Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Early Motion and Directed Exercise (EMADE) following ankle fracture fixation: a pragmatic randomized controlled trial

Aims

This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme.

Methods

A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed.

Results

Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported.

Conclusion

The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe.

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

Effectiveness of behavior change in rehabilitation interventions to improve functional recovery after lower limb fracture: a systematic review

Ankle fractures are common injuries that can significantly impact mobility and quality of life. Rehabilitation following ankle fracture treatment is crucial for recovery, yet adherence to regimens remains a challenge. Behaviour Change Techniques (BCTs) have been suggested to improve adherence, but their effectiveness in ankle fracture rehabilitation is not well established. This review aimed to evaluate the effectiveness of BCTs in the rehabilitation of ankle fracture patients. We conducted a comprehensive search across multiple databases, including MEDLINE and EMBASE, focusing on Randomised Controlled Trials (RCTs) that incorporated BCTs into rehabilitation interventions. The effectiveness of BCTs on patient-reported outcomes (PROMs), quality of life, and adverse events was analysed. Nine RCTs met the inclusion criteria, encompassing a range of interventions that employed BCTs, most commonly including goal setting and instruction on how to perform behaviours, specifically physiotherapy exercises. The review found limited evidence supporting their effectiveness in improving PROMs. Only one study showed a significant positive effect, but it was deemed at high risk of bias. The lack of integration of behavioural theory in the design of rehabilitation interventions and the varied nature of the BCTs employed across studies may contribute to these findings. The use of BCTs in ankle fracture rehabilitation is prevalent, but this review highlights a significant gap their role of enhancing patient outcomes. Future research should incorporate a theory-based approach to intervention design, utilising a broader range of BCTs, to fully evaluate their potential in improving rehabilitation adherence and outcomes following ankle fracture .

Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial

BACKGROUND

After surgery for a broken ankle, patients are usually instructed to avoid walking for 6 weeks (delayed weight-bearing). Walking 2 weeks after surgery (early weight-bearing) might be a safe and preferable rehabilitation strategy. This study aimed to determine the clinical and cost effectiveness of an early weight-bearing strategy compared with a delayed weight-bearing strategy.

METHODS

This was a pragmatic, multicentre, randomised, non-inferiority trial including 561 participants (aged ≥18 years) who received acute surgery for an unstable ankle fracture in 23 UK National Health Service (NHS) hospitals who were assigned to either a delayed weight-bearing (n=280) or an early weight-bearing rehabilitation strategy (n=281). Patients treated with a hindfoot nail, those who did not have protective ankle sensation (eg, peripheral neuropathy), did not have the capacity to consent, or did not have the ability to adhere to trial procedures were excluded. Neither participants nor clinicians were masked to the treatment. The primary outcome was ankle function measured using the Olerud and Molander Ankle Score (OMAS) at 4 months after randomisation, in the per-protocol population. The pre-specified non-inferiority OMAS margin was -6 points and superiority testing was included in the intention-to-treat population in the event of non-inferiority. The trial was prospectively registered with ISRCTN Registry, ISRCTN12883981, and the trial is closed to new participants.

FINDINGS

Primary outcome data were collected from 480 (86%) of 561 participants. Recruitment was conducted between Jan 13, 2020, and Oct 29, 2021. At 4 months after randomisation, the mean OMAS score was 65·9 in the early weight-bearing and 61·2 in the delayed weight-bearing group and adjusted mean difference was 4·47 (95% CI 0·58 to 8·37, p=0·024; superiority testing adjusted difference 4·42, 95% CI 0·53 to 8·32, p=0·026) in favour of early weight-bearing. 46 (16%) participants in the early weight-bearing group and 39 (14%) in the delayed weight-bearing group had one or more complications (adjusted odds ratio 1·18, 95% CI 0·80 to 1·75, p=0·40). The mean costs from the perspective of the NHS and personal social services in the early and delayed weight-bearing groups were £725 and £785, respectively (mean difference -£60 [95% CI -342 to 232]). The probability that early weight-bearing is cost-effective exceeded 80%.

INTERPRETATION

An early weight-bearing strategy was found to be clinically non-inferior and highly likely to be cost-effective compared with the current standard of care (delayed weight-bearing).

FUNDING

National Institute for Health and Care Research (NIHR), NIHR Barts Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

Comparing immediate and delayed weight bearing in patients with ankle open reduction internal fixation-A protocol for feasibility randomised controlled trial

Introduction

Uncertainty regarding the timing of weight bearing following ankle open reduction internal fixation (ORIF) in patients with different ankle fracture patterns remains. Traditional rehabilitation methods, including six weeks of non-weight bearing (NWB), is still a common approach in many hospitals, while some previous evidence has shown immediate weight bearing (IWB) to be beneficial.

Method

32 adult participants with unimalleolar, bimalleolar or trimalleolar ankle fractures and stable fixation following ankle ORIF will be randomly allocated to either Immediate Weight Bearing (IWB) or Delayed Weight Bearing (DWB) groups. Stability of fixation is a subjective assessment made by the operating surgeon at the completion of fixation and is independent of fracture pattern. Participants in the IWB group will be allowed to weight bear as tolerated within 24 h, while participants in the DWB group will remain non-weight bearing for six weeks. Participants' data including Olerud and Molander Ankle Score, Self-Reported Foot and Ankle Score, SF-36 health survey, time to return to work will be collected. X-rays will be assessed by orthopaedic team members for fixation-related complications including reduction loss, malreduction/malunion, implant failure and non-union. Participants data will be collected at six weeks, three and six-months post-surgery. We will determine the feasibility of a full RCT through assessing the recruitment rate, adherence rate, and drop-out rate.

Results

Not applicable.This pilot RCT will endeavour to optimise standard rehabilitation protocols post ankle ORIF.

To cast or not to cast? Postoperative care of ankle fractures: a meta-analysis of randomized controlled trials

Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was conducted with the aim of comparing early mobilization and weightbearing to traditional postoperative protocols. A systematic search of electronic databases was conducted according to the PRISMA guidelines. Only randomized clinical trials were included. Data about clinical outcome, time to return to work and complications were extracted and summarized. Meta-analyses were performed. Twenty studies for a total of 1328 patients were included. Early mobilization was compared to immobilization in 724 patients: the two groups did not significantly differ in terms of short- and long-term clinical outcome (p = 0.08 and p = 0.41, respectively). However, early mobilization resulted to be significantly associated with faster return to work (p = 0.047). Early weightbearing was compared to nonweightbearing in 1088 patients. While the clinical difference between the two groups was not significant at short term (p = 0.08), it was significant at long term (p = 0.002). No other significant differences, in particular regarding complications, were highlighted between different groups. Early motion, early weightbearing and traditional postoperative protocols are all safe strategies after ORIF for unstable ankle fractures. Early mobilization is significantly associated with faster return to work and early weightbearing improves long term clinical outcome.Level of evidence: I.

