Weight-bearing or Non-Weight-Bearing after Surgical Treatment of Ankle Fractures: A Multicenter Randomized Controlled Trial
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?