Ankle fractures account for approximately 9% of all adult fractures and are increasing in incidence.1–3 More specifically, trimalleolar ankle fractures represent 7% to 10% of these injuries and are unstable.4 Comparisons of trimalleolar and bimalleolar ankle fractures have shown increased long-term pain and stiffness in the trimalleolar group, with larger posterior malleolus fragments correlating with poorer outcomes.2,5–8
Until recently, the standard of care after operative fixation of trimalleolar ankle fractures involved approximately 6 to 8 weeks of non-weight bearing (NWB).9,10 Surveys have shown that bone quality, medical comorbidities, and fracture stability are among the issues that have led the orthopedic community to recommend this period of NWB.11,12 However, there may be disadvantages for long-term immobilization after fixation. Significant decreases in the cross-sectional area of the thigh and calf muscles have been shown, most notably during the first 4 weeks of immobilization.13–15 In addition, ankle strength and range of motion (ROM) decrease at an even higher rate in this population and may take months to return to baseline.16–18 Neurologic adaptations as a result of immobilization are believed to play a role in ankle strength and ROM, and for these reasons, interest in early weight bearing (EWB) after unstable ankle fracture fixation has increased.15,19 This concept extends to trimalleolar fractures, which traditionally have been managed even more conservatively than bimalleolar fractures.11
Several specific concerns exist after unstable ankle fracture fixation, including loss of fracture reduction, delayed healing, and risk of wound complications.20–22 However, recent trials have challenged these beliefs in isolated fibular fractures and bimalleolar ankle fractures with the idea that EWB may provide significant benefits, including improvements in ROM and functional scores, more rapid return to work, and lower rates of implant irritation.9,23–29 Additionally, loss of reduction has not been a significant complication with EWB.9,30–34 Some biomechanical data support EWB for trimalleolar fractures without displacement, but most studies of EWB have excluded trimalleolar variants.9,10,35 However, several studies prospectively compared EWB with casted NWB in patients with posterior malleolar fractures and concluded that clinical outcomes were unchanged.36,37
The goal of this study was to evaluate radiographic and clinical outcomes in patients who were managed with EWB vs late weight bearing (LWB) after fixation of trimalleolar ankle fracture. The hypothesis was that patients in the EWB group would show no difference in radiographic or clinical outcomes or complication rates. To the authors' knowledge, this is among the few recent studies comparing EWB and LWB in trimalleolar ankle fractures undergoing fixation of the posterior malleolus.
Materials and Methods
After formal institutional review board approval was obtained, a retrospective review was performed of patients 18 years or older who underwent operative fixation of isolated trimalleolar ankle fracture between 2010 and 2019. All procedures were performed at an urban level I trauma center by 1 of 5 fellowship-trained orthopedic traumatologists. Specific exclusion criteria included follow-up for less than 6 months, previous ankle surgery, and primary fusion or treatment with external fixation. Demographic information is shown in Table 1.
Demographic Features and Injury Information
All participants underwent rigid fixation of trimalleolar ankle fracture with standard osteosynthesis techniques. The lateral malleolus was fixed with either a lag screw and neutralization plate, an antiglide plate, or a bridge plating technique with comminution. The medial malleolus fragment was secured with two 3.5- or 4.0-mm screws or a medial mini-fragment plate in cases of comminution. Attention was paid to the posterior malleolus where surgeon discretion dictated fragment fixation. If the posterior malleolus was fixed, lag screws or plates were used from a small fragment or mini-fragment set (DePuy Synthes). Syndesmotic stability was assessed intraoperatively with the Cotton test and external rotation maneuver. Regardless of posterior malleolus fixation, if widening of the syndesmotic clear space was noted, the surgeon placed one or two 3.5-mm screws or a single Tightrope (Arthrex) across the syndesmosis. The specific technique was based on surgeon preference. In some cases, radiographic instability dictated the need for syndesmotic fixation, even after posterior malleolus fixation. In addition to assessing for syndesmotic widening, deltoid ligament integrity was assessed by evaluating medial clear space widening and talar tilt, and deltoid ligament repair was performed if these radiographic markers were not acceptable after provisional fixation. After satisfactory stability was obtained, incisions were irrigated and closed. Patients were placed in a 3-sided plaster splint and kept NWB until instructed otherwise (Figure 1).