Comparing the Clinical and Radiographic Outcomes of Humeral Shaft Fractures by Treatment Type

PURPOSE

Humeral shaft fractures are common orthopedic injuries, representing 1-5% of all fractures. There is conflicting literature regarding the superiority of operative versus nonoperative treatment of these fractures. The purpose of this study was to examine functional outcomes and time to radiographic union in humeral shaft fractures with the hypothesis that both would be improved in patients treated operatively relative to those treated nonoperatively.

METHODS

This retrospective cohort study examined patients with humeral shaft fractures treated at a single large healthcare system between 2010 and 2020. A chart and radiograph review were performed to collect information on demographics, fracture, treatment, and outcome information. These measures were compared between patients treated operatively and nonoperatively.

RESULTS

Five hundred seventeen adult patients meeting inclusion criteria were identified; 233 were treated nonoperatively, and 284 were treated operatively. The mean patient age was 50.2 years in those who underwent surgery relative to 59.9 years in those treated without surgery (P<0.001). Operatively-treated patients had significantly faster time to radiographic union at a median of 113 days compared to a median of 161 days in nonoperatively-treated patients (P=0.001). The operative group was made weight-bearing as tolerated significantly faster than the nonoperative group (84 days versus 98 days, respectively, P=0.002). No statistically significant difference was seen between the two treatment groups in rates of complications or range of motion at the time of radiographic union. However, patients who underwent surgery were found to be up to two times more likely to achieve full shoulder forward elevation by the time of their final follow-up than those treated without surgery (P=0.011).

CONCLUSION

Patients with humeral shaft fractures treated operatively have faster time to union, earlier weight bearing, and no change in the rate of complications compared to patients treated nonoperatively.

Effectiveness of permissive weight bearing in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities: a prospective comparative multicenter cohort study

PURPOSE

The aim of the present study was to investigate the effectiveness of a novel approach involving permissive weight bearing (PWB) in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities.

METHODS

Prospective comparative multicenter cohort study in one level 1 trauma center and five level 2 trauma centers. Surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities were included. Permissive weight bearing (PWB) in comparison to restricted weight bearing (RWB) was assessed over a 26-week post-surgery follow-up period. Patients' self-perceived outcome levels regarding activities of daily living (ADL), quality of life (QoL), pain and weight bearing compliance were used.

RESULTS

This study included 106 trauma patients (N = 53 in both the PWB and RWB groups). Significantly better ADL and QoL were found in the PWB group compared to the RWB group at 2-, 6-, 12- and 26-weeks post-surgery. There were no significant differences in postoperative complication rates between the PWB and RWB groups.

CONCLUSION

PWB is effective and is associated with a significantly reduced time to full weight bearing, and a significantly better outcome regarding ADL and QoL compared to patients who followed RWB regimen. Moreover, no significant differences in complication rates were found between the PWB and RWB groups.

LEVEL OF EVIDENCE

Level II.

REGISTRATION

This study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.

Severity of Complications after Locking Plate Osteosynthesis in Distal Femur Fractures

Background: Locked plating for distal femur fractures is widely recommended and used. We systematically reviewed clinical studies assessing the benefits and harms of fracture fixation with locked plates in AO/OTA Type 32 and 33 femur fractures. Methods: A comprehensive literature search of PubMed, Embase, Cinahl, Web of Science, and the Cochrane Database was performed. The studies included randomized and non-randomized clinical trials, observational studies, and case series involving patients with distal femur fractures. Studies of other fracture patterns, studies conducted on children, pathological fractures, cadaveric studies, animal models, and those with non-clinical study designs were excluded. Results: 53 studies with 1788 patients were found to satisfy the inclusion and exclusion criteria. The most common harms were nonunion (14.8%), malunion (13%), fixation failure (5.3%), infection (3.7%), and symptomatic implant (3.1%). Time to full weight-bearing ranged from 5 to 24 weeks, averaging 12.3 weeks. The average duration of follow-up was 18.18 months, ranging from 0.5 to 108 months. Surgical time ranged between 40 and 540 min, with an average of 141 min. The length of stay in days was 12.7, ranging from 1 to 61. The average plate length was ten holes, ranging from 5 to 20 holes. Conclusion: This review aimed to systematically synthesize the available evidence on the risk associated with locked plating osteosynthesis in distal femur fractures. Nonunion is the most common harm and is the primary cause of reoperation. The overall combined risk of a major and critical complication (i.e., requiring reoperation) is approximately 20%.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes

OBJECTIVES

The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks.

METHODS

DESIGN

Prospective case-control study.

SETTING

Academic medical center; Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort).

OUTCOME MEASURES AND COMPARISONS

The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts.

RESULTS

One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05).

CONCLUSIONS

EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Safety of early weightbearing after ankle fracture fixation

PURPOSE

Patients with surgically treated ankle fractures are traditionally kept non-weightbearing for at least six weeks post-operatively; however, recent literature suggests numerous benefits of early weightbearing (EWB) before six weeks without significantly impacting long-term outcomes. This study aims to review the safety of early vs late weightbearing following ankle fracture fixation by assessing the complication rate.

METHODS

This was a single-centre retrospective study. Between 2020 and 2023, all ankle fixations that commenced weightbearing at two weeks were added to the EWB group. An equal number of similar patients with six-week non-weightbearing were added to the late weightbearing (LWB) group. Baseline characteristics, risk factors, types of fractures and any complications in the six-month post-operative period were evaluated from these cohorts.

RESULTS

In total, 459 ankle fixations were identified of which 87 patients met the criteria for the EWB group, with a further 87 added to the LWB group. There was no significant difference in age between the two groups (51.7 ± 20.1 vs 51.0 ± 15.5, respectively; p = 0.81), but more female patients and diabetics in the EWB group. Fracture types were similar between both cohorts (p = 0.51). Complication rate in the EWB group was not significantly different to the LWB group (5 vs 9, p > 0.05).

CONCLUSION

No increase in complication rate was identified by commencing weightbearing early at two weeks after ankle fixation compared to six weeks. We therefore suggest EWB if appropriate, given its associated benefits including restoration of patient independence and improved quality of life.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Protected immediate weight-bearing is safe after fixation of ankle fractures with syndesmosis injury fixed with position screw. A retrospective case-series study

BACKGROUND

About 10% of ankle fractures are located above the syndesmosis, which causes injury to the ligament structure of the syndesmosis. There is no consensus regarding when to allow weight-bearing on the operated limb of patients who suffered ankle fractures requiring intraoperative fixation.

OBJECTIVE

The aim of this study is the evaluation of radiographic parameters of syndesmosis reduction and fixation in patients with ankle fracture who underwent immediate protected weight-bearing (use of walking-boot and crutches).

