Weight-bearing in ankle fractures: An audit of UK practice

Healthcare professionals beliefs and priorities for the rehabilitation of patients after ankle fracture surgery: A qualitative study

OBJECTIVE

The study aims to understand healthcare professionals' (HCPs) beliefs and practices in the treatment and rehabilitation of patients after ankle fracture surgery, with the goal of informing new rehabilitation interventions based on these insights.

BACKGROUND

There is considerable variation in postoperative rehabilitation advice given to patients with ankle fractures, leading to inconsistent care. Prior studies have primarily focused on patients' experiences, making it crucial to explore HCPs' perspectives to identify areas for intervention.

METHODS

The study utilised semi-structured interviews with HCPs involved in the multicentre randomised controlled Weightbearing in Ankle Fractures (WAX) trial. Interviewees included physiotherapists, consultant trauma and orthopaedic surgeons, and trainee surgeons. Interviews were conducted between February 2020 and December 2021. Data were analysed using a mixed deductive and inductive approach, aligning with the Behavioural Change Wheel framework to translate findings into potential intervention strategies.

RESULTS

18 Interviews were conducted, revealing discrepancies between patient and HCP beliefs about recovery, particularly regarding weight-bearing and managing physical symptoms like swelling and numbness. HCPs expressed varying beliefs on the safety of early weight-bearing and recognised historical practice and medicolegal concerns influencing rehabilitation advice. Themes highlighted the need for clearer communication, standardised advice, and the impact of HCPs' remarks on patients' recovery confidence.

CONCLUSIONS

Findings underscore the mismatch between patient expectations and HCP guidance, emphasising the need for consensus on rehabilitation protocols. The study advocates for tailored rehabilitation pathways that address individual patient recovery trajectories, reduce dependency on HCPs, and encourage patient self-management.

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.

Effectiveness of behavior change in rehabilitation interventions to improve functional recovery after lower limb fracture: a systematic review

Ankle fractures are common injuries that can significantly impact mobility and quality of life. Rehabilitation following ankle fracture treatment is crucial for recovery, yet adherence to regimens remains a challenge. Behaviour Change Techniques (BCTs) have been suggested to improve adherence, but their effectiveness in ankle fracture rehabilitation is not well established. This review aimed to evaluate the effectiveness of BCTs in the rehabilitation of ankle fracture patients. We conducted a comprehensive search across multiple databases, including MEDLINE and EMBASE, focusing on Randomised Controlled Trials (RCTs) that incorporated BCTs into rehabilitation interventions. The effectiveness of BCTs on patient-reported outcomes (PROMs), quality of life, and adverse events was analysed. Nine RCTs met the inclusion criteria, encompassing a range of interventions that employed BCTs, most commonly including goal setting and instruction on how to perform behaviours, specifically physiotherapy exercises. The review found limited evidence supporting their effectiveness in improving PROMs. Only one study showed a significant positive effect, but it was deemed at high risk of bias. The lack of integration of behavioural theory in the design of rehabilitation interventions and the varied nature of the BCTs employed across studies may contribute to these findings. The use of BCTs in ankle fracture rehabilitation is prevalent, but this review highlights a significant gap their role of enhancing patient outcomes. Future research should incorporate a theory-based approach to intervention design, utilising a broader range of BCTs, to fully evaluate their potential in improving rehabilitation adherence and outcomes following ankle fracture .

Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial

BACKGROUND

After surgery for a broken ankle, patients are usually instructed to avoid walking for 6 weeks (delayed weight-bearing). Walking 2 weeks after surgery (early weight-bearing) might be a safe and preferable rehabilitation strategy. This study aimed to determine the clinical and cost effectiveness of an early weight-bearing strategy compared with a delayed weight-bearing strategy.

METHODS

This was a pragmatic, multicentre, randomised, non-inferiority trial including 561 participants (aged ≥18 years) who received acute surgery for an unstable ankle fracture in 23 UK National Health Service (NHS) hospitals who were assigned to either a delayed weight-bearing (n=280) or an early weight-bearing rehabilitation strategy (n=281). Patients treated with a hindfoot nail, those who did not have protective ankle sensation (eg, peripheral neuropathy), did not have the capacity to consent, or did not have the ability to adhere to trial procedures were excluded. Neither participants nor clinicians were masked to the treatment. The primary outcome was ankle function measured using the Olerud and Molander Ankle Score (OMAS) at 4 months after randomisation, in the per-protocol population. The pre-specified non-inferiority OMAS margin was -6 points and superiority testing was included in the intention-to-treat population in the event of non-inferiority. The trial was prospectively registered with ISRCTN Registry, ISRCTN12883981, and the trial is closed to new participants.

