local anesthetic were
excluded to remove ambiguity about the extent of the nerve block.
Additionally, patients receiving regional anesthesia alone were
excluded due to inadequate sample size. Presence of ICD9 code
338.18 (other acute postoperative pain) and ICD10 code G89.18
(other acute post-procedural pain) as a solitary readmit diagnosis
were utilized to determine readmission rates due to pain. Patients
were categorized into groups based on inpatient or outpatient
surgical treatment and general anesthesia alone (GA) or general
plus regional anesthesia (RA).
2.3. Variables
The primary outcome measure investigated was readmission
rate (including readmission for pain) with secondary outcome
measures of hospital length of stay (LOS), and operative duration.
Hospital LOS in the outpatient group was defined as PACU stay
until discharge. The operative duration included the time to
administer the RA block. Secondary outcome measures addition-
ally included the following 30-day morbidities: unplanned
reoperation, wound disruption, urinary tract infection (UTI),
surgical site infection (SSI), mortality, pneumonia, unplanned
intubation, sepsis, renal failure, cardiac arrest, pulmonary embo-
lism (PE), and deep vein thrombosis (DVT). The primary and
secondary outcome measures were compared between the two
anesthetic groups.
Please cite this article in press as: T.N. Womble, et al., Is supplemental regional anesthesia associated with more complications and
readmissions after ankle fracture surgery in the inpatient and outpatient setting?, Foot Ankle Surg (2020), https://doi.org/10.1016/j.
fas.2020.07.015
2.4. Statistical methods
The differences in covariate data, comorbidity data, and main
outcome measures for the groups were analyzed. Categorical
variables were reported using counts and column percentages (%)
and compared using chi-square and Fisher’s exact tests, as
appropriate. Continuous variables were tested for normality using
the Shapiro-Wilk normality test along with histograms. Normally
distributed continuous variables were reported using means and
standard deviations (SD), and p-values were calculated using
Welch two sample t-tests which assumed equal variances unless
the group-level SDs were determined to be meaningfully different.
Medians and first/third quartiles were reported [Q1, Q3] and
p-value were calculated using Mann-Whitney U tests. Statistical
significance was set at p  0.05. Missing observations were
reported and were excluded on an analysis-by-analysis basis.
All analyses were done in R programming language, version 3.5.1
(R Foundation for Statistical Computing, Vienna, Austria).
3. Results
3.1. Participants and descriptive data
Comparison by anesthesia administered yielded 2 groups; 7857
patients received GA, and 1602 patients received RA. Of these
cases, 3598 were done as inpatient procedures and 5681 were
done as outpatient procedures. The inpatient general anesthesia
group (GAI) and the supplemental regional anesthesia group (RAI)
included 3190 and 408 patients respectively. The outpatient
general anesthesia group (GAO) and supplemental regional
anesthesia group (RAO) included 4667 and 1194 patients
respectively. The only significant difference in demographic data
and comorbidities between GA and RA were the average age
(RA = 47.2 vs GA = 49.2, p < 0.001) and diabetes (RA = 9.2% vs GA
11.9%, p = 0.003; Table 1). There were no significant differences
between groups GAI and RAI or GAO and RAO (Tables 1a and 1b).
Similarly, there were no significant differences between anesthesia
administered and complexity of the fracture (Table 2). However,
there was a statistically significant association between the use of
supplemental nerve block and having surgery on an outpatient
basis (RAO = 74.5% vs RAI = 25.5%, p < 0.001; Table 2).
3.2. Operative duration
Median operative duration was significantly higher for those
who received a supplemental nerve block (GA = 69 min vs RA = 74
min, p < 0.001; Table 2), in both the inpatient (GAI = 71 min vs
RAI = 79 min, p = 0.002; Table 2a) and outpatient (GAO = 66 min vs
RAI = 72 min, p < 0.001; Table 2b) setting.
3.3. Hospital length of stay
Patients who received a supplemental nerve block had a
significantly lower mean LOS (GA = 1.7 days vs RA = 1.1 days,
p < 0.001; Table 3). This significant difference in mean LOS was not
observed in the inpatient setting (GAI = 3.7 days vs RAI = 3.5 days,
p = 0.557; Table 3a). However, in the outpatient setting, patients
who received a supplemental nerve block had a significantly lower
mean LOS (GAO = 0.4 days vs RAO = 0.2 days, p = 0.009; Table 3b).
3.4. Readmission rate
There were no significant differences in 30-day readmission
rates between GA and RA overall (GA = 2.3% vs RA = 1.9%, p = 0.49;
Table 3), during inpatient (GAI = 3.6% vs RAI = 3.2%, p = 0.75;
Table 3a), or outpatient setting (GAO = 1.3% vs RAO = 1.5%,
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T.N. Womble et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx 3