PATIENT AND METHODS

Retrospective case series from January 2015 to December 2020. Evaluation of the tibiofibular clear space, tibiofibular overlap, and medial clear space in the preoperative x-ray, immediate postoperative, 3-, 6- and 12-month after syndesmosis fixation and rehabilitation with protected immediate weight-bearing with crutches and walking-boot.

RESULTS

Out of 137 ankle fractures 39 were included. There was no significant difference in the tibiofibular clear space between the immediate x-ray and after 12 months (4.5 mm ± 1.1 vs. 4.6 mm ± 1.8; p > 0.999). Tibiofibular overlap hasn't shown significant difference between immediate and 12-month x-ray (6.2 mm ± 2.6 vs. 6.6 mm ± 2.6; p > 0.999). Medial clear space also has shown no worsening from immediate to 12-month x-ray (3.1 mm ± 0.9 vs. 2.8 mm ± 0.9; p > 0.999). There were no fixation failure nor postoperative infection.

CONCLUSION

Immediate weight-bearing for patients with ankle fractures with syndesmosis injury and treated with intraoperative fixation with positioning screw proved to be safe with good maintenance of the reduction, no failures of the synthesis material observed and no reports of postoperative infection in the period. LEVEL 3 EVIDENCE: therapeutic retrospective case-series.

Very early prescription of range of motion exercises in ankle fractures treated with ORIF does not increase the rate of complications and reoperations: A survival risk analysis

BACKGROUND

Ankle fractures are commonly treated with non-surgical or surgical (preferably ORIF) approaches based on fracture characteristics. The postoperative care regimens vary widely, and the impact of very early mobilization on complications and reoperation rates in ankle fractures treated with ORIF remains unclear.

METHODS

A retrospective analysis was conducted on ankle fractures treated between January 2014 and November 2020. Demographic and fracture characteristic data were collected. Very early prescription of range of motion exercises was defined as initiation within the first week after surgery, typically between the second and seventh postoperative day. Complications, reoperations, and time to these events were analyzed. Kaplan Meier survival analysis was performed to assess the risk of complications with very early mobilization.

RESULTS

A total of 299 patients met the inclusion criteria. The cohort included 83 unimalleolar, 77 bimalleolar, and 138 trimalleolar fractures. Of the patients, 116 (38.8%) underwent very early range of motion. Complications occurred in 45 events among 39 patients (13%), with 16 events (41%) in the very early range of motion group. Reoperations were required for 23 patients (3.67% of the cohort). No statistically significant differences were found in the analysis of complications, with a hazard ratio (HR) of 1.17, and in the adjusted analysis with an HR of 1.12. Similarly, the reoperation analysis showed no significant differences, with an HR of 0.85 and 0.68 in the adjusted analysis.

CONCLUSION

Very early prescription of range of motion exercises in ankle fractures treated with ORIF is a safe approach, as it does not increase the rates of complications or reoperations compared to early or late mobilization. This study supports the use of very early mobilization as a rehabilitation method for ankle fractures.

External mechanical loading overrules cell-cell mechanical communication in sprouting angiogenesis during early bone regeneration

Sprouting angiogenesis plays a key role during bone regeneration. For example, insufficient early revascularization of the injured site can lead to delayed or non-healing. During sprouting, endothelial cells are known to be mechano-sensitive and respond to local mechanical stimuli. Endothelial cells interact and communicate mechanically with their surroundings, such as outer-vascular stromal cells, through cell-induced traction forces. In addition, external physiological loads act at the healing site, resulting in tissue deformations and impacting cellular arrangements. How these two distinct mechanical cues (cell-induced and external) impact angiogenesis and sprout patterning in early bone healing remains however largely unknown. Therefore, the aim of this study was to investigate the relative role of externally applied and cell-induced mechanical signals in driving sprout patterning at the onset of bone healing. To investigate cellular self-organisation in early bone healing, an in silico model accounting for the mechano-regulation of sprouting angiogenesis and stromal cell organization was developed. Computer model predictions were compared to in vivo experiments of a mouse osteotomy model stabilized with a rigid or a semirigid fixation system. We found that the magnitude and orientation of principal strains within the healing region can explain experimentally observed sprout patterning, under both fixation conditions. Furthermore, upon simulating the selective inhibition of either cell-induced or externally applied mechanical cues, external mechanical signals appear to overrule the mechanical communication acting on a cell-cell interaction level. Such findings illustrate the relevance of external mechanical signals over the local cell-mediated mechanical cues and could be used in the design of fracture treatment strategies for bone regeneration.

Influence of Weight Bearing on Postoperative Complications after Surgical Treatment of the Lower Extremity

PURPOSE

In order to prevent implant failure and secondary fracture dislocation, it is often recommended that patients perform partial weight-bearing after surgery of the lower extremity. Previous examinations showed that patients are often not able to follow these instructions. In this study, patients who had undergone surgery of the lower extremity were studied in order to analyze whether incorrect loading influenced the number and severity of complications.

METHODS

Fifty-one patients were equipped with electronic shoe insoles, which measure loading and other parameters. The measurement period was 24 to 102 hours. Median duration of follow-up was 490 days. The primary outcome parameter was postoperative complications leading to revision surgery. Statistical analysis was performed using the chi-square and Fisher exact tests with significance set at a p < 0.05.

RESULTS

Seven out of fifty-one patients had postoperative complications. Four wound complications, one implant failure, chronic instability after fracture of the tibia, and one implant loosening of a hip prosthesis were recorded. In total, 26 of 39 patients were not able to follow the postoperative instructions. Five of the twenty-six patients with difficulties in partial weight-bearing suffered a postoperative complication. In comparison, only 2 of the other 25 patients were affected. There was no statistically significant correlation between high weight-bearing and occurrence of complications (p = 0.29).

CONCLUSION

Most of the patients were unable to follow the surgeon's instructions for partial weight-bearing. Excessive loading did not seem to influence the number and severity of postoperative complications, especially regarding implant failure. Therefore, we should continue with measurements and reevaluate the "partial weight-bearing doctrine".

Current concepts in ankle fractures

Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.

