Orthopedics

Feature Article 

Effect of Early Weight Bearing on Outcomes After Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures

Devon M. Myers, DO; Sergio H. Pulido, DO; Shane Forsting, DO; Benjamin Umbel, DO; Benjamin C. Taylor, MD

Abstract

Current practice allows early weight bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early weight bearing (EWB) vs late weight bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The goal of this study was to evaluate union rates, clinical outcomes, and complications for patients who were managed with EWB vs LWB. The authors performed a retrospective review of 185 patients who underwent surgical stabilization for trimalleolar ankle fracture. Fixation of the posterior malleolus and weight bearing status were determined by surgeon preference. For this study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate, and return to surgery. The EWB group included 47 (25.4%) patients, and the LWB group included 138 (74.6%) patients. Of the 7 non-unions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. A total of 72 (38.9%) posterior malleolar fractures were operatively stabilized, and stabilization did not affect union rates. Syndesmotic fixation was required for 12.5% of patients, despite posterior malleolar stabilization. Syndesmotic fixation increased the union rate 2.5 times. Deep infection and open fracture decreased union. No difference was seen between groups in implant failure, union rate, infection, or return to the operating room. No deleterious effect of EWB in operatively treated trimalleolar ankle fractures was found for union, implant failure, infection, or reoperation. Syndesmotic fixation may offer an advantage over posterior malleolar fixation, with improved union rates. [Orthopedics. 2021;44(x):xx–xx.]

Abstract

Current practice allows early weight bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early weight bearing (EWB) vs late weight bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The goal of this study was to evaluate union rates, clinical outcomes, and complications for patients who were managed with EWB vs LWB. The authors performed a retrospective review of 185 patients who underwent surgical stabilization for trimalleolar ankle fracture. Fixation of the posterior malleolus and weight bearing status were determined by surgeon preference. For this study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate, and return to surgery. The EWB group included 47 (25.4%) patients, and the LWB group included 138 (74.6%) patients. Of the 7 non-unions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. A total of 72 (38.9%) posterior malleolar fractures were operatively stabilized, and stabilization did not affect union rates. Syndesmotic fixation was required for 12.5% of patients, despite posterior malleolar stabilization. Syndesmotic fixation increased the union rate 2.5 times. Deep infection and open fracture decreased union. No difference was seen between groups in implant failure, union rate, infection, or return to the operating room. No deleterious effect of EWB in operatively treated trimalleolar ankle fractures was found for union, implant failure, infection, or reoperation. Syndesmotic fixation may offer an advantage over posterior malleolar fixation, with improved union rates. [Orthopedics. 2021;44(x):xx–xx.]

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

Table 1:

Demographic Features and Injury Information

Technique

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.

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.

Follow-up

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.

Outcome Measures

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

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.

Results

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

Table 2:

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).

Discussion

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.

Conclusion

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.

