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
Take My Advice, Perform your Home Exercises
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Thank you for this article. I am currently an athletic training student and having taken orthopedic rehabilitation last year I found this article very interesting. Clinically, I have not witnessed weight-bearing activities early on. Instead it is usually stationary exercises starting with range of motion exercises seated while immobilized. The next step is usually moving on to strengthening exercises also while seated.
As I will be a clinician soon I think this topic is worth looking into and conducting evidence based practice. Especially, with the results showing that individuals who began weight -bearing exercises early on returned to work earlier and reported greater function on the OMAS and Short-Form 36. Currently, I do think individuals are beginning weight-bearing exercises to late in the rehabilitation process which is creating a greater deficit in range of motion and strength measures.
Throughout my education we have placed an emphasis on disability index’s and I really appreciated that both the OMAS and Short-Form 36 were included in the study. I think the individual’s perception of their functionality plays a role in the rehabilitation process and when they may be able to begin weight-bearing exercises. An individual who reports greater functionality will succeed to a greater degree with weight-bearing exercises early on compared to an individual who scores a lower functionality.
I think it would be interesting to see what type of work places individuals in the study worked in. For example, some job environments are sedentary, where an individual would not be weight bearing for long periods of time. Also, there are other environments in which an individual may be standing for the majority of their shift resulting in increased stress on their ankle. Also, I found it interesting individuals returning to both sport and their jobs were compared due to the difference in the demands of each.
Hello, thank you for your comment and insight on the topic. In your opening statement the clinical protocol you have witnessed is considered the standard, however evidence (like this article) is starting to show early weight-bearing following surgical intervention for ankle fractures is best for long term outcomes. Although, this study was not conducted in the typical “college student-athlete population” therefore the results are hard to generalize to that population, especially considering the athletic population have higher functional demands. The biggest concern following ankle fracture surgery is the reduced range of motion which is associated with a higher risk of other lower extremity musculoskeletal injuries. This study found each protocol had a similar number and type of complication postoperative, which is one of the most encouraging finding to me as a clinician. As always, it is important to consult with the treating orthopedic surgeon in regards to their postoperative protocol and as a clinician to continually re-evaluate your patient to determine if a weight-bearing protocol following surgery is not causing any complications.
Danielle M. Torp, MS, ATC