Weight-Bearing Following ORIF of Unstable Ankle Fractures
The results of a recently published study challenge the status quo on the timing of return to weight-bearing following open reduction and internal fixation of this common orthopaedic injury.
Nicole Stevens, MD, and Philipp Leucht, MD
Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, et al. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016;30(7):345-352
Ankle fractures are common orthopaedic injuries and account for approximately 13% of all fractures. Current dogma dictates postoperative immobilization and non-weight-bearing for 6 weeks. This has been shown to lead to joint stiffness, muscle atrophy, and inconvenience for the patient.
The goal of the study by Dehghan et al was to compare 2 postoperative rehabilitation protocols for unstable ankle fractures treated with open reduction and internal fixation:
- The current standard of 6 weeks non-weight-bearing in a cast
- Weight-bearing as tolerated and formal ankle range of motion therapy starting at 2 weeks
The primary outcome in this study was time to return to work, and secondary outcomes included ankle range of motion, functional and health outcome scores and complication rates.
This multicenter, randomized controlled trial, which was conducted at 2 Level 1 trauma centers in Canada, enrolled 110 patients who underwent operative fixation of an unstable ankle fracture, excluding syndesmotic injury.
At the first postoperative, 2-week clinic visit, patients were randomized to either early or late weight-bearing. The early weight-bearing group was placed in a boot orthosis at 2 weeks and was allowed to bear weight as tolerated. Patients were instructed to come out of the boot 4 times per day for range of motion exercises. At 6 weeks, they could wean out of the boot.
The late weight-bearing group was transitioned from a splint to a cast with continued non-weight-bearing. At 6 weeks, they received a boot orthosis and started weight-bearing as tolerated and range of motion exercises.
At 2 weeks, the time of randomization, 33% of late weight-bearing and 16% of early weight-bearing patients had already returned to work. Beyond this point, there was no statistically significant difference in return to work.
At 6 weeks postoperatively, there was a significant difference in range of motion improvement between the early and late weight-bearing groups (total arc 41° vs. 29°; P<0.0001), but no difference at subsequent visits.
The SF-36 scores on both physical and mental components showed a statistically significant improvement in the early weight-bearing group at 6 weeks (physical: 51 vs. 42, P=0.008; mental: 66 vs 54, P= 0.0008), and trended toward statistical significance at all subsequent visits.
No difference was observed in the rate of complications between the 2 groups, including surgical site infections, wound complications, loss of fixation or reduction, or reoperation rates.
Interestingly, there was a statistically significant difference in the rate of elective hardware removal, with fewer patients in the early weight-bearing group requiring a second operation (2% vs. 19%; P= 0.005).
Priorities in modern ankle fracture management should include efficient return to function, minimal disability, and maximum patient convenience, all without sacrificing fracture fixation. The current standard of postoperative care for ankle fractures – namely, 6 weeks of non-weight-bearing – does not necessarily align with these goals.
The study by Dehghan et al confirms that weight-bearing as tolerated can be started as early as 2 weeks postoperatively without risking fixation failure or wound complications. In addition, they show that early weight-bearing is associated with increased functional outcome scores.
Patients did not return to work sooner in the early weight-bearing group. This may be represent some intrinsic bias toward the late weight-bearing group, as this group had a significantly higher number of patients who had already returned to work at the time of randomization.
Previous studies examining early weight-bearing for ankle fractures showed conflicting results pertaining to return to work and functional outcomes, but none has shown an increase in loss of fixation. Therefore, all studies combined, including this randomized controlled trial, suggest that early weight-bearing is safe and not associated with increased fixation failure or wound complications.
Although a larger randomized controlled trial or meta-analysis on the topic may give us more insight as to the ultimate economic and functional impact of early weight-bearing in ankle fractures, based on this article and previous works on the topic, it seems that a standardized early weight-bearing protocol is a safe and patient-centered postoperative rehabilitation option for ankle fracture management.
Nicole Stevens, MD, is a Resident in the Department of Orthopaedic Surgery and Philipp Leucht, MD, is an Assistant Professor of Orthopaedic Surgery and Cell Biology at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.