Table 1
Patient characteristics stratified by anesthesia type among the entire sample (N = 9459).

Clinical values Overall (n = 9459) RAa (n = 1602) GAb (n = 7857) P value

Age, years, Mean (SD) 48.9 (17.9) 47.2 (17.4) 49.2 (18.0) <0.001
BMI, Mean (SD) 30.8 (7.1) 30.7 (6.9) 30.8 (7.1) 0.707
Male, N (%) 3856 (40.8) 664 (41.4) 3192 (40.6) 0.560
Smoking, N (%) 2393 (25.3) 436 (27.2) 1957 (24.9) 0.057
Hypertension, N (%) 2922 (30.9) 473 (29.5) 2449 (31.2) 0.205
Diabetes, N (%) 1082 (11.4) 148 (9.2) 934 (11.9) 0.003
Dyspnea, N (%) 225 (2.4) 40 (2.5) 185 (2.4) 0.802
Bleeding disorder, N (%) 314 (3.3) 44 (2.7) 270 (3.4) 0.184
Transfusion, N (%) 33 (0.3) 1 (0.1) 32 (0.4) 0.057
ASA Class, N (%) 0.151
I–II 6886 (72.9) 1199 (74.8) 5687 (72.5)
III 2341 (24.8) 368 (23.0) 1973 (25.1)
IV–V 222 (2.3) 35 (2.2) 187 (2.4)
a
Patients who received supplemental regional anesthesia in addition to general anesthesia.
b
Patients who received general anesthesia alone.

Table 1a
Patient characteristics stratified by anesthesia type among inpatient cases (N = 3598).

Clinical values Overall (n = 3598) RAIa (n = 408) GAIb (n = 3190) P value

Age, years, Mean (SD) 55.3 (18.4) 54.5 (18.1) 55.4 (18.4) 0.377
BMI, Mean (SD) 31.6 (7.8) 31.3 (7.6) 31.7 (7.8) 0.417
Male, N (%) 1210 (33.6) 143 (35.0) 1067 (33.4) 0.556
Smoking, N (%) 811 (22.5) 99 (24.3) 712 (22.3) 0.411
Hypertension, N (%) 1515 (42.1) 166 (40.7) 1349 (42.3) 0.573
Diabetes, N (%) 626 (17.4) 65 (15.9) 561 (17.6) 0.447
Dyspnea, N (%) 125 (3.5) 17 (4.2) 108 (3.4) 0.504
Bleeding disorder, N (%) 238 (6.6) 32 (7.8) 206 (6.5) 0.340
Transfusion, N (%) 28 (0.8) 0 (0.0) 28 (0.9) 0.067
ASA Class, N (%) 0.546
I–II 2139 (59.6) 236 (57.8) 1903 (59.8)
III 1266 (35.3) 147 (36.0) 1119 (35.2)
IV–V 184 (5.1) 25 (6.1) 159 (5.0)
c
The following variables had missing observations: ASA Class had N = 9 missing observations, BMI had N = 293 missing observations, and BMI > 30 had N = 293 missing
observations.
a
Inpatients who received supplemental regional anesthesia in addition to general anesthesia.
b
Inpatients who received general anesthesia alone.

Table 1b
Patient characteristics stratified by anesthesia type among outpatient cases (N = 5861).

