EXACT: exercise or advice after ankle fracture. Design of a randomised controlled trial

Rehabilitation for ankle fractures in adults

BACKGROUND

Ankle fracture is one of the most common lower limb fractures. Whilst immobilisation of the ankle can support and protect the fracture site during early healing, this also increases the risk of ankle weakness, stiffness, and residual pain. Rehabilitation aims to address the after-effects of this injury, to improve ankle function and quality of life. Approaches are wide-ranging and include strategies to improve ankle joint movement, muscle strength, or both. This is an update of a Cochrane review last published in 2012.

OBJECTIVES

To assess the effects of rehabilitation interventions following surgical or non-surgical management of ankle fractures in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers in May 2022, and conducted additional searches of CENTRAL, MEDLINE, and Embase in March 2023. We also searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing any rehabilitation intervention delivered to adults with ankle fracture. Interventions could have been given during or after the initial fracture management period (typically the first six weeks after injury), which may or may not have included surgical fixation. We excluded participants with multi-trauma, pathological fracture, or with established complications secondary to ankle fracture.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for five outcomes: activity limitation (ankle function), health-related quality of life (HRQoL), participant satisfaction with treatment, pain, and adverse events (we focused on re-operation, defined as unplanned return to theatre). We report the findings up to six months after injury.

MAIN RESULTS

We included 53 studies (45 RCTs, 8 quasi-RCTs) with 4489 adults with ankle fracture. In most studies, orthopaedic management included surgical fixation but was non-surgical in five studies, and either surgical or non-surgical in six studies. Here, we summarise the findings for three common rehabilitation comparisons; these included the most data and were the most clinically relevant. Because of different intervention approaches, we sometimes included a study in more than one comparison. Data for other less common comparisons were also available but often included few participants and were imprecise. All studies were unavoidably at high risk of performance and detection bias. We downgraded the certainty of all evidence for this reason. We also downgraded for imprecision and when we noted inconsistencies between studies that precluded meta-analysis of data. Early (within 3 weeks of surgery) versus delayed weight-bearing (12 studies, 1403 participants) Early weight-bearing probably leads to better ankle function (mean difference (MD) 3.56, 95% confidence interval (CI) 1.35 to 5.78; 5 studies, 890 participants; moderate-certainty evidence); however, this does not include a clinically meaningful difference. Early weight-bearing may offer little or no difference to HRQoL compared to delayed weight-bearing (standardised mean difference (SMD) 0.15, 95% CI -0.01 to 0.30; 5 studies, 739 participants; low-certainty evidence); when translated to the EQ-5D scale (a commonly-used HRQoL questionnaire), any small difference was not clinically important. We were unsure whether there were any differences in participant satisfaction or pain because these outcomes had very low-certainty evidence. For adverse events, there may be little or no difference in re-operation (risk ratio (RR) 0.50, 95% CI 0.09 to 2.68; 7 studies, 1007 participants; low-certainty evidence). Removable versus non-removable ankle support (25 studies, 2206 participants) Following surgery, using a removable ankle support may lead to better ankle function (MD 6.39, 95% CI 1.69 to 11.09; 6 studies, 677 participants; low-certainty evidence). This effect included both a clinically important and unimportant difference. There is probably an improvement in HRQoL with a removable ankle support, although this difference included both a clinically important and unimportant difference when translated to the EQ-5D scale (SMD 0.30, 95% CI 0.11 to 0.50; 3 studies, 477 participants; moderate-certainty evidence). No studies reported participant satisfaction. We were unsure of the effects on pain because of very low-certainty evidence (1 study, 29 participants). There may be little or no difference in re-operations (RR 1.20, 95% CI 0.39 to 3.71; 6 studies, 624 participants; low-certainty evidence). Following non-surgical management, there may be little or no difference between removable and non-removable ankle supports in ankle function (MD 1.08, 95% CI -3.18 to 5.34; 3 studies, 399 participants), and HRQoL (SMD -0.04, 95% CI -0.24 to 0.15; 3 studies, 397 participants); low-certainty evidence. No studies reported participant satisfaction. We were unsure of the effects on pain (2 studies, 167 participants), or re-operation because of very low-certainty evidence (1 study, 305 participants). Physical therapy interventions versus usual care or other physical therapy interventions (9 studies, 857 participants) Types of interventions included the use of active controlled motion, a spring-loaded ankle trainer, an antigravity treadmill, and variations of enhanced physiotherapy (e.g. additional stretching, joint mobilisation, neuromuscular exercises), delivered during or after the initial fracture management period. We were unable to pool data because of the differences in the design of interventions and their usual care comparators. Studies often included very few participants. The certainty of the evidence for all outcomes in this comparison was very low, and therefore we were unsure of the effectiveness of these therapies. No studies in this comparison reported re-operation.

