Early weight-bearing in operatively fixed ankle fractures: a systematic review

Changes in Motor Strategy and Neuromuscular Control During Balance Tasks in People with a Bimalleolar Ankle Fracture: A Preliminary and Exploratory Study

Ankle fractures can lead to issues such as limited dorsiflexion, strength deficits, swelling, stiffness, balance disorders, and functional limitations, which complicate daily activities. This study aimed to describe neuromuscular adaptations at 6 and 12 months post-surgery during static and dynamic balance tasks, specifically using the Y-Balance Test (YBT). Additionally, the relationship between neuromuscular patterns, balance, and musculoskeletal deficits was evaluated. In 21 participants (14 at 6 months and 21 at 12 months) with bimalleolar fractures, hip strength, ankle dorsiflexion, ankle functionality, and static and dynamic balance were assessed using electromyography of five lower limb muscles (tibialis anterior, peroneus longus, lateral gastrocnemius, biceps femoris, and gluteus medius). A significant interaction effect (limb × proximal [hip]-distal [ankle] muscle) (F = 30.806, p < 0.001) was observed in the anterior direction of the Y-Balance Test (YBTA) at 6 months post-surgery. During the YBTA and YBT posteromedial (YBTPM), it was found that a lower dorsiflexion range of movement was associated specifically at 6 months with greater activation of the lateral gastrocnemius. However, these differences tended to diminish by 12 months. These findings suggest that neuromuscular patterns differ between operated and non-operated limbs during the YBTA at 6 months post-surgery. The Y-Balance Test, particularly its anterior direction, effectively highlighted these neuromuscular changes. This is a preliminary study; further research is needed to explore these findings in depth.

Early Motion and Directed Exercise (EMADE) following ankle fracture fixation: a pragmatic randomized controlled trial

Aims

This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme.

Methods

A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed.

Results

Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported.

Conclusion

The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe.

Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis

Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.

Full weight bearing after internal fixation of isolated distal fibular fractures with anatomically contoured locking plates: Our institutional experience

Isolated fractures of the distal fibula mainly affect young, active people. In most cases, fixation is by open reduction with or without casting for six weeks without weight bearing. The current trend is to reduce this period of non-weight-bearing in order to promote earlier functional rehabilitation. The improved mechanical stability resulting from the use of plates with locking screws has changed the postoperative management of many fractures, but there is little evidence for the ankle. Between October 2013 and August 2015, 36 patients were enrolled in a prospective study to evaluate the performance of internal fixation of isolated distal fibular fractures using a lateral anatomically contoured titanium locking plate (InitialA® plate from Newclip Technics, Haute Goulaine, France) with immediate mobilisation and full weight bearing. No patient required further surgery due to mechanical failure or non-union. The bone healing rate was 100 % at 3 months. Two patients had septic complications requiring plate removal and antibiotic treatment and were eventually cured. The use of anatomically contoured locking plates provides strong and stable fixation, allowing immediate full weight-bearing. Such a technique has the advantage of a short recovery time and an early return to work without additional complications.

Comparing immediate and delayed weight bearing in patients with ankle open reduction internal fixation-A protocol for feasibility randomised controlled trial

Introduction

Uncertainty regarding the timing of weight bearing following ankle open reduction internal fixation (ORIF) in patients with different ankle fracture patterns remains. Traditional rehabilitation methods, including six weeks of non-weight bearing (NWB), is still a common approach in many hospitals, while some previous evidence has shown immediate weight bearing (IWB) to be beneficial.

Method

32 adult participants with unimalleolar, bimalleolar or trimalleolar ankle fractures and stable fixation following ankle ORIF will be randomly allocated to either Immediate Weight Bearing (IWB) or Delayed Weight Bearing (DWB) groups. Stability of fixation is a subjective assessment made by the operating surgeon at the completion of fixation and is independent of fracture pattern. Participants in the IWB group will be allowed to weight bear as tolerated within 24 h, while participants in the DWB group will remain non-weight bearing for six weeks. Participants' data including Olerud and Molander Ankle Score, Self-Reported Foot and Ankle Score, SF-36 health survey, time to return to work will be collected. X-rays will be assessed by orthopaedic team members for fixation-related complications including reduction loss, malreduction/malunion, implant failure and non-union. Participants data will be collected at six weeks, three and six-months post-surgery. We will determine the feasibility of a full RCT through assessing the recruitment rate, adherence rate, and drop-out rate.

Results

Not applicable.This pilot RCT will endeavour to optimise standard rehabilitation protocols post ankle ORIF.

To cast or not to cast? Postoperative care of ankle fractures: a meta-analysis of randomized controlled trials

Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was conducted with the aim of comparing early mobilization and weightbearing to traditional postoperative protocols. A systematic search of electronic databases was conducted according to the PRISMA guidelines. Only randomized clinical trials were included. Data about clinical outcome, time to return to work and complications were extracted and summarized. Meta-analyses were performed. Twenty studies for a total of 1328 patients were included. Early mobilization was compared to immobilization in 724 patients: the two groups did not significantly differ in terms of short- and long-term clinical outcome (p = 0.08 and p = 0.41, respectively). However, early mobilization resulted to be significantly associated with faster return to work (p = 0.047). Early weightbearing was compared to nonweightbearing in 1088 patients. While the clinical difference between the two groups was not significant at short term (p = 0.08), it was significant at long term (p = 0.002). No other significant differences, in particular regarding complications, were highlighted between different groups. Early motion, early weightbearing and traditional postoperative protocols are all safe strategies after ORIF for unstable ankle fractures. Early mobilization is significantly associated with faster return to work and early weightbearing improves long term clinical outcome.Level of evidence: I.

Effectiveness of permissive weight bearing in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities: a prospective comparative multicenter cohort study

PURPOSE

The aim of the present study was to investigate the effectiveness of a novel approach involving permissive weight bearing (PWB) in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities.

METHODS

Prospective comparative multicenter cohort study in one level 1 trauma center and five level 2 trauma centers. Surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities were included. Permissive weight bearing (PWB) in comparison to restricted weight bearing (RWB) was assessed over a 26-week post-surgery follow-up period. Patients' self-perceived outcome levels regarding activities of daily living (ADL), quality of life (QoL), pain and weight bearing compliance were used.

