Study: Weight Bearing OK After ORIF for Ankle Fracture

A study to be presented today found that for patients who underwent open reduction and internal fixation (ORIF) for an ankle fracture, weight bearing as tolerated (WBAT) was safe, regardless of the fracture pattern.

The study, to be presented by Fernando A. Peña, MD, of the University of Minnesota, compared functional results and level of complications seen with immediate WBAT after ORIF in 159 patients versus 222 patients treated with ORIF and a traditional postoperative protocol of non–weight bearing (NWB) for 6 weeks after surgery. Those in the WBAT group had an average time to weight bearing (WB) of 2.6 weeks, and at 6 weeks they showed a higher level of function compared to the NWB group (P = 0.04); no significant differences in bother or functional indices were seen at all other time points.

In the paper reporting the study, the authors commented: “An extended period of NWB can have a significant impact on patient satisfaction as well as significant social implications including potentially lost productivity and income for the patient. NWB can also cause transportation challenges for patients, which can cause work limitations, and may increase other indirect costs of these injuries. Despite the importance of this decision, the ideal time of NWB for various injuries has not been established in the literature, although several studies have compared varying periods of NWB.”

Dr. Peña said that the findings confirm the hypothesis that he and his colleagues formulated: that patients could safely bear weight shortly after surgery, with no more adverse consequences than those who kept weight off the foot for the traditional period. He said that this hypothesis emerged from clinical experience and patient behavior; his team undertook the study “to find out if patients were right—some of them were walking after surgery against medical advice—or ‘we’ were right.”

The results demonstrate, Dr. Peña said, “that it is perfectly safe to walk after surgery for an ankle fracture. Patients with normal sensation on their ankles/feet are safe to walk after an ankle fracture.”

Limitations of the study include nonstandardized surgical techniques, the authors noted. However, they wrote, “all patients underwent surgery at the same facility and fracture fixation techniques are similar between all surgeons in the study. Additionally, while the study was prospective in nature, there was no randomization performed; however, because patients who were NWB were part of a consecutive series, and patients who were treated with WBAT were part of a consecutive series, this is similar to the limitations of all other WB studies after ankle fracture in the literature, and is something that should be considered in future studies.”

Below is the abstract for the study, which will be presented at 8:30 a.m. in room W304A.

Introduction: Numerous postoperative protocols are utilized after ORIF of ankle fractures. Increasing emphasis on early return to activity and the value of early rehabilitation have led to protocols allowing earlier weight bearing after ankle fracture. The purpose of this project was to determine if immediate WBAT after ORIF of an ankle fracture provided the same functional results and level of complications as a more traditional postoperative protocol of NWB for 6 weeks after surgery.

Material and Methods: Patients who underwent ORIF of a unilateral ankle fracture with no concomitant injuries were eligible for the study. Ankle fractures included single lateral, medial, and posterior malleoli fractures or any combination of the three. Patients with a decreased sensory exam were excluded from the study in both groups. For both groups comorbidities such as smoking, diabetes, use of insulin, anticoagulation treatment, use of nonsteroidal anti-inflammatory medication, were assessed. Short Musculoskeletal Functional Assessment (SMFA) scores were collected 6 weeks and 6 months postoperatively. Time to WB from the time of surgery for the WBAT group was also collected.

Results: There were 381 consecutive patients who were included in the final analysis.  Of these, 222 consecutive patients with ankle fractures were treated with ORIF and NWB for 6 weeks and were compared to another group of 159 consecutive patients with ankle fractures who were treated with ORIF and immediate WBAT. Both groups had similar demographics with an average age of 37 years for both groups, body mass index of 27.8 for the WBAT group and 28.7 for the NWB group, and 39 percent incidence of comorbidities for the WBAT group versus 39 percent for the NWB group. The WBAT group had 1 superficial infection and one deep infection requiring an irrigation and debridement (I & D), (0.01%). The NWB patients had 5 superficial infections and 4 deep infections, requiring I & D (0.04%). No fracture in either group required a reoperation to address the fixation or reduction of the fracture. Average time to WB in the WBAT group was 2.6 weeks. Analysis showed a statistically significant difference in functional index from the SMFA at 6 weeks (P = 0.04) but failed to show statistically significant difference in bother or functional indices at all other time points.

Conclusions: In patients with a normal sensory exam, it is safe to allow WBAT after undergoing ORIF of an ankle fracture regardless of the fracture pattern. A higher level of function is acquired at an earlier time of the recovery when compared to a protocol of NWB for 6 weeks.

Coauthors of “Weight Bearing After Open reduction and Internal Fixation of Ankle Fractures” are Jordan Hauschild, MD; Robby Sikka, MD; and Megan Reams, MA/OTR/L.

Details of the authors’ disclosure as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at www.aaos.org/disclosure

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