SLR - January 2022 - Elliot Olenchek

Is Early Full Weight Bearing Safe Following Locking Plate ORIF of Distal Fibula Fractures?

Reference: Zyskowski M, Wurm M, Greve F, Pesch S, von Matthey F, Pflüger P, Crönlein M, Biberthaler P, Kirchhoff C. Is Early Full Weight Bearing Safe Following Locking Plate ORIF of Distal Fibula Fractures? BMC Musculoskelet Disord. 2021 Feb 9;22(1):159.

Level of Evidence: I

Scientific Literature Review

Reviewed By: Elliot Olenchek, DPM
Residency Program: Inova Fairfax Medical Campus, Falls Church, VA

Podiatric Relevance: Ankle fractures are a common trauma that faces the foot & ankle surgeon. As such, there has always been room for new techniques and treatments. This article looks to not only challenge the generally accepted 4-6 weeks of NWB post ORIF, but it also investigates the sole use of a dynamic locking compression plate for fixation. Methods of fixation and post-operative protocol have always been a hotly debated topic, especially recently with advancing technologies.

Methods: AO 44 B1.1, 1.2, 1.3 type fractures were prospectively enrolled and randomized into two groups. Group 1 was treated with 3.5 millimeter lag screw with 1/3 semi-tubular plate (Synthes) and Group 2 was treated with locking plate (NEWCLIP TECHNICS). Exclusion criteria included open, pathologic and osteoporotic fractures. Post operatively both were allowed 20 kilograms of weight bearing weeks 1-3 for group 2 and 1-6 for group 1. Full weight bearing was allowed following the weeks listed. Follow up evaluation included Visual Analog Scale (VAS), Olerud and Molander Foot and Ankle Outcome Score (OMAS), Foot and Ankle Outcome Score (FAOS) and Karlsson and Peterson Scoring System for Ankle function (KPSS). Secondary outcome measures included radiographic measurements and evaluation of complications.

Results: Forty-five patients with a mean age of 43 were enrolled. Twenty-five were assigned to group 1 and 20 for group 2. There were no demographic significant differences found between the groups. As for clinical outcomes, at six and 12 weeks, there was a statistically significantly better OMAS, FAOS and KPSS scores for group 2. Later months follow up visits did not show this significance. VAS scores never differed. 51 percent of group 2 had hardware removed due to irritation and group 1 had 43 percent. There were no differences with ROM at follow up examinations. As for radiographic outcomes, no significant differences were found including no non-unions.

Conclusions: Early full weight bearing at three weeks with the sole use of polyaxial locking plates for distal fibula fractures leads to good clinical results. There were some limitations in this study including the difficulty in comparing two groups with two different post-operative protocols and the power of the population size was lacking. Further studies could look at the cost benefit analysis of early weight bearing and advanced post operative rehabilitation using these fixation methods. This would help enhance their secondary hypothesis that this reduces health costs to the patient and facilities. 

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