RESULTS

This study included 106 trauma patients (N = 53 in both the PWB and RWB groups). Significantly better ADL and QoL were found in the PWB group compared to the RWB group at 2-, 6-, 12- and 26-weeks post-surgery. There were no significant differences in postoperative complication rates between the PWB and RWB groups.

CONCLUSION

PWB is effective and is associated with a significantly reduced time to full weight bearing, and a significantly better outcome regarding ADL and QoL compared to patients who followed RWB regimen. Moreover, no significant differences in complication rates were found between the PWB and RWB groups.

LEVEL OF EVIDENCE

Level II.

REGISTRATION

This study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Rehabilitation effect of standing bed combined with early anti-gravity running table training on ankle fracture

To explore the clinical effect of standing bed combined with early anti-gravity running table training in the healing and functional recovery of anterior rotation external rotation ankle fractures. Fifty-two patients with ankle fractures of degree III or degree IV of PER admitted to Pingle Orthopaedic and Traumatology Hospital of Shenzhen City between September 2021 and January 2023 were selected for observation, and they were divided into 26 cases in each group according to the method of randomised numerical table into the control group and the observation group. The patients in the control group started the routine rehabilitation treatment on the 1st day after operation, and in the 0-2 weeks after operation, the affected limb was elevated and ankle pump training was carried out; in the 3-6 weeks after operation, joint mobility training, strength training and soft tissue release were carried out; and in the 6-8 weeks after operation, weight-bearing training was increased. The observation group added standing bed training on the 7th postoperative day and anti-gravity running table training on the 28th postoperative day on the basis of the treatment protocol of the control group. Bone density, ankle mobility and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores, pain, ankle mobility and swelling evaluations were compared between the 2 groups before and after 8 weeks of treatment, and the quality scores of bone scabs were compared between the 2 groups after 4 weeks of treatment. There was no statistical significance in the comparison of the items between the two groups before treatment (all P > 0.05), and the difference in the bone scab quality score was not statistically significant after 4 weeks of treatment (P > 0.05), and after 8 weeks of treatment, the bone scab quality score, bone mineral density and AOFAS scores, pain, ankle mobility, and evaluations were higher than those of the control group (all P < 0.05), and there was no significant difference in the degree of swelling (P > 0.05). Standing bed combined with early anti-gravity running table training applied to postoperative patients with PER III or IV degree ankle fracture can reduce the degree of pain and improve the ankle joint function.

Safety of early weightbearing after ankle fracture fixation

PURPOSE

Patients with surgically treated ankle fractures are traditionally kept non-weightbearing for at least six weeks post-operatively; however, recent literature suggests numerous benefits of early weightbearing (EWB) before six weeks without significantly impacting long-term outcomes. This study aims to review the safety of early vs late weightbearing following ankle fracture fixation by assessing the complication rate.

METHODS

This was a single-centre retrospective study. Between 2020 and 2023, all ankle fixations that commenced weightbearing at two weeks were added to the EWB group. An equal number of similar patients with six-week non-weightbearing were added to the late weightbearing (LWB) group. Baseline characteristics, risk factors, types of fractures and any complications in the six-month post-operative period were evaluated from these cohorts.

RESULTS

In total, 459 ankle fixations were identified of which 87 patients met the criteria for the EWB group, with a further 87 added to the LWB group. There was no significant difference in age between the two groups (51.7 ± 20.1 vs 51.0 ± 15.5, respectively; p = 0.81), but more female patients and diabetics in the EWB group. Fracture types were similar between both cohorts (p = 0.51). Complication rate in the EWB group was not significantly different to the LWB group (5 vs 9, p > 0.05).

CONCLUSION

No increase in complication rate was identified by commencing weightbearing early at two weeks after ankle fixation compared to six weeks. We therefore suggest EWB if appropriate, given its associated benefits including restoration of patient independence and improved quality of life.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Hindfoot nailing without joint preparation for ankle fractures in extremely elderly patients: Comparison of clinical and patient-reported outcomes with standard ORIF

INTRODUCTION

Tibiotalocalcaneal (TTC) nailing without joint preparation has been indicated as an alternative to open reduction and internal fixation (ORIF) in the treatment of unstable fragility ankle fractures. We hypothesized that primary hindfoot nailing without joint preparation, and immediate weight bearing can provide a safe and effective treatment for unstable fragility fractures of the ankle compared to ORIF.

METHODS

A retrospectively single-center cohort was reviewed for all surgically treated ankle fractures in patients aged 75 years and older between 2016 and 2021. The cases were grouped by the surgical technique: ORIF or TTC nailing. Diagnosis and treatment were validated by a review of the radiographs and the patients' charts. Primary outcomes included complication rates and revision rates. The PROMs questionnaires included the Foot and Ankle-Ability Measure (FAAM-ADL) and the Olerud-Molander Ankle Score (OMAS).

RESULTS

Forty-six cases met the inclusion criteria during the study period. Eighteen in the TTC group and 28 in the ORIF group. The average follow-up was 46.4 months (Median 49.5, SD ± 25.3). The mean age of the TTC group was significantly higher (88.6 versus 81.8, p < 0.001). The mean surgery duration and length of stay were similar. The complication rates were 50.0 % in the ORIF group (28.6 % major) versus 22.2 % in the TTC group (5.6 % major), (p = 0.060). The revision rates were 28.6 % and 11.1 % in the ORIF and TTC groups respectively (p = 0.161). The FAAM-ADL was higher in the ORIF group (62.6 % versus 32.4 %, p = 0.020), as well as the OMAS (60.0 versus 32.8, p = 0.029).

CONCLUSION

TTC nailing without joint preparation for unstable fragility fractures of the ankle in the extremely elderly provided a better complication profile compared to traditional ORIF. However, PROMs were inferior.

Very early prescription of range of motion exercises in ankle fractures treated with ORIF does not increase the rate of complications and reoperations: A survival risk analysis

BACKGROUND

Ankle fractures are commonly treated with non-surgical or surgical (preferably ORIF) approaches based on fracture characteristics. The postoperative care regimens vary widely, and the impact of very early mobilization on complications and reoperation rates in ankle fractures treated with ORIF remains unclear.