Influence of Patient-Reported Outcome Measures by Surgical Versus Conservative Management in Adult Ankle Fractures: A Systematic Review and Meta-Analysis

Background and Objective: This meta-analysis was performed to compare the effectiveness of surgical treatment and conservative treatment in adult ankle fractures. Methods: Pubmed, Embase, and Cochrane-Library databases were searched to retrieve prospective randomized-controlled studies that compared the efficacy of surgical treatment and conservative treatment in adult ankle fractures. The meta package in R language was used to organize and analyze the obtained data. Results: A total of eight studies involving 2081 patients was considered eligible, including 1029 patients receiving surgical treatment and 1052 receiving conservative treatment. This systematic review and meta-analysis was prospectively registered on PROSPERO, and the registration number is CRD42018520164. Olerud and Molander ankle-fracture scores (OMAS) and the health survey 12-item Short-Form (SF-12) were used as main outcome indicators, and the follow-up outcomes were grouped according to the follow-up time. Meta-analysis results showed significantly higher OMAS scores in patients receiving surgical treatment than those with conservative treatment at six months (MD = 1.50, 95% CI: 1.07; 1.93) and over 24 months (MD = 3.10, 95% CI: 2.46; 3.74), while this statistical significance was absent at 12-24 months (MD = 0.08, 95% CI: -5.80; 5.96). At six months and 12 months after treatment, patients receiving surgical treatment exhibited significantly higher SF12-physical results than those receiving conservative treatment (MD = 2.40, 95% CI: 1.89; 2.91). The MD of SF12-mental data at six months after meta-analysis was -0.81 (95% CI: -1.22; 0.39), and the MD of SF12-mental data at 12+ months was -0.81 (95% CI: -1.22; 0.39). There was no significant difference in SF12-mental results between the two treatment methods after six months, but after 12 months, the SF12-mental results of patients receiving surgical treatment were significantly lower than those of conservative treatment. Conclusions: In the treatment of adult ankle fractures, surgical treatment is more efficacious than conservative treatment in improving early and long-term joint function and physical health of patients, but it is associated with long-term adverse mental health.

Immediate weight bearing without immobilization for operatively treated ankle fractures is safe - A systematic review

BACKGROUND

This systematic literature review compared weight bearing (WB) vs. partial- / non-weight bearing (NWB) and mobilization (MB) vs. immobilization (IMB) for surgically treated ankle fractures.

METHODS

Five databases were searched. Eligible were (quasi-)randomized controlled trials comparing at least two different postoperative treatment protocols. The risk of bias was assessed using the RoB-2 toolkit. The primary outcome was complication rate, secondary outcome Olerud and Molander Ankle Score (OMAS), range of motion (ROM), and return to work (RTW).

RESULTS

Out of 10,345 studies, 24 papers were eligible. Thirteen studies (n = 853) compared WB/NWB, 13 studies (n = 706) MB/IMB with a moderate study quality. WB did not increase the risk for complications but resulted in superior short-term outcomes for OMAS, ROM, RTW. 12 studies found no inferior results for MB compared to IMB.

CONCLUSION

Early and immediate WB and MB do not increase the complication rates but result in superior short term outcome scores.

LEVEL OF EVIDENCE

Level I Systematic Review.

Effectiveness of Postoperative Physiotherapy Compared to Postoperative Instructions by Treating Specialist Only in Patients With an Ankle Fracture: A Systematic Review

Background

In current literature, the benefit of postoperative physiotherapy versus postoperative instructions by treating specialist only remains unclear. The aim of this review is to systematically assess existing literature regarding the functional outcome of postoperative physiotherapy compared to postoperative instructions by treating specialist only in the rehabilitation of patients with an ankle fracture. The secondary aim is to determine if there is a difference in ankle range of motion, strength, pain, complications, quality of life, and patient's satisfaction between these 2 rehabilitation methods.

Methods

For this review, the PubMed/MEDLINE, PEDro, Embase, Cochrane, and CINAHL databases were searched for studies that compared postoperative rehabilitation groups.

Results

The electronic data search detected 20 579 articles. After exclusion, 5 studies with a total of 552 patients were included. Overall, no significant benefit in functional outcome of postoperative physiotherapy was seen compared to the instructions-only group. One study even found a significant benefit in favor of the instructions-only group. An exemption for beneficial effect of the use of physiotherapy could be made for younger patients, as 2 studies described younger age as a factor for better outcomes (functional outcome and ankle range of motion) in the postoperative physiotherapy group. Patients' satisfaction, described by one study, was found to be significantly higher in the physiotherapy group (P = .047). All other secondary aims showed no significant difference.

Conclusion

Because of the limited number of studies and the heterogeneity among studies, a valid conclusion about the general effect of physiotherapy cannot be formed. However, we identified limited evidence suggesting a possible benefit of physiotherapy in younger patients with an ankle fracture in functional outcome and ankle range of motion.

Cerclage Wiring Improves Biomechanical Stability in Distal Tibia Spiral Fractures Treated by Intramedullary Nailing

BACKGROUND

Partial weight-bearing after operatively treated fractures has been the standard of care over the past decades. Recent studies report on better rehabilitation and faster return to daily life in case of immediate weight-bearing as tolerated. To allow early weight-bearing, osteosynthesis needs to provide sufficient mechanical stability. The purpose of this study was to investigate the stabilizing benefits of additive cerclage wiring in combination with intramedullary nailing of distal tibia fractures.

METHODS

In 14 synthetic tibiae, a reproducible distal spiral fracture was treated by intramedullary nailing. In half of the samples, the fracture was further stabilized by additional cerclage wiring. Under clinically relevant partial and full weight-bearing loads the samples were biomechanically tested and axial construct stiffness as well as interfragmentary movements were assessed. Subsequently, a 5 mm fracture gap was created to simulate insufficient reduction, and tests were repeated.

RESULTS

Intramedullary nails offer already high axial stability. Thus, axial construct stiffness cannot be significantly enhanced by an additive cerclage (2858 ± 958 N/mm NailOnly vs. 3727 ± 793 N/mm Nail + Cable; p = 0.089). Under full weight-bearing loads, additive cerclage wiring in well-reduced fractures significantly reduced shear (p = 0.002) and torsional movements (p = 0.013) and showed similar low movements as under partial weight-bearing (shear 0.3 mm, p = 0.073; torsion 1.1°, p = 0.085). In contrast, additional cerclage had no stabilizing effect in large fracture gaps.

CONCLUSIONS

In well-reduced spiral fractures of the distal tibia, the construct stability of intramedullary nailing can be further increased by additional cerclage wiring. From a biomechanical point of view, augmentation of the primary implant reduced shear movement sufficiently to allow immediate weight-bearing as tolerated. Especially, elderly patients would benefit from early post-operative mobilization, which allows for accelerated rehabilitation and a faster return to daily activities.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation"

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes^® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss^®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Characteristics and Effectiveness of Postoperative Rehabilitation Strategies in Ankle Fractures: A Systematic Review

OBJECTIVES

To explore the characteristics and to report on the effectiveness of postoperative rehabilitation strategies for people with an ankle fracture.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL were searched to identify studies published from January 2010 to November 2021.

STUDY SELECTION

Studies that described or evaluated postoperative rehabilitation strategies for surgically repaired ankle fractures were included.