Anteroposterior (A) and lateral (B) radiographs of trimalleolar ankle fracture. Axial computed tomography at the time of injury (C). Anteroposterior (D) and lateral (E) postoperative radiographs.
Based on surgeon protocol, patients began weight bearing at different times; EWB was defined as occurring at 3 weeks or less (mean±SD, 2.9±0.2 weeks) and LWB occurred at greater than 3 weeks (mean±SD, 9.2±4.2 weeks). Earlier studies used 3 weeks as a cutoff for weight bearing, and this timing was believed to lead to a significantly more rapid return to weight bearing compared with the 6-to 8-week standard of care.9 This time-line also coincided with the initial office follow-up visit and splint removal. The EWB group was allowed to begin full weight bearing at 3 weeks, whereas the LWB group was strictly NWB for more than 3 weeks from the procedure, as decided by the surgeon. All patients were encouraged to perform ROM exercises after the first visit. Follow-up visits occurred at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Radiographs were obtained at each visit, and complications were noted. The need for a secondary procedure, including routine hardware removal, also was documented.
The primary outcome of this study was to compare the clinical and radiographic outcomes of patients who had EWB or LWB after fixation of trimalleolar ankle fracture. Clinical outcomes included ambulatory status at final follow-up, return to the operating room, and rate of superficial and deep infections. Radiographic outcomes were based on fracture union and implant failure. A secondary outcome was the effect of both syndesmotic and posterior malleolus fixation on weight bearing status and the outcomes described earlier.
Statistical analysis was performed, with continuous variables reported as mean values and standard deviations and categorical variables reported as percentages. Univariate tests of continuous variables were conducted with either an independent t test or a Mann–Whitney U test. For categorical comparisons, chi-square tests of independence and Fisher exact tests were used. A Holm-Bonferroni step-down method was used to account for increases in type I errors as a result of multiple comparisons. Logistic regression was used to estimate the odds of nonunion associated with multiple other variables while adjusting for confounding factors. Significance was set at P<.05.
Of the 185 patients included in this study, the EWB group included 47 (25.4%) patients and the LWB group included 138 (74.6%) patients. All fractures were AO/OTA 44 trimalleolar ankle fractures. A higher rate of illicit drug use was found in the EWB group (21.2% EWB vs 7.9% LWB, P=.01), but no other demographic differences between groups were noted (Table 1).
Time to weight bearing was significantly lower in the EWB group (2.9±0.2 weeks) compared with the LWB group (9.6±4.2 weeks) (P<.01). Earlier weight bearing with posterior malleolar (P<.01) and syndesmotic (P<.01) fixation was observed. As expected, higher blood loss (P<.01) and longer operative time (P<.01) were noted when the posterior malleolus was fixed. Of the 7 nonunions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. Among the patients, 3 had open fracture and 3 had deep infection. A total of 72 (38.9%) posterior malleolar fractures were stabilized operatively, 24 (51.1%) in the EWB group and 48 (34.8%) in the LWB group. Syndesmotic fixation was necessary for 9 of 72 (12.5%) patients, despite posterior malleolus fixation. In addition, 65 (35.1%) patients underwent syndesmotic fixation independent of posterior malleolar fixation. Demographically, the group without posterior malleolus fixation had more neuropathy (13.1% vs 0%, P<.01) and higher body mass index (32.9 vs 30.1 kg/m2, P=.02).
For 26 of the 185 (14.1%) patients, return to the operating room was necessary (Table 2). Of these, 9 were in the EWB group and 17 were in the LWB group. Of these procedures, 10 were needed for planned removal of symptomatic hardware, 1 was needed because of reinjury, and 7 were needed because of nonunion. A total of 8 patients returned to the operating room because of infection. Of these, 2 had open fracture and 4 had a history of diabetes, and only 1 was in the EWB group. When the symptomatic hardware cohort is disregarded, the rate of return to the operating room decreased to 16 of 185 (8.6%) overall and the rate of return to the operating room for infection was 2.1% for the EWB group vs 5.8% for the LWB group. When the infection rate was considered independently of return to the operating room, no significant difference was found between the EWB and LWB groups in the rate of superficial infection (P=.12) vs deep infection (P=.08).