METHODS

A retrospective analysis was conducted on ankle fractures treated between January 2014 and November 2020. Demographic and fracture characteristic data were collected. Very early prescription of range of motion exercises was defined as initiation within the first week after surgery, typically between the second and seventh postoperative day. Complications, reoperations, and time to these events were analyzed. Kaplan Meier survival analysis was performed to assess the risk of complications with very early mobilization.

RESULTS

A total of 299 patients met the inclusion criteria. The cohort included 83 unimalleolar, 77 bimalleolar, and 138 trimalleolar fractures. Of the patients, 116 (38.8%) underwent very early range of motion. Complications occurred in 45 events among 39 patients (13%), with 16 events (41%) in the very early range of motion group. Reoperations were required for 23 patients (3.67% of the cohort). No statistically significant differences were found in the analysis of complications, with a hazard ratio (HR) of 1.17, and in the adjusted analysis with an HR of 1.12. Similarly, the reoperation analysis showed no significant differences, with an HR of 0.85 and 0.68 in the adjusted analysis.

CONCLUSION

Very early prescription of range of motion exercises in ankle fractures treated with ORIF is a safe approach, as it does not increase the rates of complications or reoperations compared to early or late mobilization. This study supports the use of very early mobilization as a rehabilitation method for ankle fractures.

Early versus late weight-bearing in operatively treated ankle fractures with syndesmotic injury: A systematic review

BACKGROUND

Over the past 30 years, several studies have compared early weight-bearing versus late weight-bearing following open reduction and internal fixation of ankle fractures; however, no review strictly including patients with ankle fractures and complete syndesmotic disruption has been performed.

OBJECTIVE

The objective of this systematic review was to compare early versus late weight-bearing following surgery for ankle fracture with syndesmotic injury regarding clinical and patient-reported outcomes.

METHODS

A comprehensive search strategy was applied to the Cochrane Library, MEDLINE, Embase, CINAHL and PubMed databases from their inception to the 17th of January 2022. The articles were screened independently by two blinded reviewers. Data were extracted by one author, then cross-checked and approved by the other.

RESULTS

No comparative studies were found; therefore, studies describing either early or late weight-bearing were included. It was thus not possible to perform a meta-analysis. 11 studies and 751 patients were included. An early partial weight-bearing protocol was used in three studies (253 patients) and late in eight studies (498 patients). Functional outcomes suggested that there were no clear differences between early partial weight-bearing and late weight-bearing. The reoperation rate was 9-31% in the early group and 0-11% in the late. Similar results were seen for loss of syndesmotic reduction, malreduction, infection, and fixation failure.

CONCLUSION

Pros and cons were reported for early partial weight-bearing and late weight-bearing, but the evidence was very limited as our results were based on noncomparative studies. In the future, high-quality comparative studies focusing on functional outcomes within 6 months postoperatively are needed.

LEVEL OF CLINICAL EVIDENCE

1.

Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients

Background

Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization.

Methods

A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups.

Results

We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05).

Conclusion

Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time.

Level of Evidence

Level III, retrospective cohort study.

Characteristics and Effectiveness of Postoperative Rehabilitation Strategies in Ankle Fractures: A Systematic Review

OBJECTIVES

To explore the characteristics and to report on the effectiveness of postoperative rehabilitation strategies for people with an ankle fracture.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL were searched to identify studies published from January 2010 to November 2021.

STUDY SELECTION

Studies that described or evaluated postoperative rehabilitation strategies for surgically repaired ankle fractures were included.

DATA EXTRACTION

Data on postoperative rehabilitation were extracted in accordance with the Template for Intervention Description and Replication guide. Quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools.

DATA SYNTHESIS

Meta-analysis was planned to look at the effectiveness of postoperative rehabilitation strategies. Forty studies described postoperative rehabilitation strategies without evaluating effectiveness, whereas 15 studies focused on evaluating effectiveness. Because of the large variety in postoperative strategies and outcomes, narrative synthesis was deemed most suitable to answer our aims. Characteristics of postoperative rehabilitation strategies varied widely and were poorly described in a way that could not be replicated. Most of the studies (48%) used a late weight-bearing approach, although definitions and details around weight-bearing were unclear.

CONCLUSIONS

Late weight-bearing has been the most common postoperative approach reported in the past 10 years. The variety of definitions around weight-bearing and the lack of details of rehabilitation regimens limit replication and affect current clinical practice. The authors propose to adopt consistent definitions and terminology around postoperative practices such as weight-bearing to improve evidence for effectiveness and ultimately patient outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early versus late weight bearing & ankle mobilization in the postoperative management of ankle fractures: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

While open reduction and internal fixation is currently considered the optimum treatment option for displaced ankle fractures, the most optimal post-operative rehabilitation strategy in this setting remains unclear. The objective of this investigation was to compare the effect of early vs. late weight bearing and ankle mobilization in the post-operative management of ankle fractures.

METHODS

Medline, Embase, CENTRAL, Scopus, CINHAL, and Web of Science were searched to identify randomized controlled trials (RCTs) and quasi-RCTs. Two review authors screened articles, abstracted data, and evaluated risk of bias in duplicate. Outcomes of interest included post-operative ankle function and overall time to return to work. Studies on weight bearing and ankle mobilization were analysed separately and all data were pooled using random-effects models.

RESULTS

Eighteen trials were included in the review of which 14 were included in the meta-analysis of at least one outcome of interest. Majority of the studies presented a high overall risk of bias. Early weight bearing demonstrated significantly better short-term postoperative functional scores at 6-9 weeks postoperatively (SMD: 0.39, 95% CI: 0.19, 0.58; p < 0.0001; I² = 0%). However, the functional effect of early weight bearing compared to late weight bearing gradually became equivalent by the 6 month postoperative time-period. Early weight bearing also demonstrated a significant reduction in the time to return to work/daily activities (MD: -12.29, 95% CI: -17.39, -7.19; p < 0.0001; I² = 0%). In comparison, no significant differences were found between early ankle mobilization/exercises and immobilization.