DATA EXTRACTION

Data on postoperative rehabilitation were extracted in accordance with the Template for Intervention Description and Replication guide. Quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools.

DATA SYNTHESIS

Meta-analysis was planned to look at the effectiveness of postoperative rehabilitation strategies. Forty studies described postoperative rehabilitation strategies without evaluating effectiveness, whereas 15 studies focused on evaluating effectiveness. Because of the large variety in postoperative strategies and outcomes, narrative synthesis was deemed most suitable to answer our aims. Characteristics of postoperative rehabilitation strategies varied widely and were poorly described in a way that could not be replicated. Most of the studies (48%) used a late weight-bearing approach, although definitions and details around weight-bearing were unclear.

CONCLUSIONS

Late weight-bearing has been the most common postoperative approach reported in the past 10 years. The variety of definitions around weight-bearing and the lack of details of rehabilitation regimens limit replication and affect current clinical practice. The authors propose to adopt consistent definitions and terminology around postoperative practices such as weight-bearing to improve evidence for effectiveness and ultimately patient outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early versus late weight bearing & ankle mobilization in the postoperative management of ankle fractures: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

While open reduction and internal fixation is currently considered the optimum treatment option for displaced ankle fractures, the most optimal post-operative rehabilitation strategy in this setting remains unclear. The objective of this investigation was to compare the effect of early vs. late weight bearing and ankle mobilization in the post-operative management of ankle fractures.

METHODS

Medline, Embase, CENTRAL, Scopus, CINHAL, and Web of Science were searched to identify randomized controlled trials (RCTs) and quasi-RCTs. Two review authors screened articles, abstracted data, and evaluated risk of bias in duplicate. Outcomes of interest included post-operative ankle function and overall time to return to work. Studies on weight bearing and ankle mobilization were analysed separately and all data were pooled using random-effects models.

RESULTS

Eighteen trials were included in the review of which 14 were included in the meta-analysis of at least one outcome of interest. Majority of the studies presented a high overall risk of bias. Early weight bearing demonstrated significantly better short-term postoperative functional scores at 6-9 weeks postoperatively (SMD: 0.39, 95% CI: 0.19, 0.58; p < 0.0001; I² = 0%). However, the functional effect of early weight bearing compared to late weight bearing gradually became equivalent by the 6 month postoperative time-period. Early weight bearing also demonstrated a significant reduction in the time to return to work/daily activities (MD: -12.29, 95% CI: -17.39, -7.19; p < 0.0001; I² = 0%). In comparison, no significant differences were found between early ankle mobilization/exercises and immobilization.

CONCLUSION

Our findings suggest a potential role of EWB in improving post-operative ankle-function in the short-term and reducing the overall time to return to work/daily activities, but no clinical benefit associated with early ankle mobilization post-surgery.

Ankle tibiotalocalcaneal nailing in elderly ankle fractures as an alternative to open reduction internal fixation: technique and literature review

The use of tibiotalocalcaneal nails for unstable ankle fractures in low demand elderly patients has been introduced as an alternative to open reduction internal fixation to allow early weight-bearing and to decrease soft tissue complications and mechanical failures. This paper describes the technique of hindfoot nailing and reviews the current literature. Overall, it is a minimally invasive and expeditious procedure that provides stable fixation to withstand immediate ambulation of the frail elderly patient. Future high-quality randomized controlled trials will determine if complications and outcomes compare favorably to open reduction and internal fixation.

Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systematic Literature Review and Meta-Analysis

BACKGROUND

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. Traditional postoperative nonweightbearing cast immobilization may prevent loss of fixation and protect the soft tissue envelope but may also be associated with poorer functional outcomes. This systematic review and meta-analysis aimed to compare the complication rate and functional outcomes of early weightbearing (EWB) vs late weightbearing (LWB) following open reduction and internal fixation of ankle fractures.

METHODS

We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies using 3 databases. We included all studies that investigated the effect of weightbearing following internal fixation of ankle fractures in adult patients by any means. Studies that investigated mobilization but not weightbearing, non-English-language publications, and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomized controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3.

RESULTS

This systematic review included 10 randomized controlled trials and 4 comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There was no significant difference in the complication rate between the protected EWB and LWB groups (the risk ratio [RR] for infection was 1.30, 95% CI 0.74, 2.30; I² = 0%; P = .36), but better functional outcome scores were detected in the EWB group only at 6 weeks postoperatively (MD =10.08, 95% CI 5.13, 15.02; I² = 0%; P ≤ .0001), with no significant difference seen at 6 or 12 months postoperatively.

CONCLUSION

Based on the studies reviewed, it appears that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing and is associated with better early functional outcomes at 6 weeks, but not 6 or 12 months, postoperatively.

How to assess applicability and methodological quality of comparative studies of operative interventions in orthopedic trauma surgery

PURPOSE

It is challenging to generate and subsequently implement high-quality evidence in surgical practice. A first step would be to grade the strengths and weaknesses of surgical evidence and appraise risk of bias and applicability. Here, we described items that are common to different risk-of-bias tools. We explained how these could be used to assess comparative operative intervention studies in orthopedic trauma surgery, and how these relate to applicability of results.

METHODS

We extracted information from the Cochrane risk-of-bias-2 (RoB-2) tool, Risk Of Bias In Non-randomised Studies-of Interventions tool (ROBINS-I), and Methodological Index for Non-Randomized Studies (MINORS) criteria and derived a concisely formulated set of items with signaling questions tailored to operative interventions in orthopedic trauma surgery.

RESULTS

The established set contained nine items: population, intervention, comparator, outcome, confounding, missing data and selection bias, intervention status, outcome assessment, and pre-specification of analysis. Each item can be assessed using signaling questions and was explained using good practice examples of operative intervention studies in orthopedic trauma surgery.

CONCLUSION

The set of items will be useful to form a first judgment on studies, for example when including them in a systematic review. Existing risk of bias tools can be used for further evaluation of methodological quality. Additionally, the proposed set of items and signaling questions might be a helpful starting point for peer reviewers and clinical readers.

Early Return to Daily Life through Immediate Weight-Bearing after Lateral Malleolar Fracture Surgery

Lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for weight-bearing has not been standardized. In the present study, we investigated the prognostic difference between immediate and delayed weight-bearing on lateral malleolus fractures. The medical records of matched patients in the immediate and delayed weight-bearing groups (50 and 50, respectively) were reviewed retrospectively. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate with a lag screw. In the immediate weight-bearing group (IWB), tolerable weight-bearing (i.e., what can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight-bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise was permitted in both groups, starting from the day after surgery. Radiographic assessment data and clinical outcomes were reviewed between the two groups. No significant differences in radiographic assessments and complications were found between the two groups. Significant differences in terms of a shortened length of hospital stay and time to return to work with the IWB rehabilitation protocol compared with DWB were confirmed (6.0 vs. 9.2 days, p = 0.02 and 6.1 vs. 8.3 weeks, p = 0.02, respectively). A significant difference in sport factor was observed in the Foot and Ankle Outcome Score at 3 months postoperatively (72.3 vs. 67.4, p = 0.02). We found no significant differences between the two groups concerning postoperative radiological outcomes and complications. The benefits of shortening the time to return to work and length of hospital stay associated with the IWB rehabilitation protocol were confirmed. In conclusion, immediate weight-bearing is recommended in patients with lateral malleolus fracture after anatomical reduction and firm fixation by surgery.

