Scientific Articles   |    
Factors Associated with Longer Length of Hospital Stay After Primary Elective Ankle Surgery for End-Stage Ankle Arthritis
Hossein Pakzad, MD, FRCSC1; Gowreeson Thevendran, MBChB, MFSEM(UK), FRCSEd(Tr&Orth)2; Murray J. Penner, MD, FRCSC3; Hong Qian, MSc4; Alastair Younger, MBChB, FRCSC1
1 Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, St. Paul’s Hospital, Suite 560, 1144 Burrard Street, Vancouver, BC, V6Z 2A5, Canada. E-mail address for H. Pakzad: hpakzad@yahoo.com. E-mail address for A. Younger: asyounger@shaw.ca
2 Foot & Ankle Service, Department of Trauma & Orthopaedics, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. E-mail address: xanthus23@hotmail.com
3 Department of Orthopaedics, University of British Columbia, Suite 1000, 1200 Burrard Street, Vancouver, BC, V6Z 2C7, Canada. E-mail address: penner@vbjc.ca
4 The Centre for Health Evaluation and Outcome Sciences (CHÉOS), St. Paul’s Hospital, Suite 570, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. E-mail address: hqian@cheos.ubc.ca
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Investigation performed at St. Paul’s Hospital and Mount Saint Joseph Hospital, Vancouver, British Columbia, Canada

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Jan 01;96(1):32-39. doi: 10.2106/JBJS.K.00834
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Longer length of stay in the hospital after elective surgery results in increased use of health-care resources and higher costs. Improved perioperative care permits many foot and ankle surgical procedures to be performed as day surgery. This study determined perioperative factors associated with a longer length of stay after elective total ankle replacement or ankle arthrodesis.


Data were prospectively collected on patients who underwent open or arthroscopic ankle fusion or total ankle replacement for end-stage ankle arthritis at our institution from 2003 to 2010. Univariate and multivariable generalized linear regression models with gamma distribution and log link function were conducted with use of the length of the hospital stay as the dependent variable and preselected risk factors of age, sex, physical and mental functional scores, comorbid factors, American Society of Anesthesiologists grade, body mass index, type of surgery, duration of surgery, and surgery day of the week as the independent variables.


This study included 343 patients with a median length of stay of seventy-five hours (interquartile range, fifty-two to ninety-seven hours). With use of regression analyses, the variables of age, female sex, higher American Society of Anesthesiologists grade, multiple medical comorbidities, rheumatoid arthritis, lower Short Form-36 Physical Component Summary and General Health domain scores, and open surgery were significantly associated with increased length of stay. Conversely, the variables of obesity, Short Form-36 Mental Component Summary score, surgery day of the week, and surgical duration were not associated with length of stay. Two predictive models of the length of stay were developed: one included only patient-related factors, and the other included patient and surgery-related factors.


The patients who are identified with a higher risk of a longer length of stay may warrant better education and more focused perioperative care when designing care pathways and allocating health-care resources.

Level of Evidence: 

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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