CONCLUSION

Our findings suggest a potential role of EWB in improving post-operative ankle-function in the short-term and reducing the overall time to return to work/daily activities, but no clinical benefit associated with early ankle mobilization post-surgery.

Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systematic Literature Review and Meta-Analysis

BACKGROUND

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. Traditional postoperative nonweightbearing cast immobilization may prevent loss of fixation and protect the soft tissue envelope but may also be associated with poorer functional outcomes. This systematic review and meta-analysis aimed to compare the complication rate and functional outcomes of early weightbearing (EWB) vs late weightbearing (LWB) following open reduction and internal fixation of ankle fractures.

METHODS

We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies using 3 databases. We included all studies that investigated the effect of weightbearing following internal fixation of ankle fractures in adult patients by any means. Studies that investigated mobilization but not weightbearing, non-English-language publications, and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomized controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3.

RESULTS

This systematic review included 10 randomized controlled trials and 4 comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There was no significant difference in the complication rate between the protected EWB and LWB groups (the risk ratio [RR] for infection was 1.30, 95% CI 0.74, 2.30; I² = 0%; P = .36), but better functional outcome scores were detected in the EWB group only at 6 weeks postoperatively (MD =10.08, 95% CI 5.13, 15.02; I² = 0%; P ≤ .0001), with no significant difference seen at 6 or 12 months postoperatively.

CONCLUSION

Based on the studies reviewed, it appears that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing and is associated with better early functional outcomes at 6 weeks, but not 6 or 12 months, postoperatively.

Early Return to Daily Life through Immediate Weight-Bearing after Lateral Malleolar Fracture Surgery

Lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for weight-bearing has not been standardized. In the present study, we investigated the prognostic difference between immediate and delayed weight-bearing on lateral malleolus fractures. The medical records of matched patients in the immediate and delayed weight-bearing groups (50 and 50, respectively) were reviewed retrospectively. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate with a lag screw. In the immediate weight-bearing group (IWB), tolerable weight-bearing (i.e., what can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight-bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise was permitted in both groups, starting from the day after surgery. Radiographic assessment data and clinical outcomes were reviewed between the two groups. No significant differences in radiographic assessments and complications were found between the two groups. Significant differences in terms of a shortened length of hospital stay and time to return to work with the IWB rehabilitation protocol compared with DWB were confirmed (6.0 vs. 9.2 days, p = 0.02 and 6.1 vs. 8.3 weeks, p = 0.02, respectively). A significant difference in sport factor was observed in the Foot and Ankle Outcome Score at 3 months postoperatively (72.3 vs. 67.4, p = 0.02). We found no significant differences between the two groups concerning postoperative radiological outcomes and complications. The benefits of shortening the time to return to work and length of hospital stay associated with the IWB rehabilitation protocol were confirmed. In conclusion, immediate weight-bearing is recommended in patients with lateral malleolus fracture after anatomical reduction and firm fixation by surgery.

Measuring Recovery and Understanding Long-Term Deficits in Balance, Ankle Mobility and Hip Strength in People after an Open Reduction and Internal Fixation of Bimalleolar Fracture and Their Impact on Functionality: A 12-Month Longitudinal Study

To analyze how balance and other physical capacities evolved after surgery in patients with a bimalleolar fracture and how these capacities and clinical variables (immobilization or unloading time) contribute to restoring patients’ functionality, 22 patients and 10 healthy people (HC) were assessed for static and dynamic balance (Y-Balance test, YBT), dorsiflexion ankle mobility (ADFROM) and hip strength at 6 and 12 months after surgery. Patients’ functional status was assessed through the Olerud Molander Ankle Score (OMAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Twenty-one patients with ankle fractures who completed the study showed a worse static and dynamic balance at 6 months. The YBT in the anterior direction (YBTA) revealed balance deficits in the operated limb at 12 months compared to the non-operated limb (−5.6%) and the HC (−6.7%). They also showed a decreased ADFROM compared to the non-operated limb (−7.4°) and the HC (−11°). In addition, medium-term (6 months) deficits in abductor strength hip but no hip strength deficits were found at 12 months after surgery. Relative weight analyses showed that ADFROM and hip strength explained 35–63% of the YBTA variance and AOFAS/OMAS scores. Balance, hip strength and ADFROM seem to be reliable indexes for assessing the functional status of these patients. These results could help to understand the relationship between these physical capacities and the patients’ perceived functional status.

Systematic review of tendon transfers in the foot and ankle using interference screw fixation: Outcomes and safety of early versus standard postoperative rehabilitation

AIMS

To compare the outcomes of early and standard rehabilitation protocols following tendon transfers in the foot and ankle using interference screw fixation (ISF).

METHODS

A systematic review was performed for relevant articles (1998 to 2020) reporting foot tendon transfer using ISF in adults. The primary outcome was early tendon failure. Secondary outcomes included function and complications.

RESULTS

In total, 21 studies met the inclusion criteria, totalling 494 patients. Seven studies reported early rehabilitation protocols. The rate of early tendon failure was zero for each protocol and studies consistently reported a significant improvement in function. No differences were found comparing different rehabilitation protocols for tendon transfer for Achilles tendon pathology and foot drop.

CONCLUSION

Both early and standard rehabilitation protocols are associated with high patient satisfaction and low complication rates, but currently there is a lack of evidence to support early loaded activities or motion.

LEVEL OF EVIDENCE

IV Systematic review including case series.

