Functional Comparison of Immediate and Late Weight Bearing after Ankle Bimalleolar Fracture Surgery

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.

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Data sources identified published (PUBMED, EMBASE, CINAHL) and unpublished (ClinicalTrials.gov, CENTRAL, NIHR Open Research, OpenGrey) literature.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.

Early Functional Rehabilitation in Foot and Ankle Surgery

The traditional postoperative management of common foot and ankle procedures has involved a prolonged period of immobilization and nonweight bearing. The concern was loss of correction and fixation failure. However, it has been shown that a prolonged period of nonweight bearing can predispose patients possible deep vein thrombosis, disuse osteopenia, cardiovascular complications, and generalized deconditioning. The authors' institution has published studies reviewing the efficacy of early weight bearing after first metatarsophalangeal joint arthrodesis, modified Lapidus bunionectomy, and open reduction and internal fixation of ankle fractures. This article highlights the literature and rationale supporting the safety of early weight-bearing protocols.

Hyalofast Cartilage Repair Surgery with a Full Load-Bearing Rehabilitation Program One Day after Operation Reduces the Time for Professional Athletes to Return to Play

Background and Objectives: This study evaluated the effectiveness of Hyalofast cartilage repair surgery with an early, full load-bearing rehabilitation program one day after the operation for reducing the time needed for professional athletes to return to play. Materials and Methods: This prospective study included 49 patients aged between 19 and 38 years who had undergone surgical reconstruction of cartilage using the microfracture technique combined with a Hyalofast scaffold. All patients were active professional athletes. Early rehabilitation was implemented from the first postoperative day, fully loading the operated limb. A clinical evaluation was based on the KOOS and SF-36 questionnaires used during subsequent follow-up visits. All patients underwent magnetic resonance imaging (MRI) to evaluate the effect of the surgery after one year. Results: The clinical results demonstrated a statistically significant improvement in the number of complaints about pain and in the quality of life of the patients, measured in all of the applied scales, with comparisons made between six months or one year post-surgery and pre-surgery. Importantly for athletes, the parameter related to sports and recreation improved from 14 ± 11.1 to 95 ± 7.7 6 months after surgery and to 99.8 ± 1.8 one year after surgery. The overall quality of life score improved from 30 ± 18 to 88 ± 8.8 one year after surgery. Conclusions: These results show that this approach significantly shortened the time needed for the athletes to return to sports at the same level as before the surgery (athletes returned to sports in approximately 2.5-3 months). The mean follow-up time was 19.75 months. This technique can be considered a viable option for the treatment of cartilage injuries in professional athletes, allowing them to return to play more quickly in a safe and healthy way.

Outcomes of Early Weight Bearing in Displaced Intra-articular Calcaneus Fractures Treated with Screws-Only Fixation Technique

Background

Displaced intraarticular calcaneus fracture indicates surgical treatment. The current trend is open reduction and internal fixation with a plate or multiple screws through the sinus tarsi approach. Most postoperative protocols are prolonged non-weight bearing that causes a high socioeconomic burden. This study aims to determine the safety of the early weight-bearing protocol of screws-only fixation in calcaneal fracture.

Materials and Methods

Evaluate displaced intraarticular calcaneus fractures treated with screws-only technique via the sinus tarsi approach in our institution. The first group, from July 2017 to December 2018, allowed patients to start partial weight bearing as tolerated at 4 weeks after surgery. The second group prospectively from January 2019 to March 2020, which assign patients to keep non-weight bearing for 8 weeks. The functional outcomes (Thai Foot and ankle ability measure subjective form, FAAM) were measured 6 months after surgery. The radiographic outcome (Bohler's angle and Gissane angle) was measured on the first day postoperative and 6 months follow-up, and the changes in these angles were recorded.

Results

There were 28 patients in each group. The outcomes were collected and compared by a T-test. In the early weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 76.4 ± 14.8, 2.4 ± 3.5, and 6.6 ± 7.8, respectively. In the delayed weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 81 ± 14.8, 2 ± 1.8 and 2.6 ± 6.1, respectively. There was no statistically significant difference in FAAM score, Bohler's angle loss, and Gissane's angle change between early and delayed weight-bearing groups.

Conclusion

Screws fixation in calcaneal fracture may be safe to allow early weight-bearing protocol.

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.

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.

Return-to-Play and Rehabilitation Protocols following Cartilage Restoration Procedures of the Knee: A Systematic Review

OBJECTIVE

The purpose of this study is to systematically review the literature and to evaluate the reported rehabilitation protocols, return-to-play guidelines, and subsequent rates of return to play following cartilage restoration procedures in the knee.

DESIGN

MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA guidelines to find studies on cartilage restoration procedures in the knee, including (1) microfracture (Mfx), (2) osteochondral autograft transfer (AOT), (3) osteochondral allograft implantation (OCA), and (4) autologous chondrocyte implantation (ACI). Studies were included if they reported return-to-play data or rehabilitation protocols.

RESULTS

Overall, 179 studies fit our inclusion criteria, with 48 on Mfx, 34 on AOT, 54 on OCA, and 51 on ACI. The rate of return to play was reported as high as 88.2% with AOT, and as low as 77.2% following OCA, with rates of return to play at the same/higher level as high as 79.3% with AOT, and as low as 57.3% following ACI. The average reported time of return to play was as low as 4.9 months with AOT, and as high as 11.6 months following ACI.