FINDINGS

Primary outcome data were collected from 480 (86%) of 561 participants. Recruitment was conducted between Jan 13, 2020, and Oct 29, 2021. At 4 months after randomisation, the mean OMAS score was 65·9 in the early weight-bearing and 61·2 in the delayed weight-bearing group and adjusted mean difference was 4·47 (95% CI 0·58 to 8·37, p=0·024; superiority testing adjusted difference 4·42, 95% CI 0·53 to 8·32, p=0·026) in favour of early weight-bearing. 46 (16%) participants in the early weight-bearing group and 39 (14%) in the delayed weight-bearing group had one or more complications (adjusted odds ratio 1·18, 95% CI 0·80 to 1·75, p=0·40). The mean costs from the perspective of the NHS and personal social services in the early and delayed weight-bearing groups were £725 and £785, respectively (mean difference -£60 [95% CI -342 to 232]). The probability that early weight-bearing is cost-effective exceeded 80%.

INTERPRETATION

An early weight-bearing strategy was found to be clinically non-inferior and highly likely to be cost-effective compared with the current standard of care (delayed weight-bearing).

FUNDING

National Institute for Health and Care Research (NIHR), NIHR Barts Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

The feasibility, acceptability, safety, and effects of early weight bearing in humeral fractures - a scoping review

PURPOSE

Non-weight bearing is often recommended after humeral fractures. This review aims to summarise the extent and nature of the evidence for the feasibility, acceptability, safety, and effects of early weight bearing (EWB) in people with humeral fractures, treated operatively or non-operatively. .

METHODS

Data sources identified published (PUBMED, EMBASE, CINAHL) and unpublished (ClinicalTrials.gov, CENTRAL, NIHR Open Research, OpenGrey) literature. Independent data extraction was conducted by two reviewers.

RESULTS

13 901 records were retrieved. Ten studies, involving 515 post-operative patients and 351 healthcare professionals, were included. EWB was found to be feasible in nine studies. There was limited evidence regarding adherence to EWB. Trauma and orthopaedic surgeons reported that EWB was acceptable. This depended on surgery type and whether it was a post-operative polytrauma case. No acceptability data was reported from patients' perspectives. Only one study reported two patients who developed unsatisfactory outcomes from excessive post-operative EWB. Positive effects of EWB were reported on disability level, pain, shoulder and elbow motion, and union.

CONCLUSION

There is some evidence for the feasibility, safety, and effectiveness of post-operative EWB after humeral fractures. There was limited data on the acceptability of EWB. Heterogeneous study designs, and variations in EWB protocols limit conclusions.

Analysis of the Most Popular Online Ankle Fracture-Related Patient Education Materials

Background

Given the increasing accessibility of Internet access, it is critical to ensure that the informational material available online for patient education is both accurate and readable to promote a greater degree of health literacy. This study sought to investigate the quality and readability of the most popular online resources for ankle fractures.

Methods

After conducting a Google search using 6 terms related to ankle fractures, we collected the first 20 nonsponsored results for each term. Readability was evaluated using the Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), and Gunning Fog Index (GFI) instruments. Quality was evaluated using custom created Ankle Fracture Index (AFI).

Results

A total of 46 of 120 articles met the inclusion criteria. The mean FKGL, FRE, and GFI scores were 8.4 ± 0.5, 57.5 ± 3.2, and 10.5 ± 0.5, respectively. The average AFI score was 15.4 ± 1.4, corresponding to an "acceptable" quality rating. Almost 70% of articles (n = 32) were written at or below the recommended eighth-grade reading level. Most articles discussed the need for imaging in diagnosis and treatment planning while neglecting to discuss the risks of surgery or potential future operations.

Conclusion

We found that online patient-facing materials on ankle fractures demonstrated an eighth-grade average reading grade level and an acceptable quality on content analysis. Further work should surround increasing information regarding risk factors, complications for surgery, and long-term recovery while ensuring that readability levels remain below at least the eighth-grade level.

Use of removable support boot versus cast for early mobilisation after ankle fracture surgery: cost-effectiveness analysis and qualitative findings of the Ankle Recovery Trial (ART)

OBJECTIVES

To estimate the cost-effectiveness of using a removable boot versus a cast following ankle fracture from the National Health Service and Personal Social Services (NHS+PSS) payer and societal perspectives and explore the impact of both treatments on participants' activities of daily living.

DESIGN

Cost-effectiveness analyses and qualitative interviews performed alongside a pragmatic multicentre randomised controlled trial.

SETTING

Eight UK NHS secondary care trusts.