Comparison of Early Versus Late Weight Bearing
Finally, binary logistic regression analysis of all cases combined was performed to identify predictors of union. The analysis showed that none of the demographic variables noted in Table 1 was statistically significant when related to union; similarly, the only significant fracture-related characteristic was open fracture, and patients with open fracture were 3.8 times more likely to have nonunion (P=.02). In addition, EWB had no effect on the rate of union (P=.20) or implant failure (P=.42). Although superficial infection was not associated with union rate (P=.09), deep infection showed a 3 times increased risk of nonunion (P<.01). Interestingly, posterior malleolar plating was not associated with increased union rates (P=.42), but syndesmotic fixation showed a 2.5 times increased rate of union (P=.02).
This study showed that EWB after trimalleolar ankle fracture appears to be safe. The authors did not find a difference between the EWB and LWB groups in union rate, implant failure, infection rate, or return to the operating room. To their knowledge, this study is the first to compare EWB and LWB after trimalleolar ankle fracture. The suggestion that EWB is safe and is not detrimental to recovery appears consistent with biomechanical studies of trimalleolar ankle fracture and earlier clinical studies of bimalleolar ankle fracture.9,10,20,22,23
Papachristou et al35 performed a bio-mechanical study that showed that the posterior malleolar fracture quadrant was unloaded at 55 kg pressure for all foot positions and minimally loaded at 105 kg pressure when the foot was in dorsiflexion. These authors also followed 15 patients who underwent operative stabilization of a posterior malleolar fracture that involved 0% to 33% of the joint. Patients started weight bearing in a walking plaster cast 7 days after surgery, and all patients had an uneventful recovery.35 In the current study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Interestingly, more patients in the EWB group (51.1%) underwent posterior malleolar fixation compared with the LWB group (34.8%) (P<.01), which may suggest higher surgeon comfort with EWB with increased fixation. The findings of Papachristou et al35 correspond with the current results, which did not show a higher rate of implant failure or nonunion for patients who were allowed to bear weight early after posterior malleolar fixation.
Biomechanical studies also have suggested that fixation of the posterior malleolus decreases the need for syndesmotic stabilization by restoring the anatomy of the posterior inferior tibiofibular ligament.38 Miller et al39 restored the stability of the syndesmosis for 97.9% of their patients when the posterior malleolus was addressed first. To the current authors' surprise, 12.5% of patients required syndesmotic stabilization after fixation of the posterior malleolus, which likely means that there was a more significant ligamentous injury of the syndesmosis, even with the posterior malleolar fracture. Also of interest were the results for patients who underwent syndesmotic fixation independent of posterior malleolar fixation. The current authors found that syndesmotic fixation increased the rate of union 2.5 times. This finding was independent of changes in the type of syndesmotic fixation or the number of screws, when used. This curious finding may suggest that syndesmotic fixation provides a more rigid overall construct compared with a more anatomic method of posterior malleolus plating. Of note, the decision to perform syndesmotic fixation with or without posterior malleolar fixation was based on surgeon preference and intraoperative indications.
Dehghan et al9 performed a randomized controlled trial of 110 patients who were assigned to either EWB at 2 weeks or cast immobilization for 6 weeks. Their study excluded all posterior malleolar fractures that required fixation. Between the 2 groups, no difference was found in return to work, but patients in the EWB group had significantly improved ROM at 6 weeks. The EWB group also had better Olerud/Molander ankle function scores and Short Form-36 scores. Dehghan et al9 noticed no difference in complication rates, but the LWB group had higher rates of implant removal surgery.9 The current study found no statistically significant difference between the EWB and LWB groups in return to the operating room. However, for 10 of 26 (38.5%) patients, removal of symptomatic hardware was the reason for return to the operating room. Supporting the findings of Dehghan et al,9 70.0% of implant removals occurred in the LWB group.