Clinical values Overall (n = 5861) RAOa (n = 1194) GAOb (n = 4667) P value

Age, years, Mean (SD) 44.9 (16.4) 44.7 (16.4) 45.0 (16.4) 0.530
BMI, Mean (SD) 30.2 (6.6) 30.5 (6.7) 30.2 (6.5) 0.160
Male, N (%) 2646 (45.1) 521 (43.6) 2125 (45.5) 0.253
Smoking, N (%) 1582 (27.0) 337 (28.2) 1245 (26.7) 0.299
Hypertension, N (%) 1407 (24.0) 307 (25.7) 1100 (23.6) 0.131
Diabetes, N (%) 456 (7.8) 83 (7.0) 373 (8.0) 0.255
Dyspnea, N (%) 100 (1.7) 23 (1.9) 77 (1.6) 0.594
Bleeding disorder, N (%) 76 (1.3) 12 (1.0) 64 (1.4) 0.393
Transfusion, N (%) 5 (0.1) 1 (0.1) 4 (0.1) 1.000
ASA Class, N (%) 0.647
I–II 4747 (81.0) 963 (80.7) 3784 (81.1)
III 1075 (18.3) 221 (18.5) 854 (18.3)
IV–V 38 (0.6) 10 (0.8) 28 (0.6)
c
The following variables had missing observations: ASA Class had N = 1 missing observation, BMI had N = 169 missing observations, and BMI > 30 had N = 169 missing
observations.
a
Outpatients who received supplemental regional anesthesia in addition to general anesthesia.
b
Outpatients who received general anesthesia alone.

p = 0.69; Table 3b). However, zero inpatients and 5 outpatients
were readmitted with a diagnosis of acute postoperative pain
(2 readmitted postop day 1, 3 readmitted postop day 2). A
significantly higher amount of these patients had received a
supplemental nerve block (RAO = 4 [0.3%] vs GAO = 1 [0.0%],
p = 0.007; Table 3b).
3.5. Morbidity
There was no significant difference in superficial SSI rate
between GA and RA overall (GA = 0.7% vs RA = 0.6%, p = 0.654),
during inpatient (GAI = 0.9% vs RAI = 0.5%, p = 0.57), or outpatient
(GAO = 0.6% vs RAO = 0.6%, p = 1.00) setting. There was no

Please cite this article in press as: T.N. Womble, et al., Is supplemental regional anesthesia associated with more complications and
readmissions after ankle fracture surgery in the inpatient and outpatient setting?, Foot Ankle Surg (2020), https://doi.org/10.1016/j.
fas.2020.07.015
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4 T.N. Womble et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx

Table 2
Operative characteristics stratified by anesthesia type among the entire sample (N = 9459).

Clinical values Overall (n = 9459) RAa (n = 1602) GAb (n = 7857) P value

Outpatient, N (%) 5861 (62.0) 1194 (74.5) 4667 (59.4) <0.001
Primary procedure, N (%) 0.237
Medial malleolus 525 (5.6) 75 (4.7) 450 (5.7)
Lateral malleolus 2960 (31.3) 528 (33.0) 2432 (31.0)
Bimalleolar 3509 (37.1) 574 (35.8) 2935 (37.4)
Trimalleolar 1911 (20.2) 326 (20.3) 1585 (20.2)
w/ out fixation of posterior lip
Trimalleolar w/ fixation of posterior lip 554 (5.9) 99 (6.2) 455 (5.8)
Total operation duration, minutes, Median [Q1,Q3] 69.0 74.0 69.0 <0.001
[50.0, 97.0] [52.2, 102.0] [49.0, 95.0]
a
Patients who received supplemental regional anesthesia in addition to general anesthesia.
b
Patients who received general anesthesia alone.

Table 2a
Operative characteristics stratified by anesthesia type among inpatient cases (N = 3598).

Clinical values Overall (n = 3598) RAIa (n = 408) GAIb (n = 3190) P value

Primary Procedure, N (%) 0.560
Medial malleolus 122 (3.4) 15 (3.7) 107 (3.4)
Lateral malleolus 755 (21.0) 93 (22.8) 662 (20.8)
Bimalleolar 1551 (43.1) 171 (41.9) 1380 (43.3)
Trimalleolar w/ out fixation of posterior lip 875 (24.3) 90 (22.1) 785 (24.6)
Trimalleolar w/ fixation of posterior lip 295 (8.2) 39 (9.6) 256 (8.0)
Total operation duration, minutes, Median [Q1, Q3] 72.0 79.0 71.0 0.002
[52.0, 99.0] [56.0, 108.0] [52.0, 98.0]
a
Inpatients who received supplemental regional anesthesia in addition to general anesthesia.
b
Inpatients who received general anesthesia alone.

