Weight-bearing or Non-Weight-Bearing after
Surgical Treatment of Ankle Fractures: A Multicenter Randomized Controlled
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]
Text Freely Available
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 versus 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