Immobilization can lead to muscle atrophy and decreased motor control after prolonged disuse.13,16 Clark16 stated that immobilization has a greater effect on decreasing strength than bed rest and limb suspension. Clark16 attributed loss of control to decreased neurologic and skeletal muscle strength as a result of prolonged immobilization. Although this finding did not reach statistical significance, in the current study, 10.9% of patients in the LWB group showed at least 1 level of ambulatory functional decline (ie, walker to wheelchair) compared with 4.3% of patients in the EWB group, perhaps in line with loss of strength and proprioception, leading to decreases in postoperative ROM and functional ability.9,23–29 In addition, fracture healing is affected by mechanical loading.40 Proponents of EWB at the authors' institution believe in the inherent benefits of EWB in promoting bone healing, decreasing muscle atrophy, and preventing functional decline.
Union rates were not statistically different between the EWB and LWB groups. Interestingly, 6 of 7 of the non-unions occurred in the LWB group. Specifically, patients who had open fracture and deep infection showed higher rates of nonunion, whereas no association was found between nonunion and age, body mass index, or the incidence of diabetes. It is possible that this study was not sufficiently powered to detect other notable differences.
Limitations of this study included its retrospective nature and the inherent associated bias. The authors did not assess functional outcome scores to determine patient perceptions of well-being. The timing of weight bearing was not randomized but was decided by the surgeons, who had differing protocols. Therefore, weight bearing was not randomized to the patient but to which surgeon was on call for that patient. A randomized control trial should be designed to prospectively assess functional outcomes and fixation failures after operative fixation of trimalleolar ankle fracture with EWB.
Early weight bearing at 3 weeks or less postoperatively appears to be safe for patients with trimalleolar ankle fractures. This is evidenced by the fact that no difference was seen between groups in union rate, infection, implant failure, or return to the operating room. Syndesmotic fixation appears to increase the likelihood of fracture union 2.5 times, whereas posterior malleolar fracture fixation has no effect. This information may allow orthopedic surgeons to safely mobilize patients early after trimalleolar ankle fractures without concern for increased complication rates.
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Demographic Features and Injury Information
|Age, mean±SD (range), y||50.1±18.0 (18–91)|
|Sex, male, No.||60 (32.4%)|
|Weight, mean±SD (range), lb||198.3±51.8 (105–365)|
|Body mass index, mean±SD (range), kg/m2||31.9±7.7 (18.8–61.6)|
|Diabetes mellitus, No.||31 (16.7%)|
| Hemoglobin A1C, mean±SD (range)||7.5%±1.9% (4.7%–12.2%)|
| Neuropathy, No.||15 (8.1%)|
|Tobacco use, No.||64 (34.4%)|
|Illicit substance use, No.||21 (11.2%)|
|Employed, No.||89 (47.9%)|
|Open fracture, No.||24 (13.0%)|
Comparison of Early Versus Late Weight Bearing
|Variable||Early weight bearing||Late weight bearing||P|
|Time from injury to surgery, mean±SD, h||60.5±120.0||40.8±60.3||.14|
|Operative time, mean±SD, min||109.2±40.4||107.1±51.5||.80|
|Estimated blood loss, mean±SD, mL||99.2±109.9||65.9±69.9||.02|
|Posterior malleolus fixation, No.||24 (51.1%)||48 (34.8%)||<.01|
|Syndesmotic fixation, No.||10 (21.3%)||64 (46.3%)||<.01|
|Time to weight bearing, mean±SD, wk||2.9±0.2||9.6±4.2||<.01|
|Superficial infection, No.||5 (10.6%)||6 (4.3%)||.12|
|Deep infection, No.||4 (8.5%)||2 (1.4%)||.08|
|Return to operating room, No.||9 (19.1%)||17 (12.3%)||.32|
|Implant failure, No.||3 (6.4%)||5 (3.6%)||.42|
|Decreased ambulatory status, No.||2 (4.3%)||15 (10.9%)||.24|