References

  1. Petrisor BA, Poolman R, Koval K, Tornetta P III, Bhandari MEvidence-Based Orthopaedic Trauma Working Group. Management of displaced ankle fractures. J Orthop Trauma. 2006;20(7):515–518. doi:10.1097/00005131-200608000-00012 [CrossRef] PMID:16891946
  2. Evers J, Barz L, Wähnert D, Grüneweller N, Raschke MJ, Ochman S. Size matters: the influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures. Injury. 2015;46(4)(suppl 4):S109–S113. doi:10.1016/S0020-1383(15)30028-0 [CrossRef] PMID:26542855
  3. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures: an increasing problem?Acta Orthop Scand. 1998;69(1):43–47. doi:10.3109/17453679809002355 [CrossRef] PMID:9524517
  4. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. 2007;21(5):307–315. doi:10.1097/BOT.0b013e318059aea3 [CrossRef] PMID:17485995
  5. Hong CC, Roy SP, Nashi N, Tan KJ. Functional outcome and limitation of sporting activities after bimalleolar and trimalleolar ankle fractures. Foot Ankle Int. 2013;34(6):805–810. doi:10.1177/1071100712472490 [CrossRef] PMID:23426611
  6. Hong CC, Nashi N, Prosad Roy S, Tan KJ. Impact of trimalleolar ankle fractures: how do patients fare post-operatively?Foot Ankle Surg. 2014;20(1):48–51. doi:10.1016/j.fas.2013.10.001 [CrossRef] PMID:24480500
  7. Tejwani NC, Pahk B, Egol KA. Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma. 2010;69(3):666–669. doi:10.1097/TA.0b013e3181e4f81e [CrossRef] PMID:20838137
  8. Bartonicek J, Rammelt S, Tucek M, Nanka O. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg. 2015;41(6):587–600. doi:10.1007/s00068-015-0560-6 [CrossRef] PMID:26253884
  9. Dehghan N, McKee MD, Jenkinson RJ, et al. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016;30(7):345–352. doi:10.1097/BOT.0000000000000572 [CrossRef] PMID:27045369
  10. Tan EW, Sirisreetreerux N, Paez AG, Parks BG, Schon LC, Hasenboehler EA. Early weightbearing after operatively treated ankle fractures: a biomechanical analysis. Foot Ankle Int. 2016;37(6):652–658. doi:10.1177/1071100715627351 [CrossRef] PMID:26802427
  11. Swart E, Bezhani H, Greisberg J, Vosseller JT. How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members. Injury. 2015;46(6):1127–1130. doi:10.1016/j.injury.2015.03.029 [CrossRef] PMID:25816708
  12. Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008;90(7):1570–1578. doi:10.2106/JBJS.G.01673 [CrossRef] PMID:18594108
  13. Yoshiko A, Yamauchi K, Kato T, et al. Effects of post-fracture non-weight-bearing immobilization on muscle atrophy, intramuscular and intermuscular adipose tissues in the thigh and calf. Skeletal Radiol. 2018;47(11): 1541–1549. doi:10.1007/s00256-018-2985-6 [CrossRef] PMID:29948037
  14. Stevens JE, Walter GA, Okereke E, et al. Muscle adaptations with immobilization and rehabilitation after ankle fracture. Med Sci Sports Exerc. 2004;36(10):1695–1701. doi:10.1249/01.mss.0000142407.25188.05 [CrossRef] PMID:15595289
  15. Vandenborne K, Elliott MA, Walter GA, et al. Longitudinal study of skeletal muscle adaptations during immobilization and rehabilitation. Muscle Nerve. 1998;21(8):1006–1012. doi:10.1002/(SICI)1097-4598(199808)21:8<1006::AID-MUS4>3.0.CO;2-C [CrossRef] PMID:9655118
  16. Clark BC. In vivo alterations in skeletal muscle form and function after disuse atrophy. Med Sci Sports Exerc. 2009;41(10):1869–1875. doi:10.1249/MSS.0b013e3181a645a6 [CrossRef] PMID:19727027
  17. Shaffer MA, Okereke E, Esterhai JL Jr, et al. Effects of immobilization on plantarflexion torque, fatigue resistance, and functional ability following an ankle fracture. Phys Ther. 2000;80(8):769–780. doi:10.1093/ptj/80.8.769 [CrossRef] PMID:10911415
  18. Chesworth BM, Vandervoort AA. Comparison of passive stiffness variables and range of motion in uninvolved and involved ankle joints of patients following ankle fractures. Phys Ther. 1995;75(4):253–261. doi:10.1093/ptj/75.4.253 [CrossRef] PMID:7899483
  19. Lundbye-Jensen J, Nielsen JB. Immobilization induces changes in presynaptic control of group Ia afferents in healthy humans. J Physiol. 2008;586(17):4121–4135. doi:10.1113/jphysiol.2008.156547 [CrossRef] PMID:18599534
  20. Thomas G, Whalley H, Modi C. Early mobilization of operatively fixed ankle fractures: a systematic review. Foot Ankle Int. 2009;30(7):666–674. doi:10.3113/FAI.2009.0666 [CrossRef] PMID:19589314
  21. Lehtonen H, Järvinen TL, Honkonen S, Nyman M, Vihtonen K, Järvinen M. Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture: a prospective, randomized study. J Bone Joint Surg Am. 2003;85(2):205–211. doi:10.2106/00004623-200302000-00004 [CrossRef] PMID:12571295
  22. Gul A, Batra S, Mehmood S, Gillham N. Immediate unprotected weight-bearing of operatively treated ankle fractures. Acta Orthop Belg. 2007;73(3):360–365. PMID:17715727
  23. Nash CE, Mickan SM, Del Mar CB, Glasziou PP. Resting injured limbs delays recovery: a systematic review. J Fam Pract. 2004;53(9):706–712. PMID:15353159
  24. Ahl T, Dalén N, Holmberg S, Selvik G. Early weight bearing of displaced ankle fractures. Acta Orthop Scand. 1987;58(5):535–538. doi:10.3109/17453678709146394 [CrossRef] PMID:3425284
