Evaluating the Costs of Surgically Managed Ankle Fractures Treated in an Inpatient vs Outpatient Setting: A Systematic Review and Meta-analysis.

Background: Ankle fractures are prevalent, with 21% to 40% of cases requiring surgical intervention. Treatment decisions regarding non-complex fractures, whether in an inpatient (IP) or outpatient (OP) setting, are often influenced by local resource availability. Although IP care is generally expected to be more expensive, the magnitude of this difference and its interpretation across heterogeneous cost definitions, health care systems, and operative settings remain unclear. This systematic review and meta-analysis evaluates the cost differences between IP and OP surgical management of isolated ankle fractures, offering evidence to guide surgeons in optimizing care pathways while minimizing health care expenditures. Methods: This PROSPERO-registered systematic review and meta-analysis (CRD420251134624) of comparative studies evaluated cost differences for OP and IP management of ankle fractures. We queried PubMed, EMBASE, and CINAHL from inception through August 17, 2025. Because of the inconsistent definition "cost" across the literature, we extracted and analyzed the cost construct as defined by each included study and performed a random effects meta-analysis of the unstandardized mean differences (standardized to a common price year/currency)and reported them with 95% CIs. Results: Seven articles were included, with a final sample size of 21,955 patients with an average age of 43.50 ± 2.87 years and a 2.5-month mean follow-up. Overall, 53.8% (n = 11 813) of patients were treated in the IP setting and 46.2% (n = 10 142) were treated in the OP setting. The mean hospital length of stay (LOS) for IPs was 2.27 ± 0.25 days across the 5 studies reporting this value (n = 5718 IP patients). The average study reported direct cost for IP management was significantly higher than OP management ($11 236.37 ± $2205.05 vs $6990.18 ± $1670.72; Conclusion: Outpatient ORIF for isolated ankle fractures is associated with lower study-reported economic burden than inpatient management in appropriately selected patients, without clear evidence of worse short-term safety outcomes in the available comparative literature. These findings support outpatient pathways for patients with acceptable reduction and immobilization, manageable soft tissues, limited comorbidity burden, safe non-weightbearing mobility, and reliable follow-up. Because included studies used heterogeneous economic definitions and were observational, future prospective studies should use standardized economic outcomes and longer follow-up to better define the value of outpatient vs inpatient care.