Early full weight-bearing in patients with isolated displaced lateral malleolar fracture after rigid internal fixation with locking plates

SLR - June 2022 - Vincent Lefler, DPM

Reference: Yeung CY, Hung SH, Hsu KH, Chiu FY. Early full weight-bearing in patients with isolated displaced lateral malleolar fracture after rigid internal fixation with locking plates. J Chin Med Assoc. 2021. Apr 1;84(4):438-40.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Vincent Lefler, DPM
Residency Program: McLaren Oakland Hospital (Pontiac, MI)

Podiatric Relevance: The article explores the outcomes of patients undergoing a post-operative protocol of full early weightbearing (WB) after open surgically repaired isolated lateral malleolar ankle fractures. This article attempts to functional outcomes after early WB post-operatively at two-weeks.  However, the paper has severe flaws that questions the results.

Methods: From 2012 to 2018, 46 patients who had closed isolated displaced lateral malleolar fractures were included in the study. Recorded outcome variables were time to union; AOFAS hindfoot score, and complications. All fractures were managed with open reduction and internal fixation using locking plates. The patients were fully WB starting on the two-week post-operative visit (authors do not specify if they were in protected WB or in regular shoes). The average follow-up period was 41.5mo (range: 12-70mo).

Results: The average fracture union rate was 10.5wk (range: 8-16wk). At final follow-up, the average AOFAS hindfoot score was 91 (range: 85-98). No complications were reported in the results section, but there were two patients who underwent local debridement of the surgical wound due to poor wound healing (cultures taken did not show bacterial growth). In these cases, no associated medical conditions were noted and the fracture union times were 12- and 14-weeks. Additionally, implants were removed in six patients due to personal preference.

Conclusions: The study’s authors attempted to determine how early WB following surgical repair of isolated fibular fractures impacted functional outcomes. It is not clear if the patients were in protected WB in a cast or immobilizer or if they were in shoegear.  There is no data on when patients were able to return to regular shoegear. The authors acknowledge the small sample size. The paper could have been strengthened by having a control group with comparable demographics who were non-weightbearing initially. Due to the vague description of the post-operative protocol, the findings of this paper are questionable and should be taken cautiously. Not considering the wound healing cases as complications also raises questions as to the reported findings. The protocol should be replicated with a control group and early WB management needs to be better described to provide more meaningful outcomes. Although the paper’s findings may show promising findings and warrant a better designed study, this particular study should not be used to support early WB after isolated fibular fractures based on the study design and findings.