Measuring Recovery and Understanding Long-Term Deficits in Balance, Ankle Mobility and Hip Strength in People after an Open Reduction and Internal Fixation of Bimalleolar Fracture and Their Impact on Functionality: A 12-Month Longitudinal Study

To analyze how balance and other physical capacities evolved after surgery in patients with a bimalleolar fracture and how these capacities and clinical variables (immobilization or unloading time) contribute to restoring patients’ functionality, 22 patients and 10 healthy people (HC) were assessed for static and dynamic balance (Y-Balance test, YBT), dorsiflexion ankle mobility (ADFROM) and hip strength at 6 and 12 months after surgery. Patients’ functional status was assessed through the Olerud Molander Ankle Score (OMAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Twenty-one patients with ankle fractures who completed the study showed a worse static and dynamic balance at 6 months. The YBT in the anterior direction (YBTA) revealed balance deficits in the operated limb at 12 months compared to the non-operated limb (−5.6%) and the HC (−6.7%). They also showed a decreased ADFROM compared to the non-operated limb (−7.4°) and the HC (−11°). In addition, medium-term (6 months) deficits in abductor strength hip but no hip strength deficits were found at 12 months after surgery. Relative weight analyses showed that ADFROM and hip strength explained 35–63% of the YBTA variance and AOFAS/OMAS scores. Balance, hip strength and ADFROM seem to be reliable indexes for assessing the functional status of these patients. These results could help to understand the relationship between these physical capacities and the patients’ perceived functional status.

Fractures of the lateral malleolus - a retrospective before-and-after study of treatment and resource utilization following the implementation of a structured treatment algorithm

Background

In 2015 a study of isolated lateral malleolar fractures (AO/OTA44-B1) treated at Sahlgrenska University hospital (SU) during two consecutive years revealed large-scale variation in the choice of treatment and planned follow-up. The study resulted in the development of a structured treatment algorithm (TA) for ankle fractures. We investigated the effects of this well-implemented TA on the classification, treatment and follow-up of lateral malleolar fractures.

Methods

The current study is an uncontrolled, non-randomized, retrospective before-and-after study comparing a group of AO/OTA44-B1 fractures treated at SU before the introduction of the TA for ankle fractures (1 April 2012 to 31 March 2014) with a group treated after the introduction of the TA (1 September 2017 to 31 August 2019).

Results

In all the studied parameters regarding treatment for AO/OTA44-B1 fractures, a statistically significant change was seen after the introduction of the TA. Surgical treatment reduced from 32% (95% CI 27.5 – 36.5) pre-TA to 10% (95% CI 6.9 – 13.1) post-TA, while the number of patients permitted full weight-bearing increased from 41% (95% CI 36.3 – 45.7) to 84% (95% CI 80.1 – 87.9).

Conclusions

A thoroughly implemented treatment algorithm can reduce the number of surgical treatments for stable ankle fractures. The current study demonstrates that a structured treatment algorithm can standardize the management of ankle fractures and make decisions less dependent on the surgeon’s discretion.

Weight-bearing in Trauma Surgery (WiTS) Study: A national survey of UK Trauma & Orthopaedic multidisciplinary health professionals

INTRODUCTION

Weight-bearing (WB) status following a fracture or surgical fixation is an important determinant of the mechanical environment for healing. In order for healthcare professionals to communicate and understand the extent of bearing weight through a limb, clear terminology must be used. There is widespread variation in the usage and definitions of WB terminology in the literature and clinical practice. This study sought to define the understanding and extent of variation across the United Kingdom.

METHODS

A nationwide online survey of UK-based Trauma & Orthopaedic (T&O) multidisciplinary healthcare professionals was conducted. Participants answered seven questions assessing their usage and understanding of various WB terminology.

RESULTS

A total of 707 responses were received: 48% by doctors, 32% by physiotherapists, 13% by occupational therapists and 7% from other healthcare professionals. In terms of understanding of WB terminology with respect to percentage body weight (BW), 89% of respondents interpret 'full WB' as 100% BW, 97% interpret 'non WB' as 0% BW, 80% interpret 'partial WB' as 50% BW, and 89% interpret 'touch/toe-touch WB' as 10% or 20% BW. There were statistically significant differences between the responses of doctors and therapists for these four terms, with doctors tending to give higher %BW values. 'Protected WB' and 'WB as tolerated' had less consensus and more variability in responses. The majority (68%) of respondents do not usually quantify terminology such as 'partial WB' with a value, and 94% agreed that standardisation of WB terminology would improve communication amongst professionals.

CONCLUSION

This study provides evidence of the substantial variation in the understanding of WB terminology amongst healthcare professionals, which likely results in ambiguous rehabilitation advice. Existing literature has shown that patients struggle to comply with terms such as 'partial weight-bearing'. We recommend consensus within the T&O multidisciplinary community to standardise and define common weight-bearing terminology.

Early Unprotected Weight Bearing and Pre-Scheduled Supervised Rehabilitation Program after Surgical Treatment of Ankle Fractures

BACKGROUND

Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weight-bearing and rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditional methods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearing along with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotected immediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the mid-term clinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with the unaffected side.

METHODS

Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included (mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, Pain Disability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative period and a standardized supervised prescheduled rehabilitation program was undertaken following surgery.

RESULTS

The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supination-external rotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronation-external rotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid union was achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was 80.93±17.24. Although patients' health-related quality of life was at a good level, the injured-side ankle ROM was lower than the healthy side (p ≤ 0.05).

CONCLUSION

Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearing as tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of ankle fractures. However, this protocol is not studied in patients with associated comorbidities.

An overview on the treatment and outcome factors of ankle fractures in elderly men and women aged 80 and over: a systematic review

INTRODUCTION

This article is a systematic review of the literature on elderly aged 80 and over with an ankle fracture. Low energy trauma fractures are a major public health burden in developed countries that have aged populations. Ankle fractures are the third most common fractures after hip and wrist fractures. The purpose of this review is to provide an overview of the treatments and the used outcome factors.

METHODS

PubMed, Embase, Cochrane Library, and CINAHL were searched to retrieve relevant studies. Studies published in English or Dutch concerning the treatment of ankle fractures in patients aged 80 and over were included.