CONCLUSIONS

The majority of patients are able to return to play following cartilage restoration procedures in the knee, regardless of surgical procedure utilized. However, while the rate of return to play at the same level was similar to the overall rate of return following AOT, there was a large number of patients unable to return to the same level following Mfx, OCA, and ACI. Additionally, there is wide variety in the rehabilitation protocols, and scant literature on return-to-play protocols.

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.].

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.

Ankle fractures in the elderly: Current concepts

Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.

Safety of Early Weight Bearing Following Fixation of Bimalleolar Ankle Fractures

Ankle fractures are common orthopedic injuries. Although operative indications and subsequent stabilization of these fractures have not significantly changed, postoperative protocols remain highly variable. Effects of early weight bearing (EWB) on fracture characteristics in operatively stabilized bimalleolar and bimalleolar equivalent ankle fractures remain poorly publicized. This study seeks to clarify postoperative fracture union rates, rates of hardware loosening or failure, and radiographic medial clear space changes when comparing EWB to late weight bearing (LWB) following open reduction and internal fixation (ORIF).

A total of 95 patients with either bimalleolar (66%) or bimalleolar equivalent (34%) fractures who underwent ORIF were retrospectively reviewed. Weight bearing was allowed at three weeks in the EWB group and when signs of radiographic union were noted in the LWB group. Postoperatively, patients were evaluated at regular intervals for fracture union, signs of implant failure, and evidence of medial clear space widening radiographically.

There were 38 patients (40%) in the EWB group and 57 patients (60%) comprising the LWB cohort. There were no significant demographic differences between groups. The EWB group on average began to weight bear at 3.1 + 1.4 weeks postoperatively, whereas the LWB group began at 7.2 + 2.1 weeks postoperatively (p<0.01). Union rate (p=0.51), time to union (p=0.23), and implant failure (p>0.1 at all time intervals) were not notably different between groups. No differences in medial clear space were detected at any postoperative interval between groups (p>0.1 at all time intervals). This study suggests that EWB at three weeks postoperatively does not increase markers of radiographic failure compared to six weeks of non-weight bearing (NWB), which has been regarded as the gold standard of treatment to allow for healing; this may represent an improvement to rehabilitation protocols after bimalleolar ankle ORIF of unstable ankle fractures.

Effect of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures on Wound Complications or Failures of Fixation

BACKGROUND

There is a growing trend toward early weightbearing as tolerated (WBAT) after open reduction and internal fixation (ORIF) of ankle fractures. To date, studies have excluded fractures with associated syndesmotic injuries from their cohorts.

METHODS

In this retrospective cohort study, a chart review was performed at a single level 1 trauma center, identifying all unstable ankle fractures that underwent operative fixation between July 2016 and July 2017. After exclusion criteria, 63 patients were identified and 31 were included in the final analysis, with 14 undergoing syndesmotic fixation. WBAT was initiated after suture removal, between 2 and 4 weeks postoperatively. Outcomes included fracture union, radiographic maintenance of alignment, hardware failures, wound complications, and the need for repeat surgery.

RESULTS

Weightbearing was initiated at an average of 17.8 days. All 31 patients progressed toward fracture union, with no hardware failures. Three patients developed superficial wound breakdown, which was treated with protected weightbearing in all cases and oral antibiotics in 1 case. All 3 went on to heal from their incisions. One patient had delayed wound breakdown and required a split-thickness skin graft that subsequently healed without complication. One patient underwent hardware removal 6 months postoperatively. There were no revision ORIF procedures.

CONCLUSION

There is literature supporting early WBAT after ORIF of unstable ankle fractures in patients without major comorbidities. This article supports this trend, demonstrating that a group of ankle fractures requiring syndesmotic fixation were included in the early weightbearing cohort without a higher rate of catastrophic failure or increased wound problems.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation

PURPOSE

Early post-operative exercise and weight-bearing activities are found to improve the functional recovery of patients with displaced intra-articular calcaneal fractures (DIACFs). We hypothesized that early functional exercise after surgery might have a secondary reduction effect on the subtalar joint, in particular the smaller fracture fragments that were not fixed firmly. A prospective study was conducted to verify this hypothesis.

METHODS

From December 2012 to September 2013, patients with unilateral DIACFs were enrolled and received a treatment consisting of percutaneous leverage and minimally invasive fixation. After surgery, patients in the study group started exercising on days two to three, using partial weight bearing starting week three, and full weight bearing starting week 12. Patients in the control group followed a conventional post-operative protocol of partial weight bearing after week six and full weight bearing after the bone healed. Computed tomography (CT) scanning was performed at post-operative day one, week four, week eight, and week 12 to reconstruct coronal, sagittal, and axial images, on which the maximal residual displacements of the fractures were measured. Function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale at the 12th post-operative month.

RESULTS

Twenty-eight patients in the study group and 32 in the control group were followed up for more than 12 months; their data were collected and used for the final analysis. Repeated-measures analysis of variance (ANOVA) of the maximal residual displacements of the fracture measured on CT images revealed significant differences between the study and the control groups. There were interaction effects between group and time point. Except for the first time point, the differences between the groups at all studied time points were significant. In the study group, the differences between all studied time points were significant. Strong correlations were observed between the AOFAS score at post-operative month 12 and the maximal residual displacement of the fractures on the CT images at postoperative week 12.

CONCLUSIONS

Early functional exercise and weight bearing activity can smooth and shape the subtalar joint and reduce the residual displacement of the articular surface, improving functional recovery of the affected foot. Therefore, early rehabilitation functional exercise can be recommended in clinical practice.