PARTICIPANTS

243 participants (60.5% female, on average 48.2 years of age (SD 16.4)) with ankle fracture. Qualitative interviews with 16 participants. Interventions removable air boot versus plaster cast 2 weeks after surgery weight bearing as able with group-specific exercises.

PRIMARY AND SECONDARY OUTCOME MEASURES

Quality-adjusted life years (QALYs) estimated from the EQ-5D-5L questionnaire, costs and incremental net monetary benefit statistics measured 12 weeks after surgery, for a society willing-to-pay £20 000 per QALY.

RESULTS

Care in the boot group cost, on average, £88 (95% CI £22 to £155) per patient more than in the plaster group from the NHS+PSS perspective. When including all societal costs, the boot saved, on average, £676 per patient (95% CI -£337 to £1689). Although there was no evidence of a QALY difference between the groups (-0.0020 (95% CI -0.0067 to 0.0026)), the qualitative findings suggest participants felt the boot enhanced their quality of life. Patients in the boot felt more independent and empowered to take on family responsibilities and social activities.

CONCLUSIONS

While the removable boot is slightly more expensive than plaster cast for the NHS+PSS payer at 12 weeks after surgery, it reduces productivity losses and the need for informal care while empowering patients. Given that differences in QALYs and costs to the NHS are small, the decision to use a boot or plaster following ankle surgery could be left to patients' and clinicians' preferences.

TRIAL REGISTRATION NUMBER

ISRCTN15497399, South Central-Hampshire A Research Ethics Committee (reference 14/SC/1409).

A Stability-Based Management Protocol for Isolated Lateral Malleolar Ankle Fractures at the Level of the Syndesmosis Reduces the Need for Surgical Intervention

Purpose

The study aimed to establish and subsequently improve the rate of stability assessments of fractures with uncertain stability and the impact on the avoidance of potentially unnecessary surgery.

Methods

Two independent audit cycles were conducted from October 2019 to May 2020. All patients had closed isolated lateral malleolar fractures at the level of the tibiotalar syndesmosis involving skeletally mature bone. A stability-based management protocol was introduced, incorporating an education programme and management guideline.

Results

75 ankles fractures were included. In the initial audit cycle, 13 patients did not undergo stability X-rays within 2 weeks of injury. Interestingly, only one stability assessment was performed for five operated ankles in the first audit, versus a 100% compliance rate in the second cycle. We observed more accurate documentation following education and awareness of clinical importance.

Conclusion

By implementing a stability-based management guideline, there was an improvement in compliance with guidance towards stability assessments of ankle fractures. This potentially led to the avoidance of unnecessary surgery on fractures where stability assessments supported non-operative management.

Clinical outcomes of ankle fractures in sub-Saharan Africa: a systematic review

PURPOSE

Ankle fractures may cause disability and socioeconomic challenges, even when managed in a high-resource setting. The outcomes of ankle fractures in sub-Saharan Africa are not widely reported. We present a systematic review of the patient-reported outcomes and complications of patients treated for ankle fractures in sub-Saharan Africa.

METHODS

Medline, Embase, Google Scholar and the Cochrane Central Register of Controlled Trials were searched, utilising MeSH headings and Boolean search strategies. Ten papers were included. Data included patient demographics, surgical and non-surgical management, patient-reported outcome measures and evidence of complications.

RESULTS

A total of 555 patients with ankle fractures were included, 471 of whom were followed up (range 6 weeks-73 months). A heterogenous mix of low-quality observational studies and two methodologically poor-quality randomised trials demonstrated mixed outcomes. A preference for surgical management was found within the published studies with 87% of closed fractures being treated operatively. A total of five different outcome scoring systems were used. Most studies included in this review were published by well-resourced organisations and as such are not representative of the actual clinical practice taking place.

CONCLUSION

The literature surrounding the clinical outcomes of ankle fractures in sub-Saharan Africa is sparse. There appears to be a preference for surgical fixation in the published literature and considering the limitations in surgical resources across sub-Saharan Africa this may not be representative of real-life care in the region.

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.

The association between person and fracture characteristics with patient reported outcome after ankle fractures in adults: A systematic review

BACKGROUND

The incidence of ankle fractures is increasing and the clinical outcome is highly variable.

QUESTION

What person and fracture characteristics are associated with patient reported outcomes after surgically or conservatively managed ankle fractures in adults?

DATA SOURCES

Medline, EMBASE, and Allied and Complimentary Health Medical Database (AMED) databases were searched from the earliest available date until 16th July 2020.

STUDY SELECTION

Prognostic factors studies recruiting adults of age 18 years or older with a radiologically confirmed ankle fracture, and evaluating function, symptoms and quality of life by patient reported outcome measures, were included.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed by the Quality in Prognostic Factors Studies tool. Correlation coefficients were calculated and data were analysed using narrative synthesis.