Results From an All Wales Trainee Led Collaborative Prospective Audit on Management of Ankle Fractures

Aim The purpose of this all Wales national audit was to compare compliance against British Orthopedic Association Standards for Trauma (BOAST) guidelines on the management of ankle fractures. Methods A multi-center prospective audit of the management of adult ankle fractures was conducted between February 2, 2020, and February 17, 2020, via the Welsh Orthopedic Research Collaborative (WORC). Regional leads were recruited in nine NHS hospitals across six university health boards, and recruited collaborators in their respective hospitals. Questionnaires for the data collection on both surgical and conservative management were made available via a password-protected website (walesortho.co.uk). We defined early weight-bearing (EWB) as unrestricted weight-bearing on the affected leg within three weeks of injury or surgery and delayed weight-bearing (DWB) as unrestricted weight-bearing after three weeks of injury or surgery. Results A total of 28 collaborators contributed data for 238 ankle fractures. Poor documentation at the time of injury was noted. Less than 50% of patients with posterior malleolus fracture had a CT scan for further evaluation. Eighty-four percent of the non-operatively treated patients did not have a weight-bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43% and 10% of the non-operatively and operatively treated patients, respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis. Conclusion There is poor compliance with BOAST guidelines on the management of ankle fractures across Wales. We need to improve documentation and also consider performing a CT scan when the posterior malleolus is fractured. A weight-bearing X-ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight-bearing. The guidelines need to be clearer regarding weight-bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.

Early Weightbearing Versus Nonweightbearing After Operative Treatment of an Ankle Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial

BACKGROUND

Acute ankle fractures can occur during sports activities, and unstable ankle fractures are commonly treated operatively. However, controversy exists about the optimal time to allow weightbearing.

HYPOTHESIS

Early weightbearing after the stable fixation of an ankle fracture is not inferior to nonweightbearing in terms of ankle function assessed at 12 months after injury.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 258 patients were assessed for eligibility. Of these patients, 194 were randomly allocated to either the early weightbearing group (95 patients who were allowed weightbearing at 2 weeks postoperatively) or the nonweightbearing group (99 patients who were not allowed weightbearing until 6 weeks postoperatively). The primary outcome measure was the mean difference in the Olerud-Molander ankle score (OMAS) between the groups, assessed at the 12-month follow-up examination. The secondary outcome measures were the time to return to preinjury activities and patients' subjective satisfaction. Complications such as hardware loosening or failure, fracture displacement, and nonunion were evaluated.

RESULTS

The mean difference in the OMAS for the early weightbearing group compared with the nonweightbearing group was 1.6 (95% CI, -1.9 to 5.0) in the intention-to-treat analysis. The lower limit of the 95% CI (-1.9) exceeded the noninferiority margin of -8, indicating that early weightbearing was not inferior to nonweightbearing. The difference in the proportion of patients who were satisfied or very satisfied with their treatment was not statistically significant (84.3% vs 76.2%; P = .19); however, the time taken to return to preinjury activities was shorter with early weightbearing than with nonweightbearing (9.1 ± 3.0 vs 11.0 ± 3.0 weeks; P < .001). No cases of nonunion were observed in either group.

CONCLUSION

Early weightbearing after the operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months after injury. The patients' subjective satisfaction was similar between the groups, although the time taken to return to preinjury activities was shorter in the early weightbearing group.

REGISTRATION

NCT02029170 (ClinicalTrials.gov identifier).

Effect of Early Weight Bearing on Outcomes After Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures

Current practice allows early weight bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early weight bearing (EWB) vs late weight bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The goal of this study was to evaluate union rates, clinical outcomes, and complications for patients who were managed with EWB vs LWB. The authors performed a retrospective review of 185 patients who underwent surgical stabilization for trimalleolar ankle fracture. Fixation of the posterior malleolus and weight bearing status were determined by surgeon preference. For this study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate, and return to surgery. The EWB group included 47 (25.4%) patients, and the LWB group included 138 (74.6%) patients. Of the 7 nonunions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. A total of 72 (38.9%) posterior malleolar fractures were operatively stabilized, and stabilization did not affect union rates. Syndesmotic fixation was required for 12.5% of patients, despite posterior malleolar stabilization. Syndesmotic fixation increased the union rate 2.5 times. Deep infection and open fracture decreased union. No difference was seen between groups in implant failure, union rate, infection, or return to the operating room. No deleterious effect of EWB in operatively treated trimalleolar ankle fractures was found for union, implant failure, infection, or reoperation. Syndesmotic fixation may offer an advantage over posterior malleolar fixation, with improved union rates. [Orthopedics. 2021;44(3):160-165.].

Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures

BACKGROUND

Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes.

METHODS

A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications.

RESULTS

A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8).

CONCLUSION

Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.

Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study

OBJECTIVES

We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications.

DESIGN

Retrospective case-control study.

SETTING

Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area.

PATIENTS/PARTICIPANTS

Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non-weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85).

INTERVENTION

IWBAT and IROM after ankle ORIF versus NWB for 6 weeks.

MAIN OUTCOME MEASUREMENTS

Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction.

RESULTS

There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation.

CONCLUSIONS

We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

BACKGROUND

Postoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates.

METHODS

A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance.

DISCUSSION

Traditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN76410775 . Retrospectively registered on 30 June 2019.

Outpatient Physical Therapy Use Following Tibial Fractures: A Retrospective Commercial Claims Analysis

OBJECTIVE

The purpose of this study was to characterize outpatient physical therapy (OPT) use following tibial fractures and examine the variability of OPT attendance, time of initiation, number of visits, and length of care by patient, injury, and treatment factors. In the absence of clinical guidelines, results will guide future efforts to optimize OPT following tibial fractures.

METHODS

This study used 2016 to 2017 claims from the IBM MarketScan Commercial Claims Research Database. The cohort included 9079 patients with International Classification of Diseases: Tenth Revision (ICD-10) diagnosis codes for tibial fractures. Use in the year following initial fracture management was determined using Current Procedural Terminology codes. Differences in use were examined using χ2 tests, t tests, and Kruskal-Wallace tests.

RESULTS

Sixty-seven percent of patients received OPT the year following fracture. OPT attendance was higher in female patients, in patients with 1 or no major comorbidity, and in the western United States. Attendance was higher in patients with upper tibial fractures, moderate-severity injuries, and treatment with external fixation and in patients discharged to an inpatient rehabilitation facility. Patients started OPT on average [SD] 50 [52.6] days after fracture and attended 18 [16.1] visits over the course of 101 [86.4] days. The timing of OPT, the number of visits attended, and the length of OPT care varied by patient, injury, and treatment-level factors.