AUTHORS' CONCLUSIONS

Early weight-bearing may improve outcomes in the first six months after surgery for ankle fracture, but the difference is likely to be small and may not always be clinically important. A removable ankle support may also provide a better outcome, but again, the difference may not always be clinically important. It is likely that neither approach increases the re-operation risk. We assume that the findings for these comparisons are applicable to people with closed ankle fractures, and that satisfactory fracture stabilisation had been achieved with surgery. For people who have non-surgical treatment, there is no evidence that either a removable or non-removable ankle support may be superior. We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions. We encourage investigators of future studies on rehabilitation interventions for ankle fracture to use a core outcome set.

Functional assessment and influencing factors after staged functional training in patients with ankle fractures

BACKGROUND

The recovery of limb function after ankle fracture surgery is a gradual process. The main purpose of implementing early functional exercise, joint mobility, muscle contraction function, passive ankle flexion and extension exercises, or physical factor therapy techniques is to achieve the rapid recovery of normal physiological limb function. However, currently the most effective rehabilitation training method is staged limb functional exercise, which promotes rapid recovery of limb function while preventing adverse consequences caused by overwork or insufficient training. Staged limb functional exercise divides the rehabilitation process into multiple stages, each of which has specific training objectives and contents. This method helps patients gradually restore limb function. Nevertheless, some patients still exhibit poor limb function after standardized exercise. Therefore, a functional evaluation should be performed to analyze the impact of staged functional training after ankle fracture surgery.

AIM

To perform a functional evaluation and determine the influencing factors of staged functional training in patients with ankle fracture.

METHODS

A retrospective study enrolled 150 patients who underwent surgical treatment for ankle fracture from May 2020 to May 2022 at our hospital. Univariate and multivariate linear regression analyses were performed on general data, functional exercise compliance scale for orthopedic patients, Social Support Rating Scale (SSRS), American Orthopedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot Score, and pain factors [serum bradykinin (BK), prostaglandin E2 (PGE2), 5-hydroxytryptamine (5-HT)].

RESULTS

Based on the AOFAS Ankle-Hindfoot Scale, the cases were divided into the excellent function (n = 111) and ordinary function (n = 39) groups. Univariate analysis revealed that monthly family income, education level, diabetes mellitus, functional exercise compliance scale of orthopedic patients score, SSRS, BK, PGE2, and 5-HT significantly influenced limb function after ankle fracture (P < 0.05); Multiple linear regression analysis showed that the functional exercise compliance scale score, SSRS, BK, PGE2, and 5-HT were independent risk factors affecting functional performance after staged functional exercise (P < 0.05).

CONCLUSION

Exercise compliance, SSRS, and pain level are the independent risk factors affecting functional performance after staged functional training following ankle surgery. Clinical nursing care after ankle surgery should include analgesic and health education measures to ensure optimal recovery of limb function.

Comprehensive Physiotherapy Protocol in Post-operative Case of Trimalleolar Fracture: A Case Report

A common ankle fracture that can have major consequences and expensive medical bills is the trimalleolar fracture. The trimalleolar fracture is the least frequent type of ankle fracture. The number of afflicted malleoli, the kind of fracture of the lateral and medial malleolus and the congruence of the ankle joint were all examined in detail for the trimalleolar ankle fracture. This type of fracture is brought on by high-energy trauma. In this case report, we describe a 56-year-old female patient who was involved in a road traffic accident. After being taken to the hospital for further examination, her ankle fracture was determined to be a trimalleolar one. She had an internal fixation with canulated cancellous screws and nails for open reduction. For such patients, we designed a physiotherapy course based on early rehabilitation and sensorimotor retraining to help with proprioception training, gait training and lower-limb muscular strength training. The lower limb's strength and range of motion were improved with the treatment. The outcomes used were the numerical pain rating scale (NPRS), functional independence measure (FIM), lower-extremity functional scale (LEFS), range of motion (ROM), gait parameters and manual muscle testing (MMT).