Table 2b
Operative characteristics stratified by anesthesia type among outpatient cases (N = 5861).

Clinical values Overall (n = 5861) RAOa (n = 1194) GAOb (n = 4667) P value

Primary procedure, N (%) 0.011
Medial malleolus 403 (6.9) 60 (5.0) 343 (7.3)
Lateral malleolus 2205 (37.6) 435 (36.4) 1770 (37.9)
Bimalleolar 1958 (33.4) 403 (33.8) 1555 (33.3)
Trimalleolar w/ out fixation of posterior lip 1036 (17.7) 236 (19.8) 800 (17.1)
Trimalleolar w/ fixation of posterior lip 259 (4.4) 60 (5.0) 199 (4.3)
Total operation duration, minutes, Median [Q1, Q3] 68.0 72.0 66.0 <0.001
[48.0, 95.0] [51.0, 100.8] [47.0, 93.0]
a
Outpatients who received supplemental regional anesthesia in addition to general anesthesia.
b
Outpatients who received general anesthesia alone.

significant difference in 30-day postoperative minor or major
morbidity overall between GA and RA (Table 3), during inpatient
(Table 3a), or outpatient (Table 3b) setting. However, rate of UTI
was significantly higher in GA (GA = 0.8% vs RA = 0.2%, p = 0.021).
There was no significant difference in unplanned 30-day reopera-
tion rate between GA and RA (GA = 1.2% vs RA = 0.9%, p = 0.31;
Table 3), during inpatient (GAI = 1.6% vs RAI = 1.2%, p = 0.69;
Table 3a), or outpatient setting (GAO = 0.9% vs RAO = 0.8%,
p = 0.71; Table 3b).
4. Discussion
This study offers a comprehensive comparison of patients with
surgically treated ankle fractures who received a supplemental
regional nerve block compared to those who received general
anesthesia alone. Operative duration, length of hospital stay,
30 day readmission rate including readmission for pain, and
postoperative morbidity between the two groups were analyzed.
We found that the use of supplemental regional anesthesia was
associated with significantly higher 30-day readmission due to
postoperative pain as well as longer case duration. However, the
use of a supplemental nerve block was associated with a decreased
hospital LOS. Though these differences existed between the
groups, there was no significant difference in 30-day postoperative
morbidity when patients received a supplemental regional block
regardless of the surgical setting.
This study confirmed a significantly higher readmissions rate
for postoperative pain in outpatients who received a supplemental
nerve block versus general anesthesia alone, which is in accor-
dance with a prior study documenting the same phenomenon after
ambulatory wrist fracture surgery [25]. However, should rebound
pain be a major concern with the use of these blocks? There were
only 5 total readmissions due to postoperative pain (all occurring
on or before postop day 2) in the entire sample of 9459 patients.
Four in the RA group and 1 the GA group. This finding, while
statistically significant, is not likely to be significant in a clinical
context.
Significantly increased operative duration in patients who
received a nerve block likely results from the time taken to
administer the block, as some centers which contribute to the
NSQIP database administer their blocks within the OR, and this is
consistent with prior studies [8,17,18,20,30]. This increased OR
time may offset any cost benefit gained from decreased LOS.
However, the administration of supplemental nerve blocks prior to
the patient entering the OR via a “block room” has been proposed
and shown to be effective in curtailing increases in operative

Please cite this article in press as: T.N. Womble, et al., Is supplemental regional anesthesia associated with more complications and
readmissions after ankle fracture surgery in the inpatient and outpatient setting?, Foot Ankle Surg (2020), https://doi.org/10.1016/j.
fas.2020.07.015
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T.N. Womble et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx 5

Table 3
Thirty-day outcomes stratified by anesthesia type among the entire sample (N = 9459).