CONCLUSIONS

One-third of insured patients do not receive OPT following tibial fracture. The timing of OPT initiation, the length of OPT care, and the number of visits attended by patients with tibial fractures were highly variable. Further research is needed to standardize referral and prescription practices for OPT following tibial fractures.

IMPACT

OPT use varies based on patient, injury, and treatment-level factors following tibial fractures. Results from this study can be used to inform future efforts to optimize rehabilitation care for patients with tibial fractures.

Operative Treatment of Ankle Fractures: Predictive Factors Affecting Outcome

Purpose

Surgical management of ankle fractures has been extensively studied in literature but studies investigating validated clinical results are lacking and controversial. The purpose of this study was to evaluate functional and health-related quality of life (HRQL) outcomes after surgically treated ankle fractures and to detect some of their predictors.

Methods

Two hundred sixty-six skeletally mature patients who underwent surgery for an isolated ankle fracture from 2006 to 2017 were retrospectively identified from our hospital records and included in the study. All patients were evaluated at one, three, six and 12 months post-injury with clinical and radiographic examination. Outcome measures recorded at final two years minimum follow-up included patient-reported pain, patient satisfaction, functional (American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score) and quality of life (Short Form (SF) 36 score) status.

Results

Patient satisfaction score was 8.4 out of 10, Visual Analogue Scale mean score was 2.3, complication rate was 36.5% and mean AOFAS ankle-hindfoot score was 87.3. Mean SF36-physical summary score was 77.9 and SF36-mental summary score was 81.1. The injury demonstrated a significant effect on physical function, role-physical, bodily pain and social functioning SF-36 subdomains. Functional outcome was significantly related to occupation, syndesmotic lesion, number of fractured malleoli and delay to surgery. Main predictors of quality of life were age, occupation, cause of injury, syndesmotic lesion, number of fractured malleoli and waiting time to surgery.

Conclusions

Ankle fractures have a considerable impact on functional and quality of life status of patients. Occupation, presence of syndesmotic injury, Pott's classification and surgery delay must be considered as predictors of final outcome.

Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial

OBJECTIVE

To compare the functional outcomes and length of hospital stay for patients treated with conventional physiotherapy compared to a new ankle trainer device after Weber B ankle fractures.

DESIGN

The patients were randomized, and then followed up at 3, 6, 12 and 52 weeks by a blinded physiotherapist.

SETTING

This study was done at a level 1 trauma centre.

SUBJECTS

One hundred and forty consecutive patients with Weber B ankle fractures that were operated on were screened for eligibility, of whom 113 were included in the study.

INTERVENTIONS

Conventional physiotherapy with stretching exercises, using a non-elastic band or using new ankle trainer.

MAIN MEASURES

Outcomes were evaluated with Olerud-Molander ankle score, Visual analogue scale for pain and ankle dorsiflexion at 3, 6, 12 and 52 weeks follow-up. Time of hospitalization and complications were registered.

RESULTS

Superior Olerud-Molander ankle scores were observed at three weeks follow-up in the ankle trainer group 40.9 (10.8), compared to the conventional group 35.3 (14.2) (P = 0.021). At one-year follow-up, there was no difference between the groups (P = 0.386). The ankle trainer group had a shorter hospital stay with a mean 2.6 days (0.98) compared to 3.2 days (1.47) in the conventional group (P = 0.026).

CONCLUSION

The patients who were treated with the new ankle trainer device recovered more rapidly, evaluated by the Olerud-Molander ankle score and had a shorter stay in hospital compared to the conventional physiotherapy group. No between group differences could be observed at long-term follow-up.

Patient-reported quality of life and pain after permissive weight bearing in surgically treated trauma patients with tibial plateau fractures: a retrospective cohort study

INTRODUCTION

A Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime.

MATERIALS AND METHODS

This retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected.

RESULTS

This cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively.

CONCLUSION

PWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.

Immediate weight bearing after plate fixation of fractures of the tibial plateau

BACKGROUND

Proximal articular fractures of the tibia are commonly stabilised with internal fixation using plates and screws. There is a lack of evidence and conflicting guidelines as to the most suitable post-operative rehabilitation regime including weight bearing status. There are numerous physiological and socioeconomic benefits of early weight bearing after orthopaedic surgery, but concerns remain around loss of fracture reduction. Therefore, the aim of this study is to investigate whether the weight bearing status after tibial plateau plate fixation is associated with any loss of reduction or articular collapse.

METHODS

We retrospectively analysed data from our prospectively collected major trauma centre database. All tibial plateau fractures that required open reduction and internal fixation with plate and screws were included. The immediate post-operative weight bearing status of these patients was recorded. Group I consisted of those patients that were either non-weight bearing or touch weight bearing for the first six post-operative weeks. Group II consisted of patients who were instructed to weight bear fully (as tolerated) immediately after the operation. Radiographs were taken on day one post-operation, at six weeks and at three months and analysed for fracture displacement and joint depression or loss of fixation.

RESULTS

A total of 90 patients were included in the study. Group I (non-weight bearing or touch weight bearing) consisted of 60 patients (67%). Group II (full weight bearing as tolerated) consisted of 30 patients (33%). The follow up radiographs demonstrated no failure of fixation in either study group. One patient from the weight bearing group had >1 mm joint depression (4 mm) identified at the first follow up, which did not progress.

CONCLUSIONS

This study shows immediate post-operative full weight bearing does not affect the fixation or cause articular collapse up to three months after surgery and thus we propose that patients should be allowed to weight bear immediately after surgical stabilisation of tibial plateau fractures. This will enable patients to benefit from the positive effects on fracture healing of early weight bearing post-surgery and avoid the complications of non-weight bearing without loss of fixation or articular collapse.

Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients

INTRODUCTION

Retrograde transplantar intramedullary nailing (TIMN) is a recently described option for ankle fracture in elderly patients with multiple comorbidity contraindicating classical internal fixation. The main objective of the present study was to assess mobility after TIMN for ankle fracture in the elderly. The secondary objective was to assess complications.

HYPOTHESIS

Retrograde TIMN provides reliable fixation of ankle fracture in the elderly, enabling early resumption of walking.