RESULTS

Initially 2054 studies were found in the databases. After removing duplicate entries, 1182 remained. Finally, after screening six studies were included, of which three cohorts studies and three case series. Six different treatments were identified and described; ORIF, transarticular Steinmann pin, plaster cast with or without weight-bearing, Gallagher nail and the TCC nail. Furthermore, 32 outcome factors were identified.

DISCUSSION

The various studies show that practitioners are careful with early weight-bearing. However, if we look closely to the results and other literature, this seems not necessary and it could potentially be of great value to implement early weight-bearing in the treatment. Furthermore, quality of life seems underreported in this research field.

CONCLUSIONS

ORIF with plaster cast and permissive weight-bearing should be considered for this population since it seems to be a safe possibility for a majority of the relatively healthy patients aged 80 and over. In cases where surgery is contra-indicated and a plaster cast is the choice of treatment, early weight-bearing seems to have a positive influence on the outcome in the very old patient.

Do Early Weight-Bearing and Range of Motion Affect Outcomes in Operatively Treated Ankle Fractures: A Systematic Review and Meta-Analysis

OBJECTIVES

This systematic review was performed to answer the following questions: (1) Does early weight-bearing (WB) after ankle fracture (AF) open reduction internal fixation (ORIF) affect outcomes? (2) Does early WB after AF ORIF cause an increase in complications? (3) Does early ankle motion after AF ORIF affect outcomes? and (4) Does early ankle motion after AF ORIF cause an increase in complications?

DATA SOURCES

Articles from 1970 to 2020 were found using the PubMed database.

STUDY SELECTION

Level I studies of adult patients with operatively treated ankle fractures were selected. A total of 1130 cases across 20 studies fit the participant criteria.

DATA EXTRACTION

Studies were reviewed for data pertaining to the current study questions.

DATA SYNTHESIS

The meta-analysis used logistic regression and standardized mean difference.

RESULTS

Based on the current literature, early WB in operative ankle fractures with stable fixation showed no difference in outcomes when compared with delayed WB protocols. Early WB after ORIF did not significantly increase complications. Early ankle motion after AF ORIF did not have significant standardized mean differences between range of motion and immobilization outcomes. Early range of motion before wound healing may lead to an increase in complications [pooled odds ratio: 3.11, 95% confidence interval (CI): 1.64-5.90] but did not show an increase in infection.

CONCLUSIONS

The authors recommend that early WB at 2 weeks postoperatively can be safely considered for ankle fractures when stable fixation has been obtained. Early ankle motion before wound healing is not recommended due to increased wound complications, without improvement in long-term results.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Early Weightbearing Versus Nonweightbearing After Operative Treatment of an Ankle Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial

BACKGROUND

Acute ankle fractures can occur during sports activities, and unstable ankle fractures are commonly treated operatively. However, controversy exists about the optimal time to allow weightbearing.

HYPOTHESIS

Early weightbearing after the stable fixation of an ankle fracture is not inferior to nonweightbearing in terms of ankle function assessed at 12 months after injury.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 258 patients were assessed for eligibility. Of these patients, 194 were randomly allocated to either the early weightbearing group (95 patients who were allowed weightbearing at 2 weeks postoperatively) or the nonweightbearing group (99 patients who were not allowed weightbearing until 6 weeks postoperatively). The primary outcome measure was the mean difference in the Olerud-Molander ankle score (OMAS) between the groups, assessed at the 12-month follow-up examination. The secondary outcome measures were the time to return to preinjury activities and patients' subjective satisfaction. Complications such as hardware loosening or failure, fracture displacement, and nonunion were evaluated.

RESULTS

The mean difference in the OMAS for the early weightbearing group compared with the nonweightbearing group was 1.6 (95% CI, -1.9 to 5.0) in the intention-to-treat analysis. The lower limit of the 95% CI (-1.9) exceeded the noninferiority margin of -8, indicating that early weightbearing was not inferior to nonweightbearing. The difference in the proportion of patients who were satisfied or very satisfied with their treatment was not statistically significant (84.3% vs 76.2%; P = .19); however, the time taken to return to preinjury activities was shorter with early weightbearing than with nonweightbearing (9.1 ± 3.0 vs 11.0 ± 3.0 weeks; P < .001). No cases of nonunion were observed in either group.

CONCLUSION

Early weightbearing after the operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months after injury. The patients' subjective satisfaction was similar between the groups, although the time taken to return to preinjury activities was shorter in the early weightbearing group.

REGISTRATION

NCT02029170 (ClinicalTrials.gov identifier).

Currents concepts of the perioperative management of closed ankle fractures

Ankle fractures are common injuries that can result in substantial morbidity in the population. This review discusses the management of closed ankle fractures and outlines the recent evidence and guidelines on perioperative management. In general, a detailed history should be undertaken, followed by examination and imaging of the affected limb. Fixation is based on the AO principles of fracture management that aims towards restoring stability of the joint and reducing the risk of long-term complications. A multidisciplinary approach towards perioperative management is recommended in view of the increasing proportion of aging patients with significant comorbidities.

Do levels of sedentary behaviour and physical activity differ according to weight-bearing status after lower limb fracture? A prospective cohort study

Background/purpose:

To determine whether sedentary behaviour and physical activity differ according to initial weight-bearing status 2 weeks and 6 months after lower limb (LL) fracture.

Methods:

Two weeks and 6 months following LL fracture, 47 adults aged 18–69 wore ActiGraph and activPAL accelerometers for 10 days. Sitting time, steps, and moderate-intensity physical activity (MPA) were compared between weight-bearing (WB) and non-weight-bearing (NWB) groups.

Results:

Two weeks post-discharge, the NWB group sat significantly more than the WB group (median: 14.1 h/day vs. 13.3 h/day; p = 0.04). These differences were apparent for female and middle-aged participants. At 6 months, there were no significant differences between weight-bearing groups for sitting time, steps or MPA.

Conclusion:

Weight-bearing restriction had an early impact on sitting time, but this impact lessened over time. While considering the need for rest, advice about reducing sitting time may be particularly important for people who are NWB post-fracture.

The role of mechanical stimulation in the enhancement of bone healing

The biomechanical environment plays a dominant role in the process of fracture repair. Mechanical signals control biological activities at the fracture site, regulate the formation and proliferation of different cell types, and are responsible for the formation of connective tissues and the consolidation of the fractured bone. The mechanobiology at the fracture site can be easily manipulated by the design and configuration of the fracture fixation construct and by the loading of the extremity (weight-bearing prescription). Depending on the choice of fracture fixation, the healing response can be directed towards direct healing or towards indirect healing through callus formation. This manuscript summarizes the evidence from experimental studies and clinical observations on the effect of mechanical manipulation on the healing response. Parameters like fracture gap size, interfragmentary movement, interfragmentary strain, and axial and shear deformation will be explored with respect to their respective effects on fracture repair. Also, the role of externally applied movement on the potential enhancement on the fracture repair process will be explored. Factors like fracture gap size, type and amplitude of the mechanical deformation as well as the loading history and its timing will be discussed.

Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

BACKGROUND

Postoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates.

METHODS

A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance.

DISCUSSION

Traditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN76410775 . Retrospectively registered on 30 June 2019.

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures

Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed.

Principles and guidelines in the management of ankle fractures in adults

Ankle fractures are common injuries that have many physical and psychosocial complications. As a result, it is important to be aware of how these patients present and are managed perioperatively. Detailed guidelines from NICE and the British Orthopaedic Association have been produced on this topic, including recent developments such as the decision to weight-bear early after surgery and the use of virtual fracture clinics. This article provides an overview of the key perioperative factors that need to be considered in cases of ankle fracture and the relevant clinical guidelines.

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

BACKGROUND

The timing of post-operative full weight-bearing in patients of isolated displaced lateral malleolar fractures remains controversial. The aim of this study was to evaluate the outcomes of early full weight-bearing after rigid internal fixation of such fractures with locking plates.

METHODS

From 2012 to 2018, 46 patients who had closed isolated displaced lateral malleolar fractures were included in the study. All fractures were managed with open reduction and internal fixation with locking plates. The patients were allowed to walk bearing their full weight 2 weeks after the operation. The follow-up period was 41.5 months on average (range: 12-70 months). The patients were available to evaluate union conditions, functional results, and complications.

RESULTS

The fractures united smoothly with an average union time of 10.5 weeks (range: 8-16). At the final follow-up, the average American Orthopaedic Foot and Ankle Score Ankle-Hindfoot Score was 91 (range: 85-98). No complications were observed.

CONCLUSION

For patients with isolated displaced lateral malleolar fractures, full weight-bearing is safe and effective, without an increase in the rate of complications, 2 weeks after open reduction and rigid fixation with locking plates.

[Aftercare following surgical treatment of ankle fractures : What is the current state of knowledge?]

BACKGROUND

Ankle fractures are among the most common fractures in adults but often with unsatisfactory long-term results. In recent years several new surgical treatment approaches have been developed but little has changed regarding the aftercare. The postoperative treatment can be divided into two main components, weight bearing and mobilization. In Germany most patients are still recommended to be immobilized with partial weight bearing for 6 weeks after surgery.

OBJECTIVE

The aim of this review is to present the current evidence on postoperative treatment based on an extensive literature search.

MATERIAL AND METHODS

A total of seven prospective randomized controlled trials (RCT) compared early and delayed full weight bearing and six RCTs compared ankle mobilization with a form of immobilization.

RESULTS

In none of these studies did early full weight bearing lead to an increased complication rate but some studies found a shortened time before return to work and, at least in the short term, better clinical results. Immediate mobilization led to an increased complication rate in only one out of six studies. It also appeared that mobilization led to a reduced time before return to work and, in the short term, to better clinical outcomes. The comparability of the studies was limited as in most cases different clinical scores and parameters were collated. In addition, information on patient age, fracture type, bone quality, comorbidities, and the implants used was often inadequate and post-treatment regimens sometimes differed significantly.

CONCLUSION

The early functional therapy following surgically treated ankle fractures increased the rate of wound healing complications in only one of 13 studies, otherwise there were no significant differences in complication rates; however, early functional therapy partly shortened the time to return to work and led to better clinical results in the short term. For future studies, standardization of the parameters assessed would be important to provide clear evidence-based guidelines on follow-up treatment for specific fractures and patient populations.

Effect on Overall Health Status With Weightbearing at 2 Weeks vs 6 Weeks After Open Reduction and Internal Fixation of Ankle Fractures

BACKGROUND

Ongoing controversy exists on postoperative weightbearing status after open reduction and internal fixation of an ankle fracture. This prospective randomized controlled trial aimed to compare patient-based and physician-based outcomes after early weightbearing at 2 vs 6 weeks postoperatively.

METHODS

Fifty patients with unstable rotational-type ankle fractures were treated operatively with subsequent immobilization in a below-the-knee cast for 2 weeks and were then randomly allocated to 2 groups. The first group had early weightbearing at 2 weeks postoperation and the second group at 6 weeks postoperation. Follow-up included subjective and objective evaluations performed at 2, 6, 12, and 26 weeks postoperatively. The primary outcome was the patient-based general health status as measured with the EuroQol-5D (EQ-5D) scoring system. Secondary outcome was the Olerud and Molander ankle score. Power analysis revealed a study group of 50 patients was needed to show a clinically relevant effect size of 10 points in both EQ-5D visual analog scale (VAS) score and Olerud and Molander score.

RESULTS

Patients in the early weightbearing group had higher mean EQ-5D VAS scores at a 6-week follow-up (P = .014) of 77 ± 14 compared to 66 ± 15 for late mobilization. No difference was found at other follow-up points or between groups for physician-based outcome measures. At 26 weeks postoperatively, mean Olerud and Molander ankle scores were similar at 84 ± 16 and 81 ± 17 for mobilization at 2 and 6 weeks postoperation, respectively.

CONCLUSION

Early weightbearing after operative fixation of rotational-type ankle fractures had a clinically relevant and statistically significant benefit in patient-based general health status, as quantified with EQ-5D VAS scores, at 6 weeks postoperation. These results contribute to our understanding of early weightbearing and may encourage consideration of weightbearing at 2 weeks postoperatively in standard protocols.

LEVEL OF EVIDENCE

Therapeutic Level I, prospective randomized controlled trial.

Foot and ankle service adaptation in response to COVID-19 and beyond

The disruption to healthcare provision as a result of the COVID-19 pandemic has compelled us to streamline healthcare delivery. This has given us an opportunity to implement healthcare technology, reform inter-disciplinary collaboration and ultimately enhance patient care. We discuss some of the advances made by the foot and ankle department at our hospital. These innovations have broad applicability and will hopefully ignite discussion amoung a number of healthcare teams about improving the future care of their patients.

Study methodology in trauma care: towards question-based study designs

The randomized controlled trial (RCT) in surgery may not always be ethical, feasible, or necessary to address a particular research question about the effect of a surgical intervention. If so, properly designed and conducted observational (non-randomized) studies may be valuable alternatives for an RCT and produce credible results. In this paper, we discus differences between RCTs and observational studies and differentiate between three types of comparisons of surgical interventions. We assert that results of different designs should be regarded as complementary to each other when evaluating surgical interventions. Criteria for credible observational research are presented to provide guidance for future observational research of surgical interventions. We argue that the research question that is being asked should guide the discussion about the value of a particular study design.