RESULTS

Fifty-one phase 1 explanatory studies with 6177 participants met the inclusion criteria. Thirty-one studies were rated as high risk of bias using the Quality in Prognostic Factors Studies tool. There was low quality evidence that age, body mass index, American Society of Anesthesiologists classification and pre-injury mobility were associated with function, and low to moderate quality evidence that age, smoking and American Society of Anesthesiologists classification were associated with quality of life. No person characteristics were associated with symptoms and no fracture characteristics were associated with any outcomes.

CONCLUSION

There was low to moderate quality evidence that person characteristics may be associated with patient reported function and quality of life following ankle fracture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020184830.

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.

Functional bracing is a safe and cost effective treatment for isolated Weber B fracture

BACKGROUND

Despite the current recommendations that stable Weber B ankle fractures can be treated with functional bracing and weightbearing as tolerated, some reluctance exists among trauma surgeons to follow these recommendations. This paper reports on our institution's experience in managing these injuries and compare it to the national guidelines.

PATIENTS AND METHODS

This is a retrospective cohort study. Consecutive patients with isolated Weber B fractures referred to the local outpatient clinic over the period of six months were included in the study. Radiographs and clinic letters were examined, the patients were interviewed via telephone to obtain outcome scores [Olerud and Molander score]. Method of immobilisation, weight-bearing status, radiological fracture union, clinical outcomes and complications were all assessed and analysed.

RESULTS

One hundred and twenty-three patients with isolated Weber B fractures were identified. This cohort of patients did not show clinical or radiographic evidence of instability, they were deemed stable and were initially treated non-operatively. Minimum follow-up period was six months. Sixty-two patients were treated in plaster and were non-weight bearing on the affected limb, while 61 were treated with functional bracing in a boot and were allowed early weight bearing. Three patients showed displacement requiring surgical fixation. All fractures progressed to union and patients were discharged irrespective of the method of immobilisation or weightbearing status during treatment. There was no statistically significant difference in the functional outcome measures between the two groups. The protocol of functional bracing and weightbearing was associated with fewer outpatient clinics and a reduced number of radiographs obtained in the clinic and fewer complications.

CONCLUSION

Isolated trans-syndesmotic Weber B ankle fractures, that are clinically and radiologically stable, can be safely treated with functional bracing in a boot and weightbearing as tolerated.

Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture

Background

Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture.

Methods

Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery (‘early weight-bearing’ group) or to not weight-bear for a further four weeks (‘delayed weight -bearing’ group). All other treatment will be as per the guidance of the treating clinician.

Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation.

A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options.

Discussion

The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures.

Trial registration

ISRCTN12883981, Registered 02 December 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04560-7.

Patient experiences of an ankle fracture and the most important factors in their recovery: a qualitative interview study

OBJECTIVE

The objective of this qualitative research study is to explore patient experiences of ankle fracture and the factors most important to them in recovery.

DESIGN

Semistructured interviews exploring patient experiences of ankle fracture recovery at 16-23 weeks following injury. Interviews followed a topic guide and were recorded with an encrypted audio recorder and then transcribed verbatim. Thematic content analysis was used to identify themes in the data.

SETTING

Individuals were recruited from a sample of participants of a UK-based clinical trial of immobilisation methods for ankle fracture (ISRCTN15537280 at the pre-results stage at time of writing). Interviews were conducted at the participants' own homes or on a university campus setting.

PARTICIPANTS

A purposive sample was used to account for key variables of age, gender and fracture management. Participants recruited from the clinical trial sample were adults aged 18 years or over with a closed ankle fracture.

RESULTS

Ten participants were interviewed, five of whom were female and six of whom needed an operation to fix their ankle fracture. The age range of participants was 21-75 years with a mean of 51.6 years. Eight themes emerged from the data during analysis; mobility, loss of independence, healthcare, psychological effects, social and family life, ankle symptoms, sleep disturbance and fatigue, and activities of daily living. Factors of importance to participants included regaining their independence, sleep quality and quantity, ability to drive, ability to walk without walking aids or weight-bearing restrictions, and radiological union.

CONCLUSIONS

The results of this research demonstrates the extensive impact of ankle fracture on individuals' lives, including social and family life, sleep, their sense of independence and psychological well-being. The results of this study will enable an increased understanding of the factors of relevance to individuals with ankle fracture, allowing collection of appropriate outcomes in clinical studies for this condition. Ultimately these results will help formulate appropriate patient-centred rehabilitation plans for these patients.

TRIAL REGISTRATION NUMBER

ISRCTN15537280; Pre-results.