MATERIAL AND METHODS

Fourteen patients, with a mean age of 79.6years (range: 65-99years), with fracture of the ankle or tibial pilon treated by retrograde TIMN, were prospectively included over a 1-year period (2014-2016). Full weight-bearing with walking cast boot was authorized as of day 1. Mobility was assessed on Parker score in consultation at 6, 12, 24 and 48 weeks.

RESULTS

Ten patients were followed up. Mean Parker score was 3.6 (range: 1-5) preoperatively, and 2.4 (range: 1-5) and 2.7 (range: 1-5) at 24 and 48 weeks, respectively: i.e., not significantly different from preoperative values (p=0.057 and p=0.054, respectively). There were no decubitus-related complications. Two patients (20%) showed other complications, including 1 deep infection requiring material ablation. Consolidation was systematic, without hindfoot malunion.

DISCUSSION

Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. It allowed immediate resumption of weight-bearing and early rehabilitation, with no increased morbidity or mortality.

LEVEL OF EVIDENCE

IV.

Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial

Background

Following surgical fixation of ankle fractures, the traditional management has included immobilisation for 6 weeks in a below-knee cast. However, this can lead to disuse atrophy of the affected leg and joint stiffness. While early rehabilitation from 2 weeks post surgery is viewed as safe, controversy remains regarding its benefits. We will compare the effectiveness of early motion and directed exercise (EMADE) ankle rehabilitation, against usual care, i.e. 6 weeks’ immobilisation in a below-knee cast.

Method/design

We have designed a pragmatic randomised controlled trial (p-RCT) to compare the EMADE intervention against usual care. We will recruit 144 independently living adult participants, absent of tissue-healing comorbidities, who have undergone surgical stabilisation of isolated Weber B ankle fractures. The EMADE intervention consists of a non-weight-bearing progressive home exercise programme, complemented with manual therapy and education. Usual care consists of immobilisation in a non-weight-bearing below-knee cast. The intervention period is between week 2 and week 6 post surgery. The primary outcome is the Olerud and Molander Ankle Score (OMAS) patient-reported outcome measure (PROM) at 12 weeks post surgery. Secondary PROMs include the EQ-5D-5 L questionnaire, return to work and return to driving, with objective outcomes including ankle range of motion. Analysis will be on an intention-to-treat basis. An economic evaluation will be included.

Discussion

The EMADE intervention is a package of care designed to address the detrimental effects of disuse atrophy and joint stiffness. An advantage of the OMAS is the potential of meta-analysis with other designs. Within the economic evaluation, the cost-utility analysis, may be used by commissioners, while the use of patient-relevant outcomes, such as return to work and driving, will ensure that the study remains pertinent to patients and their families. As it is being conducted in the clinical environment, this p-RCT has high external validity. Accordingly, if significant clinical benefits and cost-effectiveness are demonstrated, EMADE should become a worthwhile treatment option. A larger-scale, multicentre trial may be required to influence national guidelines.

Trial registration

ISRCTN, ID: ISRCTN11212729. Registered retrospectively on 20 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2691-7) contains supplementary material, which is available to authorized users.

Functional Outcomes and Quality of Life After Ankle Fracture Surgically Treated: A Systematic Review

Context:Ankle fractures (AFs) are the most common fractures of the lower limbs found in emergency services. Approximately 53% of these fractures are unstable and treated surgically.Objective:To conduct a systematic review evaluating functional outcomes and quality of life of patients with AFs surgically treated.Evidence Acquisition:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Five electronic databases were searched, without any limit on publication dates. Only patients with an unstable AF that was surgically treated were included; functional outcomes and the quality of life were controlled by the 36-Item Short-Form Health Survey instrument.Evidence Synthesis:Five studies were included in the analysis, including 267 patients. The values of the Physiotherapy Evidence Database scale ranged between a minimum of 5 and a maximum of 7 points. Patients with surgically treated AF reported less functionality and physical capacity compared with the nonfractured population. Some patients experienced vitality, emotional, and mental health limitations for a long period. Most surgically treated patients reported no pain and a good health and social status.Conclusion:Limitations in functionality and physical capacity represent the main threats to health-related quality of life in patients with surgically treated AFs.

Utility of Third-Week Postoperative Radiographs in the Management of Ankle Fractures

OBJECTIVES

To evaluate the costs and efficacy of radiographs taken in the third week after fixation of bimalleolar and trimalleolar fractures.

PATIENTS AND METHOD

A retrospective evaluation was made of patients who underwent surgical fixation because of bimalleolar and trimalleolar fractures between January 1, 2008, and October 1, 2013. Patient demographics (age, gender, body mass index), fracture type, follow-up periods, and fixation methods were recorded, and the radiographs taken on postoperative day 1, at 3 weeks, 6 weeks, and the final follow-up were examined by 2 orthopedists. Measurements were taken of the medial clear space (MCS ≤ 4 mm), the tibiofibular clear space (TFCS < 5 mm), and the talocrural angle (TCA = 83° ± 4°) on the mortise radiograph and of the overlap between the tibial tubercle and fibula (TFO > 10 mm) on the anteroposterior radiograph; residual step (mm) was measured on the lateral radiograph.

RESULTS

A total of 263 patients were examined, and of these, 112 were included for evaluation. In the measurements of postoperative day 1, third week, and sixth week and the final radiographs, no statistically significant difference was determined in the MCS, TFCS, TCA, TFO, and residual step values. Because the cost of a series of 3-way ankle radiographs in Turkey is US$3.81 per patient, the cost of the control series for the 112 patients in this study was US$ 427.3.

CONCLUSIONS

In patients treated surgically for bimalleolar and trimalleolar fractures, the radiographs taken in the third week rarely resulted in a change of patient management. Therefore, it simply constitutes an additional cost for the patient or the hospital.

LEVELS OF EVIDENCE

Level III: Retrospective Cohort study.

Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture

Background/Objective

Ankle fractures, even if treated surgically, usually take a long time to heal. For all patients with ankle fracture, immobilisation is a critical part of treatment. Short-leg walking boots (WBs) have been reported to be an effective alternative to plaster casts (PCs) that could shorten this postoperative recuperative period. The aim of this study was to compare the functional recovery of a conventional PC with that of a WB after surgery for ankle fractures.

