Association of an Intensive Multimodal Perioperative Management Bundle With Short-Term Recovery After Surgery for Trimalleolar Fractures: A Single-Center Retrospective Cohort Study

AIM: To examine the association between receipt of an intensive multimodal perioperative management bundle and short-term functional recovery, pain, and clinical outcomes in patients undergoing surgery for trimalleolar fractures. METHODS: This single-center retrospective cohort included 84 patients who underwent open reduction and internal fixation for trimalleolar fractures between September 2023 and September 2025. The intensive management bundle was a pre-existing standardized routine-care pathway rather than a research intervention developed for this study. Patients were classified retrospectively according to contemporaneous medical and nursing records: 43 patients who received routine management were assigned to a routine-management group, and 41 who received the intensive bundle were assigned to an intensive-pathway group. The investigators did not prospectively enroll patients, assign pathways, deliver study-specific interventions, or collect research-specific data. Primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and Visual Analog Scale (VAS) scores; secondary outcomes included first out-of-bed mobilization, length of hospital stay, hospitalization costs, patient satisfaction, and deep vein thrombosis (DVT). Unadjusted mean differences or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and longitudinal AOFAS and VAS data were analyzed using mixed-design repeated-measures analysis of variance (RM-ANOVA). Because the components were delivered together, no component-specific effect was estimated. RESULTS: No baseline variable differed significantly between groups, although the absence of statistical significance did not establish covariate balance. In unadjusted analyses, receipt of the intensive bundle was associated with earlier first out-of-bed mobilization (mean difference [MD], −22.80 h; 95% confidence interval [CI], −26.48 to −19.12), shorter hospitalization (MD, −3.30 days; 95% CI, −4.14 to −2.46), lower hospitalization costs (MD, −13,114 CNY (1 USD = 7.1429 CNY); 95% CI, −14,979 to −11,249), and higher patient satisfaction (OR, 5.16; 95% CI, 1.04–25.56). VAS scores were lower in the intensive-pathway group at 1 week (3.9 ± 0.9 vs. 4.8 ± 1.0), 1 month (1.3 ± 0.7 vs. 3.2 ± 1.0), and 3 months (1.0 (0.0, 1.0) vs. 2.0 (1.0, 2.0)) postoperatively (all Bonferroni-adjusted p < 0.001); RM-ANOVA showed significant group, time, and group-by-time interaction effects for both AOFAS and VAS scores. DVT occurred in 3/41 (7.3%) patients in the intensive-pathway group and 8/43 (18.6%) in the routine-management group, and the difference was not statistically significant (OR, 0.35; 95% CI, 0.08–1.41). These findings represent associations with the integrated bundle and cannot be attributed independently to preoperative optimization, ankle-pump exercise, analgesia, mobilization, or follow-up. CONCLUSIONS: In this retrospective cohort, receipt of an intensive multimodal perioperative management bundle was associated with earlier mobilization, shorter hospitalization, lower hospitalization costs, and more favorable short-term functional and pain trajectories. Because the bundle contained multiple simultaneously delivered components, the study cannot determine the independent efficacy of preoperative optimization, ankle-pump exercise, or any other individual measure. In addition, pathway allocation was non-random and the estimates were unadjusted; therefore, the findings should be interpreted as associations rather than definitive causal effects.