Quantitative initial safety range of early passive rehabilitation after ankle fracture surgery

BACKGROUND

Early rehabilitation training after ankle fracture surgery is critical to healing and avoiding complications. Inappropriate or excessive motion may impede healing or even lead to secondary injury. Currently, there is a lack of scientific quantitative postoperative rehabilitation methods after ankle fracture. Our purpose was to develop a universal method of quantifying early passive rehabilitation training after surgery by finite element (FE) analysis.

METHODS

A three-dimensional (3D) FE model of normal ankle was reconstructed from a computed tomography scan of a healthy male adult. Six types of ankle fractures were considered based on AO classification. We exerted joint motion load to explore the effect of movement on ankle joint mechanics after surgery. The corresponding relationship between the Inter-bone displacement and range of motion was measured to quantifying the ankle range of motion. The 44A3.3 fracture was used as an example to describe the implementation process in detail.

RESULTS

During ankle movement, most of the stress was sustained by the internal fixation devices, and the ratio of stress borne by the implants ranged from 67.9 to 94.9%. Flexion/extension exercise did not cause extra stress on the ankle contact surfaces. Ligament traction was the reason for ankle load during flexion/extension motion. The range of early passive postoperative rehabilitation training for six types of ankle fractures (AO classification) were provided.

CONCLUSION

A quantitative method of early passive rehabilitation training after ankle fracture surgery was developed using FE analysis. This modeling method has universality for any fracture that can be reconstructed.

Validity and Reliability of Turkish Version of Olerud-Molander Ankle Score in Patients With Malleolar Fracture

The present study was planned to translate and culturally adapt the Olerud-Molander Ankle Score (OMAS) and assess the validity and reliability of the Turkish translation of the OMAS in patients with surgically treated malleolar fracture. The OMAS was adapted for use in Turkish by first translating it and then back-translating it in accordance with published guidelines. The final Turkish version of the OMAS was administered to 91 patients participating in the present study. The OMAS questionnaire was repeated 7 days later to assess test-retest reliability. Spearman's rank correlation analysis was used for each question's score and the total score, and the intraclass correlation coefficient was calculated for test-retest reliability. The internal consistency of the OMAS-TR was assessed using Cronbach's α. Concurrent validity was evaluated by comparing the OMAS with the Foot and Ankle Outcome Score and global self-rating function (GSRF). The GSRF has 5 options: very good, good, fair, poor, and very poor. These are assessed using a 5-point Likert scale. Before validity analysis, the GSRF score was reduced to 3 groups. In the test-retest reliability assessment, the OMAS showed high correlation (r = 0.882). The intraclass correlation coefficient was 0.942. Cronbach's α was 0.762 and 0.731 at days 1 and 7 (adequate internal consistency). The correlation coefficients versus the 5 subscales of the Foot and Ankle Outcome Score ranged from r = 0.753 to r = 0.809 (p = .000) and versus the GSRF was r = -0.794 (p = .000). According to results of the present study, the Turkish version of the OMAS demonstrated adequate test-retest reliability, excellent internal consistency, and evidence of validity for Turkish-speaking patients treated surgically for ankle fracture.

Reduced Physical Activity in People Following Ankle Fractures: A Longitudinal Study

STUDY DESIGN

Longitudinal observational cohort.

BACKGROUND

The impact of ankle fracture on physical activity and sitting time and the course of recovery of physical activity are unclear.

OBJECTIVES

To assess the course of recovery of physical activity after ankle fracture and the extent to which this population may be less physically active and more sedentary than the general population.

METHODS

A cohort of individuals with ankle fracture was derived from a randomized trial and assessed with the International Physical Activity Questionnaire-Short Form (IPAQ-SF) at immobilization removal and 1, 3, and 6 months later. Total metabolic equivalent (MET) minutes per week were calculated to evaluate the course of recovery of physical activity. Sitting time (minutes per day) and the percentage of those who met the World Health Organization physical activity guidelines were calculated. Normative data were derived from a population-based cohort study that assessed physical activity using the IPAQ-SF.

RESULTS

In people with ankle fracture (n = 214), physical activity increased in the first month (from a median of 99 at immobilization removal to 979 MET min/wk) and leveled off by 6 months (1386 MET min/wk). Only 22% of the ankle fracture cohort met World Health Organization guidelines at immobilization removal, compared to 80% of the cohort from the general population (P<.001). This difference diminished over time. Sitting time in the ankle fracture cohort was higher than population norms at all time points (P<.001).

CONCLUSION

People with ankle fracture are less physically active and more sedentary than the general population. Strategies to increase physical activity must be considered. LEVEL OF EVIDENCE Prognosis, level 4.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.