SLR - May 2017 - Laura E. Sansosti
Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial
Reference: Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial. J Orthop Trauma. 2016 July; 30 (7).
Reviewed By: Laura E. Sansosti, DPM
Residency Program: Temple University Hospital
Podiatric Relevance: Indications for ORIF of ankle fractures are well defined; however, there is a lack of consistency in postoperative protocols. Most commonly, patients are maintained nonweightbearing in a cast for six weeks. Early weightbearing and mobilization are thought to have benefits, including early rehabilitation and return to function. However, this may also be associated with a higher risk of fracture displacement, wound complications and failure of the hardware construct. The aim of the study was to compare nonweightbearing and immobilization to early weightbearing and mobilization following ankle ORIF, hypothesizing that the latter would promote earlier return to work and greater functional outcomes without increasing the risk of complications.
Methods: This was a prospective, multicenter, randomized controlled trial with well-defined inclusion and exclusion criteria. All patients underwent ORIF with a fixation construct appropriate for the fracture pattern. Immediately postoperative, all patients were placed in a posterior splint and instructed to remain nonweightbearing. Randomization occurred at the two-week postoperative visit. Patients randomized to the late weightbearing group were placed in a cast for an additional four weeks of nonweightbearing. Those in the early weightbearing group were transitioned to a boot at the two-week postoperative visit, allowed to start full weightbearing and began therapy. The primary outcome measure was time to return to work. Secondary outcome measures included ankle range of motion, ankle functional outcome scores, health outcome scores, wound complications and fracture fixation complications.
Results: In total, 110 patients were included with 54 randomized to late weightbearing and 56 to early weightbearing. At two weeks postoperatively, the time of randomization, 33 percent of the late weightbearing group had already returned to work as compared to 16 percent of the early weightbearing group, which was statistically significant. There were no differences in rate of return to work at any other point. At six weeks, those in the early weightbearing group had a statistically significant greater ankle motion (41 vs. 29 degrees) and higher Olerud-Molander functional outcome scores (45 vs. 32). Overall, health outcome scores were statistically significantly higher in patients in the early weightbearing group. No statistically significant differences existed in terms of complications; however, the rate of elective hardware removal was higher in the late weightbearing group (19 percent vs. two percent).
Conclusions: The authors concluded that the results of this study support early weightbearing and mobilization following ankle ORIF. Significant differences were noted at six weeks in terms of ankle motion, function and health, which is indicative of a positive benefit to early weightbearing and mobilization, despite a lack of difference in time to return to work. Time to return to work is likely multifactorial and not able to be associated with a single factor, such as weightbearing. Another point to consider is how the authors enforced adherence to the study protocol, as deviation within either group could cause clouding of the results. While the authors excluded certain fractures, those who met the inclusion criteria were diverse and of varying degrees of severity and fixation requirements, which has the potential to affect the results. Overall, this study’s results were on par with those of other studies and indicate that early weightbearing and mobilization following ankle ORIF is a reasonable postoperative protocol that may lead to improved outcomes.