Weight-bearing or Non-Weight-Bearing after Surgical Treatment of Ankle Fractures: A Multicenter Randomized Controlled Trial
Smeeing DPJ, Houwert RM, Briet JP, Groenwold RHH, Lansick KWW, Leenen LPH, van der Zwaal P, Hoogendoorn JM, van Heijl M, Verliesdonk EJ, Segers MJM, Heitbrink F. Eur J Trauma Emerg Surg. 2018 Sep 24. doi: 10.1007/s00068-018-1016-6. [Epub ahead of print]
Take Home Message: Patients with an ankle fracture who followed an unprotected weight-bearing postoperative care protocol reported less disability and returned to work and sport quicker than patients who followed a protocol limiting their weight-bearing following surgery.
Postoperative care after an ankle fracture ranges from complete non-weight-bearing with immobilization cast to full weight-bearing as tolerated with no protective equipment. It remains unclear which approach is associated with less complications, quicker return to functional activity, and better health-related quality of life after an internal fixation surgery for a supination-external rotation Lauge-Hansen classification fracture. Therefore, the authors conducted a multicenter randomized controlled trial among patients who received surgical treatment of an ankle fracture to determine the effects of three postoperative care protocols:
- unprotected non-weight-bearing mobilization with crutches and active ankle exercises,
- protected weight-bearing with a below knee cast for 6 weeks, or
- unprotected weight-bearing with functional weight-bearing as tolerated.
The authors included patients (18 to 65 years old) who sustained a supination external rotation type 2-4 ankle fracture between January 2013 and October 2016 without pre-existing comorbidities. A total of 115 patients were included in the final analysis, 40 patients allocated to unprotected non-weight-bearing, 33 to protected weight-bearing, and 42 to unprotected weight-bearing cohorts. The authors used the Olerud Molander Ankle Score (OMAS) at 12-weeks as the primary outcome to assess patient-reported outcome ankle symptoms (pain, stiffness, swelling, etc). A higher score on the OMAS indicated greater functional outcome, with a max score of 100. The participants also completed the Short-Form 36 to assess health-related quality of life (higher score better; max score = 100). Other variables of interest included time in weeks returning to work and sport and number of complications. The unprotected weight-bearing group (~61) reported a higher OMAS after 6 weeks compared to the protected weight-bearing (~52) and unprotected non-weight-bearing (~46) groups. The unprotected weight-bearing group also returned to work sooner than the other groups, 4.1 weeks verses 5.7 and 7.0 weeks. The unprotected weight-bearing group also had a shorter return to sport time of 8.9 weeks versus 12.7 and 14.1 weeks. Each group had a similar number and type of complications.
Consensus among orthopedic surgeons is to be cautious with weight-bearing activities following ankle surgery to minimize postoperative complications and potential long-term consequences. However, the results of this study would argue that early unprotected weight-bearing may be the better treatment strategy. A postoperative care protocol allowing for early weight-bearing as tolerated did not increase rate of complications, reduced time-loss from work and sports, and improved functional ability and overall quality of life. It is important to note OMAS outcomes were not significantly different at 3- or 12-months post-surgery. This shows function and disability were restored in each mobilization protocol 3 most post surgery. Clinicians treating patients with Lauge-Hansen type 2-4 ankle fractures should consult with the treating orthopedic surgeon to determine which postoperative mobilization method would be best depending on the patients preferred outcomes.
Questions for Discussion:
Do you have a preferred mobilization method following ankle surgery? What is your experience with patients weight-bearing as tolerated immediately following ankle surgery?
Written by: Danielle M. Torp
Reviewed by: Jeffrey Driban