Session VII - Foot / Ankle

Sat., 10/12/13 Foot/Ankle, PAPER #78, 10:23 am OTA 2013

Δ Early Weight Bearing and Mobilization Versus Non–Weight Bearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial

Niloofar Dehghan, MD1; Richard Jenkinson, MD2; Michael McKee, MD1;
Emil H. Schemitsch, MD1; Aaron Nauth, MD1; Jeremy Hall, FRCSC1; David Stephen, MD2; Hans J. Kreder, MD2;
1St. Michael’s Hospital - University of Toronto, Toronto, Ontario, Canada
2Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Background/Purpose: The optimal postoperative protocol with respect to weight bearing and ankle range of motion (ROM) following surgical fixation of acute ankle fractures remains elusive. Convention dictates non–weight bearing and immobilization for 6 weeks postoperatively, but early weight bearing may expedite return to function (with the potential risk of loss of fixation or wound complications). Our goal was to conduct a randomized controlled trial comparing early weight bearing and mobilization versus non–weight bearing and immobilization after surgical fixation of unstable ankle fractures.

Methods: We conducted a multicenter randomized controlled trial at two Level I trauma centers. Patients who underwent acute surgical fixation of an unstable ankle fracture were recruited and randomized to one of two rehabilitation protocols: (1) early weight bearing (weight bearing and ankle mobilization at 2 weeks) or (2) delayed weight bearing (non–weight bearing and casting for 6 weeks). Patients with posterior malleolar fixation or syndesmosis injuries were excluded. Patients were seen in follow-up at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively. The primary outcome was rate of return to work; secondary outcomes included ankle ROM, SF-36 (Short Form-36) heath outcome scores, Olerud/Molander ankle function score, and rates of complications (wound complication, loss of reduction, hardware failure, reoperation).

Results: In total 110 patients were recruited: 56 were randomized to early weight bearing and 54 were randomized to the delayed weight-bearing group. Patients were 47% female, 53% male, with a mean age of 42 years; there were no differences between the two groups with regard to demographics, preinjury type of occupation, type of fracture, or time to surgery. There was no difference between the two groups with regards to rate of return to work at any time point. However, at 6 weeks postoperatively, patients in the early weight-bearing group had significantly improved ankle ROM (42° vs 28°, P = 0.001), significantly improved Olerud/Molander ankle function scores (44 vs 31, P = 0.002), as well as significantly improved SF-36 scores on both the physical (50 vs 42, P = 0.008) and mental (62 vs 54, P = 0.005) components. There were no cases of fixation failure, loss of reduction, or repeat operation in either group. There were also no differences with regards to wound complications or infections.

Conclusion: This randomized study of early versus delayed weight bearing demonstrated no significant difference with regard to rate of return to work in patients with surgically treated ankle fractures. However, patients treated with the early weight-bearing protocol had significantly improved ankle function, ankle ROM, and improved mental and physical health outcome scores early in the postoperative period. There were no failures of fixation or differences in wound complications between the two groups. Given the convenience for the patient, the early improved functional outcome, and the lack of an increased complication rate with early weight bearing, we recommend early postoperative mobilization and weight bearing in patients with surgically treated ankle fractures.

Alphabetical Disclosure Listing

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.