Clinical values Overall (n = 9459) RAa (n = 1602) GAb (n = 7857) P value

Total hospital LOS, days, Median [Q1,Q3]c 0.0 [0.0, 2.0] 0.0 [0.0, 1.0] 1.0 [0.0, 2.0] <0.001
Total hospital LOS, days, Mean (SD)c 1.6 (3.6) 1.1 (2.4) 1.7 (3.7) <0.001
Unplanned reoperation 109 (1.2) 14 (0.9) 95 (1.2) 0.309
Readmission for any reason 208 (2.2) 31 (1.9) 177 (2.3) 0.486
Readmission for pain 5 (0.1) 4 (0.2) 1 (0.0) 0.004
30-day NSQIP morbidity (any of the following), N (%) 423 (4.5) 59 (3.7) 364 (4.6) 0.107
Minor morbidity, N (%) 155 (1.6) 18 (1.1) 137 (1.7) 0.094
Wound disruption 24 (0.3) 5 (0.3) 19 (0.2) 0.586
UTI 69 (0.7) 4 (0.2) 65 (0.8) 0.021
Superficial SSI 64 (0.7) 9 (0.6) 55 (0.7) 0.654
Major morbidity, N (%) 326 (3.4) 47 (2.9) 279 (3.6) 0.246
Mortality 15 (0.2) 3 (0.2) 12 (0.2) 0.730
Deep incisional SSI 21 (0.2) 3 (0.2) 18 (0.2) 1.000
Organ/space SSI 12 (0.1) 2 (0.1) 10 (0.1) 1.000
Pneumonia 29 (0.3) 3 (0.2) 26 (0.3) 0.461
Vent. > 48 h 11 (0.1) 0 (0.0) 11 (0.1) 0.230
Unplanned intubation 17 (0.2) 1 (0.1) 16 (0.2) 0.337
Sepsis/septic shock 21 (0.2) 3 (0.2) 18 (0.2) 1.000
Renal failure/insufficiency 8 (0.1) 2 (0.1) 6 (0.1) 0.630
Card arrest, MI, or stroke 13 (0.1) 2 (0.1) 11 (0.1) 1.000
Pulmonary embolism 27 (0.3) 4 (0.2) 23 (0.3) 1.000
DVT 28 (0.3) 2 (0.1) 26 (0.3) 0.211
a
Patients who received supplemental regional anesthesia in addition to general anesthesia.
b
Patients who received general anesthesia alone.
c
The following variables had missing observations: Total hospital LOS, days had N = 11 missing observations.

Table 3a
Thirty-day outcomes stratified by anesthesia type among inpatient cases (N = 3598).

