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

Abstract

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.

The effect of early weight‐bearing and later weight‐bearing rehabilitation interventions on outcomes after ankle fracture surgery: A systematic review and meta‐analysis of randomised controlled trials

“…All studies supported that EWB helped improve ankle function at the sixth post‐operative week, and the heterogeneity among the studies was low. This is consistent with the results of previously published meta‐analyses [ 20 , 21 , 34 ]. Results of these indicated that EWB was effective in improving ankle function in the early stages of rehabilitation compared to LWB.…”

“…However, the results of a meta‐analysis by Khojaly et al. [ 21 ] indicated that there was no significant difference in the ankle function scores of patients with EWB at the third month post‐operatively compared to those with LWB. The reasons for the discrepancy may be related to the inconsistent delineation of post‐operative time phases and differences in the included studies.…”

“…This article analysed three outcome indicators (i.e., post‐operative ankle functional recovery, the time to return to work/daily life and the complication rate) from the included studies. All the studies included in this study reported patients' ankle function recovery at the following time points, so a meta‐analysis was performed at these time points: (i) six weeks post‐operatively; (ii) 12 weeks post‐operatively; (iii) 24–26 weeks post‐operatively; and (iv) one year post‐operatively [ 20 , 21 ]. Data reported at the same time points were analysed separately by meta‐analysis.…”

“…On the other hand, in a meta‐analysis by Khojaly et al. [ 21 ], a significant difference in the functional recovery of the foot and the ankle between patients receiving EWB and LWB interventions was only present within 6 weeks, and there was no significant difference in the time to return to work/daily life between the EWB and LWB groups. Therefore, the issue of EWB's midterm and long‐term effects in post‐operative rehabilitation of ankle fractures (comparison of ankle function scores at 12 weeks post‐operatively and beyond) still needs further insights.…”

What’s New in Orthopaedic Trauma

“…Additionally, the definition of early weight-bearing varied, with some studies allowing immediate weight-bearing in an immobilization device and others delaying weight-bearing until 2 weeks. Thus, at best, these results suggested that early weight-bearing is safe, although it does not have strong clinical superiority 21 .…”