Letter to editor to comment on “Outpatient versus inpatient surgery for ankle fractures: A randomized controlled non-inferiority trial”

We have read an article about “Out versus inpatient surgery for ankle fractures: A randomized control non-inferiority trial” from Rasmussen et al. that was published in a column of your prestigious publication in Denmark . We sincerely appreciate the authors’ work, as they have done a remarkable job and provided insightful information.

While the study adds valuable preliminary evidence, several methodological concerns clarification. First, the external validity of the trial is limited by its single-center design, which restricts generalizability to other healthcare settings with different patient population, surgical pathways, and postoperative care protocols ^, .

Second, the attrition rate of approximately 20 % (only 69 of 86 participants completing the 12-week follow-up) raises concerns regarding reduced statistical power, particularly for secondary outcomes and the assessment adverse events that have recognized susceptibility bias ^, .

Third, there is selection bias, given that only 21 % of the 403 patients were recruited; exclusion of patient not able to ambulate at home and patients with imperfectly reduced fractures prevents generalization to the typical patient found within an ankle fracture population observed within emergency departments ^, .

Fourth, a 7 % crossover rate from the outpatient treatment group to the inpatient treatment group, according to pain and function, indicates a possible lack of appropriate of protocols available in the outpatient setting for certain individuals; although. There was no assessment of sensitivity to treatment intention or predictors of crossover

Fifth, the longer time-to-surgery of the outpatient group than the inpatient group may generate a confounding variable, given the fact that surgery delay could significantly contribute to pain, swelling, complication rates, and functional outcomes of ankle fractures fixation ^, .

Sixth, the fact that the population had few seriously ill patients and few comorbid illnesses (mean ASA score 1.7) makes it difficult to extrapolate the finding to the increasingly prevalent group of ankle fractures in the older population with multiple coexisting illnesses ^, .

Seventh, the fact that no pre-specified sub-analyses in patient stratified by age and comorbidity period, where patient variables associated with the safe ambulatory management of hemorrhagic transformation could have been elucidated ^, .

Finally, the duration of the 12-week follow-up may be too short to accurately reflect long-term functional outcome of recovery, complication, and rehabilitation. Ankle fracture recoveries may take longer than three months ^, .

Although the findings of these authors that the surgical repair of ankle fractures in outpatient is possible are of great import, it is the view of these commentators that these flaws in design and technique warrant greater acknowledgment and that randomized trails are needed ^, .

Disclosure

The authors report no conflicts of interest in this communication.

The authors (Dr. Rasmussen et al.) of the aforementioned published paper (Outpatient versus inpatient surgery for ankle fractures: A randomized controlled non-inferiority trial), Foot and Ankle Surgery, Volume 32, Issue 1, January 2026, that this Letter to the editor pertains to were contacted by the journal but they declined the invitation to submit a reply letter.

References

1.: Rasmussen S., et al.: Outpatient versus inpatient surgery for ankle fractures: a randomized controlled non-inferiority trial . Foot Ankle Surg 2026; 32: pp. 59-65.

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