Clinical values Overall (n = 3598) RAIa (n = 408) GAIb (n = 3190) P value

All patients 3598 408 3190
Total hospital LOS, days, Median [Q1, Q3]c 3.0 [2.0, 4.0] 3.0 [2.0, 4.0] 3.0 [2.0, 4.0] 0.926
Total hospital LOS, days, Mean (SD)c 3.7 (4.5) 3.5 (3.4) 3.7 (4.6) 0.557
Total hospital LOS, daysc 0.608
0 133 (3.7) 21 (5.2) 112 (3.5)
1 701 (19.5) 77 (18.9) 624 (19.6)
2 879 (24.5) 92 (22.6) 787 (24.7)
3 654 (18.2) 76 (18.7) 578 (18.2)
4 398 (11.1) 44 (10.8) 354 (11.1)
5+ 825 (23.0) 97 (23.8) 728 (22.9)
Unplanned reoperation 57 (1.6) 5 (1.2) 52 (1.6) 0.685
Readmission for any reason 129 (3.6) 13 (3.2) 116 (3.6) 0.750
Readmission for Paind 0 (0) 0 (0) 0 (0) NA
30-day NSQIP morbidity (any of the following), N (%) 268 (7.4) 23 (5.6) 245 (7.7) 0.168
Minor morbidity, N (%) 97 (2.7) 5 (1.2) 92 (2.9) 0.074
Wound disruption 9 (0.3) 0 (0.0) 9 (0.3) 0.610
UTI 58 (1.6) 3 (0.7) 55 (1.7) 0.199
Superficial SSI 30 (0.8) 2 (0.5) 28 (0.9) 0.570
Major morbidity, N (%) 207 (5.8) 20 (4.9) 187 (5.9) 0.502
Mortality 12 (0.3) 2 (0.5) 10 (0.3) 0.638
Deep incisional SSI 10 (0.3) 1 (0.2) 9 (0.3) 1.000
Organ/space SSI 6 (0.2) 1 (0.2) 5 (0.2) 0.515
Pneumonia 27 (0.8) 2 (0.5) 25 (0.8) 0.762
Vent. > 48 h 10 (0.3) 0 (0.0) 10 (0.3) 0.616
Unplanned intubation 16 (0.4) 1 (0.2) 15 (0.5) 1.000
Sepsis/septic shock 13 (0.4) 2 (0.5) 11 (0.3) 0.652
Renal failure/insufficiency 6 (0.2) 2 (0.5) 4 (0.1) 0.141
Card arrest, MI, or stroke 11 (0.3) 2 (0.5) 9 (0.3) 0.360
Pulmonary embolism 12 (0.3) 1 (0.2) 11 (0.3) 1.000
DVT 16 (0.4) 0 (0.0) 16 (0.5) 0.244
a
Inpatients who received supplemental regional anesthesia in addition to general anesthesia.
b
Inpatients who received general anesthesia alone.
c
The following variables had missing observations: Total hospital LOS, days had N = 8 missing observations.
d
No inpatient cases experienced a readmission for pain.

duration [31–34]. Future studies should evaluate the use of “block
rooms” or other strategies for reduction of OR time associated with
administering regional anesthesia.
A significantly lower hospital LOS was observed in patients
receiving a nerve block in the overall sample as well as the
outpatient group. We theorize that shorter LOS in the RA
outpatient group occurred because of better immediate postoper-
ative pain control. However, it is unknown if postoperative pain
was the reason for prolonged length of stay in the respective
groups as opposed to disposition status or other variables and is a
limitation of the use of a database in this study. It is also unknown
why certain candidates received the supplemental nerve block

Please cite this article in press as: T.N. Womble, et al., Is supplemental regional anesthesia associated with more complications and
readmissions after ankle fracture surgery in the inpatient and outpatient setting?, Foot Ankle Surg (2020), https://doi.org/10.1016/j.
fas.2020.07.015
G Model
FAS 1499 No. of Pages 7

6 T.N. Womble et al. / Foot and Ankle Surgery xxx (2019) xxx–xxx

Table 3b
Thirty-day outcomes stratified by anesthesia type among outpatient cases (N = 5861).