Methods

Forty-seven patients (mean age, 53.9 ± 12 years) who had undergone surgical operation for an unstable ankle fracture from January 2008 to October 2014 were reviewed retrospectively. Either a PC or a WB was prescribed postoperatively, with 25 patients and 22 patients, respectively. The time that it took the patient to stand unipedal on the affected side after allowing full-weight bear and to walk without crutches were used for assessment of functional recovery. The prevalence of postoperative loss of reduction and nonunion was also reviewed.

Results

Both the time of being able to stand unipedal on the injured side and to walk without crutches were significantly shorter in patients using WBs (WB, 2.6 weeks; PC, 4.5 weeks, p = 0.01; WB, 1.4 weeks; PC, 3.1 weeks, p = 0.03). There were no patients with loss of reduction or nonunion.

Conclusion

Patients who used WBs showed a significantly faster recovery. WBs have an adjustable heel lift that allows users to change the ankle position slightly plantarflexed that helps walking in a postoperative swollen ankle. WBs are easy to slip on, and it is easy to adjust the ankle position in conformity with swelling so that the least painful position could be maintained during walking. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively. The Rocker bottom design minimises the sagittal plane motion in the specific joint of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activity at a faster rate.

Analysis of 213 currently used rehabilitation protocols in foot and ankle fractures

INTRODUCTION

Fractures of the ankle, hind- and midfoot are amongst the five most common fractures. Besides initial operative or non-operative treatment, rehabilitation of the patients plays a crucial role for fracture union and long term functional outcome. Limited evidence is available with regard to what a rehabilitation regimen should include and what guidelines should be in place for the initial clinical course of these patients. This study therefore investigated the current rehabilitation concepts after fractures of the ankle, hind- and midfoot.

METHODS

Written rehabilitation protocols provided by orthopedic and trauma surgery institutions in terms of recommendations for weight bearing, range of motion (ROM), physiotherapy and choice of orthosis were screened and analysed. All protocols for lateral ankle fractures type AO 44A1, AO 44B1 and AO 44C1, for calcaneal fractures and fractures of the metatarsal as well as other not specific were included. Descriptive analysis was carried out and statistical analysis applied where appropriate.

RESULTS

209 rehabilitation protocols for ankle fractures type AO 44B1 and AO 44C1, 98 for AO 44A1, 193 for metatarsal fractures, 142 for calcaneal fractures, 107 for 5(th) metatarsal base fractures and 70 for 5(th) metatarsal Jones fractures were evaluated. The mean time recommended for orthosis treatment was 6.04 (SD 0.04) weeks. While the majority of protocols showed a trend towards increased weight bearing and increased ROM over time, the best consensus was noted for weight bearing recommendations.

CONCLUSION

Our study shows that there exists a huge variability in rehabilitation of fractures of the ankle-, hind- and midfoot. This may be contributed to a lack of consensus (e.g. missing publication of guidelines), individualized patient care (e.g. in fragility fractures) or lack of specialization. This study might serve as basis for prospective randomized controlled trials in order to optimize rehabilitation for these common fractures.

Weight-bearing and mobilization in the postoperative care of ankle fractures: a systematic review and meta-analysis of randomized controlled trials and cohort studies

Purpose

To determine the effectiveness and safety of interventions used for rehabilitation after open reduction and internal fixation of ankle fractures.

Methods

A systematic review and meta-analysis was performed using both randomized trials and cohort studies. The effect of mobilization, weight-bearing, and unprotected weight-bearing as tolerated on postoperative recovery was compared using the Olerud Molander score, return to work/daily activities, and the rate of complications.

Results

A total of 25 articles were included. Ankle exercises resulted in earlier return to work and/or daily activities compared to immobilization (mean difference (MD) -20.76 days; 95% confidence interval (CI) -40.02 to -1.50). There was no difference in the rate of complications between exercises and immobilization (risk ratio (RR) 1.22; 95% CI 0.60 to 2.45) or between early and late weight-bearing (RR 1.26; 95%CI 0.56 to 2.85).

Interpretation

Results of this meta-analysis show that following ankle surgery, 1) active exercises accelerate return to work and daily activities compared to immobilization, 2) early weight-bearing tends to accelerate return to work and daily activities compared to late weight-bearing. Active exercises in combination with immediate weight-bearing may be a safe option.

Early ankle movement versus immobilization in the postoperative management of ankle fracture in adults: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To compare early ankle movement versus ankle immobilization after surgery for ankle fracture on clinical and patient-reported outcomes.

BACKGROUND

A significant proportion of patients undergoing surgery for ankle fracture experience postoperative complications and delayed return to function. The risks and benefits of movement of the ankle in the first 6 weeks after surgery are not known, and clinical practice varies widely.

METHODS

We searched bibliographic databases and reference lists to identify eligible trials. Two independent reviewers conducted data extraction and risk-of-bias assessments.

RESULTS

Fourteen trials (705 participants) were included in the review, 11 of which were included in the meta-analysis. The quality of the trials was universally poor. The pooled effect of early ankle movement on function at 9 to 12 weeks after surgery compared to immobilization was inconclusive (standardized mean difference, 0.46; 95% confidence interval: -0.02, 0.93; P = .06; I(2) = 72%), and no differences were observed between groups at 1 year. The odds of venous thromboembolism were significantly lower with early ankle movement compared to immobilization (Peto odds ratio = 0.12; 95% confidence interval: 0.02, 0.71; P = .02; I(2) = 0%). Deep surgical site infection (Peto odds ratio = 7.08; 95% confidence interval: 1.39, 35.99; P = .02; I(2) = 0%), superficial surgical site infection, fixation failure, and reoperation to remove metalwork were more common after early ankle movement compared to immobilization.

CONCLUSION

The quality of evidence is poor. The effects of early movement after ankle surgery on short-term functional outcomes are unclear, but there is no observable difference in the longer term. There is a small reduction in risk of postoperative thromboembolism with early ankle movement. Current evidence suggests that deep and superficial surgical site infections, fixation failure, and the need to remove metalwork are more common after early ankle movement. Level of Evidence Therapy, level 1a-.