Evaluating the Role of Early Weight-Bearing in Patients with Ankle Fractures
Early weight-bearing at 2 weeks versus 6 weeks after open reduction and internal fixation of ankle fractures shows significant improvement in general health outcomes without increased complications.
Kenneth J. Mroczek, MD
Schubert J, Lambers TA, Kimber C, Denk K, Cho M, Doornberg JN, Jaarsma RL. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot Ankle Int. 2020 Jun;41(6):658-665. doi: 10.1177/1071100720908853. Epub 2020 Mar 6.
In a prospective randomized clinical trial by Shubert et al, 50 patients undergoing an open reduction and internal fixation of unstable rotational-type ankle fractures were randomly assigned to either early weight-bearing (EWB) at 2 weeks or delayed weight-bearing (NWB) at 6 weeks.
Patients with unimalleolar, bimalleolar, and trimalleolar fractures were included in the study. Syndesmotic injuries, open fractures, significant osteoporotic fractures, skeletally immature patients, patients non-ambulatory prior to the injury, polytrauma patients, and patients unable to comply with the postoperative protocol were excluded.
The mean age of the patients was 44 years old, with a range of 17 to 73 years. All patients were initially immobilized in a below-knee posterior splint and were non-weight-bearing for 2 weeks.
Follow-up with objective and subjective measures were performed at 2, 6, 12, and 26 weeks postoperatively. The primary outcome assessed with the EuroQol-5D (EQ-5D), which is a patient-based general health status measurement. The Olerud and Molander ankle score was the secondary outcome measure.
The EWB group had higher mean EQ-5D VAS scores at 6 weeks compared with the NWB group. No other differences were found between the groups at any point, and at 26 weeks, the mean Olerud and Molander scores were similar. The were no differences between the groups with respect to surgical site infection, wound complications, loss of fixation, loss of reduction, or reoperations.
This study is helpful in providing useful information to guide our patients through a difficult postoperative period. Early weight-bearing allows for an easier recovery that places less stress on the upper extremities. This is also beneficial to patients who have stairs in their house or apartment.
A major issue for orthopaedic surgeons is the potential loss of fixation or reduction with early weight-bearing. This was not observed in the study by Schubert et al. Please note the exclusion criteria. I would still recommend non-weight-bearing for 4 to 6 weeks for patients with diabetes, neuropathy, or osteoporosis or for any patient where there is a concern about fixation due to bone quality, comminution, or complex fracture pattern.
Early weight-bearing is up to the discretion of the orthopaedic surgeon, but this study is encouraging to advance a subset of patients.
Kenneth J. Mroczek, MD, is an Assistant Professor of Orthopaedic Surgery and Chief of the Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, at NYU Langone Health, New York, New York.
Disclosures: Dr. Mroczek has no disclosures relevant to this article.