  25. Smeeing DP, Houwert RM, Briet JP, et al. Weight-bearing and mobilization in the postoperative care of ankle fractures: a systematic review and meta-analysis of randomized controlled trials and cohort studies. PLoS One. 2015;10(2):e0118320. doi:10.1371/journal.pone.0118320 [CrossRef] PMID:25695796
  26. AgirTunçer N, Küçükdurmaz F, Gümüstas S, Akgül ED, Akpinar F. Functional comparison of immediate and late weight bearing after ankle bimalleolar fracture surgery. Open Orthop J. 2015;9(1):188–190. doi:10.2174/1874325001509010188 [CrossRef] PMID:26069513
  27. Black JD, Bhavikatti M, Al-Hadithy N, Hakmi A, Kitson J. Early weight-bearing in operatively fixed ankle fractures: a systematic review. Foot. 2013;23(2–3):78–85. doi:10.1016/j.foot.2013.05.002 [CrossRef] PMID:23725766
  28. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle: a prospective, randomised comparison of management in a cast or a functional brace. J Bone Joint Surg Br. 2000;82(2):246–249. doi:10.1302/0301-620X.82B2.10039 [CrossRef] PMID:10755435
  29. Gorczyca JT. Early, rather than late, weight-bearing and range-of-motion exercise improved early function but not time to return to work after surgical fixation of unstable ankle fractures. J Bone Joint Surg Am. 2017;99(4):350. doi:10.2106/JBJS.16.01382 [CrossRef] PMID:28196037
  30. Firoozabadi R, Harnden E, Krieg JC. Immediate weight-bearing after ankle fracture fixation. Adv Orthop. 2015;2015:491976. doi:10.1155/2015/491976 [CrossRef] PMID:25785201
  31. Haller JM, Potter MQ, Kubiak EN. Weight bearing after a periarticular fracture: what is the evidence?Orthop Clin North Am.2013;44(4):509–519. doi:10.1016/j.ocl.2013.06.005 [CrossRef] PMID:24095067
  32. Kubiak EN, Beebe MJ, North K, Hitchcock R, Potter MQ. Early weight bearing after lower extremity fractures in adults. J Am Acad Orthop Surg. 2013;21(12):727–738. doi:10.5435/00124635-201312000-00003 [CrossRef] PMID:24292929
  33. Harager K, Hviid K, Jensen CM, Schantz K. Successful immediate weight-bearing of internal fixated ankle fractures in a general population. J Orthop Sci. 2000;5(6):552–554. doi:10.1007/s007760070004 [CrossRef] PMID:11180917
  34. Starkweather MP, Collman DR, Schuberth JM. Early protected weightbearing after open reduction internal fixation of ankle fractures. J Foot Ankle Surg. 2012;51(5):575–578. doi:10.1053/j.jfas.2012.05.022 [CrossRef] PMID:22819002
  35. Papachristou G, Efstathopoulos N, Levidiotis C, Chronopoulos E. Early weight bearing after posterior malleolar fractures: an experimental and prospective clinical study. J Foot Ankle Surg. 2003;42(2):99–104. doi:10.1016/S1067-2516(03)70009-X [CrossRef] PMID:12701079
  36. Ahl T, Dalén N, Holmberg S, Selvik G. Early weight bearing of malleolar fractures. Acta Orthop Scand. 1986;57(6):526–529. doi:10.3109/17453678609014785 [CrossRef] PMID:3577722
  37. van Laarhoven CJHM, Meeuwis JD, van der Werken C. Postoperative treatment of internally fixed ankle fractures: a prospective randomised study. J Bone Joint Surg Br. 1996;78(3):395–399. doi:10.1302/0301-620X.78B3.0780395 [CrossRef] PMID:8636173
  38. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res.2006;447(447):165–171. doi:10.1097/01.blo.0000203489.21206.a9 [CrossRef] PMID:16467626
  39. Miller MA, McDonald TC, Graves ML, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018;39(1):99–104. doi:10.1177/1071100717735839 [CrossRef] PMID:29058951
  40. Gardner MJ, van der Meulen MC, Demetrakopoulos D, Wright TM, Myers ER, Bostrom MP. In vivo cyclic axial compression affects bone healing in the mouse tibia. J Orthop Res. 2006;24(8):1679–1686. doi:10.1002/jor.20230 [CrossRef] PMID:16788988

Demographic Features and Injury Information

VariableValue
Age, mean±SD (range), y50.1±18.0 (18–91)
Sex, male, No.60 (32.4%)
Weight, mean±SD (range), lb198.3±51.8 (105–365)
Body mass index, mean±SD (range), kg/m231.9±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

VariableEarly weight bearingLate weight bearingP
Time from injury to surgery, mean±SD, h60.5±120.040.8±60.3.14
Operative time, mean±SD, min109.2±40.4107.1±51.5.80
Estimated blood loss, mean±SD, mL99.2±109.965.9±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, wk2.9±0.29.6±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
Authors

The authors are from the Department of Orthopedic Surgery, OhioHealth Grant Medical Center, Columbus, Ohio.

Drs Myers, Pulido, Forsting, and Umbel have no relevant financial relationships to disclose. Dr Taylor is on the speaker's bureau for Zimmer Biomet and receives royalties from Innomed and Zimmer Biomet.

Correspondence should be addressed to: Devon M. Myers, DO, Department of Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E State St, Ste 500, Columbus, OH 43215 (devon. myers@ohiohealth.com).

Received: January 27, 2020
Accepted: March 26, 2020
Posted Online: January 07, 2021

10.3928/01477447-20210104-04

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