SLR - September 2021 - Reva A. Bork

Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study

Reference: Fram BR, Rogero RG, Chang G, Krieg JC, Raikin SM. Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study. J Orthop Trauma. 2021 Jun 1;35(6):308-314.

Level of Evidence: Level III, Retrospective case-control trial

Scientific Literature Review

Reviewed By: Reva A. Bork, DPM
Residency Program: Ascension St. John Hospital – Detroit, MI

Podiatric Relevance: This article aims to evaluate whether patients with select ankle fractures can begin immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) exercises after open reduction internal fixation (ORIF). Current standard of care after ORIF of an ankle fracture is non-weight bearing for six to eight weeks, which can lead to deep venous thrombosis (DVT), falls, and delay of return to activity. The authors hypothesized that there would be no difference in complication rates or loss of reduction between the IWBAT group and the NWB group after ORIF of ankle fractures.

Methods: The study retrospectively reviewed 268 patients who underwent ORIF of an ankle fracture with two or more malleoli fractures. The IWBAT group consisted of 133 patients who were placed in a CAM walker after surgery and allowed to bear weight immediately. Additionally, these patients were allowed to remove the CAM walker for IROM exercises. The 172 patients in the NWB group remained non-weight bearing for six weeks. Patients were placed in a posterior splint after surgery and transitioned to a CAM walker after two-weeks. Primary outcomes studied included complication rates and loss of reduction.

Results: In the IWBAT group, there were eight patients with dehiscence, three patients who required oral antibiotics, and one patient who needed IV antibiotics. One patient had loss of fixation of the medial malleolus, one patient had a septic ankle joint, two patients underwent surgical debridement and one patient had exposed hardware and underwent below-knee-amputation. In the NWB group, nine patients had dehiscence, four patients required oral antibiotics, one patient had delayed union of the medial malleolus, and five patients had neuritis of the sural nerve. Two patients required surgical debridement, two patients required hardware removal, and there was one case of re-fracture of the fibula that required hardware removal and ORIF.

Conclusions:
The authors concluded that there is no difference in complication rates after IWBAT versus NWB after bi-malleolar ankle fracture ORIF. This is significant because the risk of DVT decreases when patients are allowed to bear weight postoperatively. IWBAT could also decrease injuries in the postoperative state. Many patients struggle to remain non-weight bearing and will experience falls after surgery. Patients who can bear weight will have a decreased chance of suffering further injury or disrupting surgical reduction. As such, allowing select patients to weight bear after ankle fracture ORIF is a viable option that has not been shown to increase risk of complication or create loss of reduction.  

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