Clinical values Overall (n = 5861) RAOa (n = 1194) GAOb (n = 4667) P value

All patients 5861 1194 4667
Total hospital LOS, days, Median [Q1, Q3]c 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] <0.001
Total hospital LOS, days, Mean (SD)c 0.3 (1.9) 0.2 (1.1) 0.4 (2.1) 0.009
Total hospital LOS, daysc <0.001
0 4757 (81.2) 1026 (86.0) 3731 (80.0)
1 767 (13.1) 117 (9.8) 650 (13.9)
2 217 (3.7) 28 (2.3) 189 (4.1)
3 55 (0.9) 13 (1.1) 42 (0.9)
4 30 (0.5) 4 (0.3) 26 (0.6)
5+ 32 (0.5) 5 (0.4) 27 (0.6)
Unplanned reoperation 52 (0.9) 9 (0.8) 43 (0.9) 0.705
Readmission for any reason 79 (1.3) 18 (1.5) 61 (1.3) 0.692
Readmission for pain 5 (0.1) 4 (0.3) 1 (0.0) 0.007
30-day NSQIP morbidity (any of the following), N (%) 155 (2.6) 36 (3.0) 119 (2.5) 0.428
Minor morbidity, N (%) 58 (1.0) 13 (1.1) 45 (1.0) 0.823
Wound disruption 15 (0.3) 5 (0.4) 10 (0.2) 0.206
UTI 11 (0.2) 1 (0.1) 10 (0.2) 0.706
Superficial SSI 34 (0.6) 7 (0.6) 27 (0.6) 1.000
Major morbidity, N (%) 119 (2.0) 27 (2.3) 92 (2.0) 0.604
Mortality 3 (0.1) 1 (0.1) 2 (0.0) 0.495
Deep incisional SSI 11 (0.2) 2 (0.2) 9 (0.2) 1.000
Organ/space SSI 6 (0.1) 1 (0.1) 5 (0.1) 1.000
Pneumonia 2 (0.0) 1 (0.1) 1 (0.0) 0.366
Vent. > 48 h 1 (0.0) 0 (0.0) 1 (0.0) 1.000
Unplanned intubation 1 (0.0) 0 (0.0) 1 (0.0) 1.000
Sepsis/septic shock 8 (0.1) 1 (0.1) 7 (0.1) 1.000
Renal failure/insufficiency 2 (0.0) 0 (0.0) 2 (0.0) 1.000
Card arrest, MI, or stroke 2 (0.0) 0 (0.0) 2 (0.0) 1.000
Pulmonary embolism 15 (0.3) 3 (0.3) 12 (0.3) 1.000
DVT 12 (0.2) 2 (0.2) 10 (0.2) 1.000
a
Outpatients who received supplemental regional anesthesia in addition to general anesthesia.
b
Outpatients who received general anesthesia alone.
c
The following variables had missing observations: Total hospital LOS, days had N = 3 missing observations.

while others did not. This may have been treating hospital,
surgeon, or anesthesiologist preference, all of which may influence
the results. However, this bias is less likely to be a considerable
factor given a sample size of 9459 patients.
Due to the limitations of the NSQIP database, our study was
unable to examine the percentage of patients that sought any form
of attention (albeit phone calls to provider’s office or afterhours, or
representation to ED or clinic) for postoperative pain. A 2016 study
of patients who underwent outpatient operative fixation of wrist
factures found that 20% of patients that received a nerve block
sought some form of medical attention for pain problems within
48 h after surgery compared to 5% of patients who received general
anesthesia alone [25]. This could represent a clinically relevant
problem and future studies are necessary to evaluate the effect of
rebound pain on healthcare utilization.
The main strength of the study is the large sample size of more
than 9000 patients, which was made possible by utilizing NSQIP. The
use of NSQIP leads to limitations including no data past 30-days of
surgery, no pain scores, no standardized nerve block technique, no
functional status or outcome measures, and an inability to track ED
re-presentation if patients were not readmitted. This is a significant
limitation of a database study in the sense that we know a
phenomenon occurred but are unable to accurately predict why it
occurred. Additionally, while the NSQIP PUF uses a regimented
oversight program to avoid under or over-reporting complications,
the PUF is still vulnerable to errors and inaccuracies in the input of
data [35–37]. American College of Surgeons National Surgical Quality
Improvement Program and the hospitals participating in the ACS
NSQIP are the source of the data used herein; which has not been
verified. Another limitation is that only 30-day postoperative
readmission and morbidity data for each procedure is provided.
Therefore, if morbidity or readmission occurred after 30 days, it
would not be reported. However, one would not logically anticipate
supplemental RA to have long lasting effects beyond 30 days.
While our study highlights rebound pain as a statistically
significant occurrence after regional anesthesia leading to hospital
readmission, this result is not clinically significant. Supplemental
regional nerve blocks provide the benefit of a quicker hospital
discharge without significantly increasing 30-day morbidity. In our
study overall, regional anesthesia lead to saving several thousand-
fold hospital days due to expedient hospital discharge, this far
outweighs the cost of the few readmitted patients. The effect of its
use on operative duration has been shown to be minimized when
administered prior to entering the OR. Rebound pain is an important
factor in regional anesthesia and proper patient education is
important. However, concern for readmission due to rebound pain
should not be a deterrent for considering regional anesthesia.
Conflict of interest
Authors Womble, Comadoll, Dugan, Davenport, Ali, Srinath, and
Aneja have nothing to disclose.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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