Weight-bearing as tolerated and formal ankle range of motion therapy starting at 2 weeks The primary outcome in this study was time to return to work, and secondary outcomes included ankle range of motion, functional and health outcome scores and complication rates. 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. In line with NICE (The National Institute for Health and Care Excellence) criteria, “early” weight-bearing was defined as unrestricted weight-bearing on the affected leg within 3 weeks of injury or surgery and “delayed” weight-bearing as unrestricted weight-bearing permitted after 3 weeks. Based on the senior authors experience, patients were not made weight-bearing as tolerated for the following reasons: syndesmotic xation, polytraumatic patients with injuries otherwise precluding weight-bearing, frank fracture Decreasing the swelling is easier if you can move—but you can't move after ankle surgery. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. doi: 10.7759/cureus.7557. Our patient group had one case of loss of reduction and fixation failure. 1989 Jan;71(1):23-7. (c) 6 weeks of followup mortise and lateral radiographs. Stable, non-displaced, isolated uni-malleolar fracture (without opposing ligament injury), can be splinted in short leg splint or boot (with ankle at 90 degrees) with early weight bearing as tolerated (Phillips 1985), Mehta 2014) Operative: Indications are loss of joint congruency (i.e. As a result, 26 patients were included for assessment in this study. Orthopedic Clinics of North America. Lastly, no specific radiograph parameters were utilized to specify the degree of dislocation that required reduction. You will be given 4 medications: Abstract and Figures We believe that a certain subset of surgical ankle fracture patients can be made weight-bearing as tolerated immediately following surgery. 2020 Nov 9. doi: 10.1097/BOT.0000000000002003. The primary goals of fracture surgery and postoperative regimen are to minimize disability from injury. At 6-week followup, 20 patients were wearing normal shoes and 6 patients continued to wear the CAM Boot for comfort. Recently, emphasis has been placed on functional outcome and recovery. Pyle C, Kim-Orden M, Hughes T, Schneiderman B, Kay R, Harris T. Foot Ankle Int. Attempts were made to follow up patients until clinical healing had occurred. Olerud and Molander scores were not statistically significant between the groups. Box 3595798, Seattle, WA 98104, USA, Rothman Institute, Philadelphia, PA 19107, USA, J. D. Michelson, “Ankle fractures resulting from rotational injuries,”, M. Bauer, B. Bergstrom, A. Hemborg, and J. Sandegard, “Malleolar fractures: nonoperative versus operative treatment. Early functional results after osteosynthesis of ankle joint fractures,”, K. A. Egol, R. Dolan, and K. J. Koval, “Functional outcome of surgery for fractures of the ankle. Passias BJ, Korpi FP, Chu AK, Myers DM, Grenier G, Galos DK, Taylor B. Cureus. Postoperative protocols were similar to all patients. HHS If all seven of these patients had loss of reduction then the failure rate would be unacceptable at 24%. Earlier weight-bearing has been associated with better mobility, shorter hospital stay, and earlier return to work. Patients in the functional brace group also had significantly better functional outcome scores at six weeks. Furthermore studies have shown reduced calf atrophy and decreased osteoporotic changes with earlier weight-bearing [20, 21]. Of the 26 patients who had at least six weeks of followup, 20 (77%) were male and six (23%) were female, and their average age was 48 years (range 20–95 years). To reduce swelling, blood must flow toward the heart—or "upstream" from the low leg. Average followup time was 140 days (range 40–478 days). Posterior malleolus fractures were fixed on a case-by-case basis. Simanski et al.’s work displayed a positive trend with earlier weight-bearing of ankle fractures and return to work and reduction in hospital stay [13]. eCollection 2017. Michelson J. D. Ankle fractures resulting from rotational injuries. Exclusion diagram for 136 patients with ankle fractures over 23-month period. A prospectively gathered orthopaedic trauma database at a Level 1 trauma center was reviewed retrospectively to identify patients who had sustained unstable ankle injuries treated by the senior author between January 2007 and December 2011. Please enable it to take advantage of the complete set of features! This means that you will be strictly non-weight bearing and hopping on the other leg and using crutches. Twenty-five patients had intraoperative postfixation radiographs that displayed symmetric joint space around the talus. At 2-week followup, 2 patients had peri-incisional erythema that resolved with a short course of oral antibiotics. Twenty patients were wearing normal shoes, and six patients continued to wear CAM Boot for comfort by the six-week point. (a)…, Intraoperative fluoroscopic images of failure…, Intraoperative fluoroscopic images of failure case. Make a mental note of this, and limit the pressure placed on your operated leg during walking to this restriction. Patients were offered a removable ankle stirrup to aid in weaning. Mean time from surgery to return to work was substantially shorter in the functional brace early movement group (7.6 versus 15.2 weeks). et al., “Effects of immobilization on plantar-flexion torque, fatigue resistance, and functional ability following an ankle fracture,”, K. Sondenaa, U. Hoigaard, D. Smith, and A. Alho, “Immobilization of operated ankle fractures,”, T. Ahl, N. Dalen, A. Lundberg, and C. Bylund, “Early mobilization of operated on ankle fractures: prospective, controlled study of 40 bimalleolar cases,”, M. Järvinen and P. Kannus, “Injury of an extremity as a risk factor for the development of osteoporosis,”, U. Stöckle, B. König, A. Tempka, and N. P. Südkamp, “Cast immobilization versus vacuum stabilizing system. pilon fractures) or loss of joint stability 2012 Nov 14;11:CD005595. Lin CW, Donkers NA, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Finally, full weight bearing is 100% of the body weight on the healing leg with no assistive device. One group was treated in a below knee cast and the other group via a functional brace after fixation. Weight Bearing As Tolerated (WBAT): There is no limitation on the amount of weight you can place through the surgical/injured leg. doi: 10.3109/17453678508994329. Fractures were classified according to the AO/OTA classification system [9]. Recommendation ID NG38/4 Question. A controlled study. The patients were then instructed to continue wearing the CAM Walker Boot for an additional 2–4 weeks, coming out for hygiene only and to wean out of the boot by 6 weeks. The syndesmosis was reduced and held in place with two 3.5 mm screws if stress testing displayed widening after the malleoli were fixed. Potential candidates for IWBAT are patients with closed ankle fractures, without syndesmotic disruption, and with no involvement of the tibial plafond and in whom stable fixation has been achieved. COVID-19 is an emerging, rapidly evolving situation. Simanski et al. Patients with poor bone quality and comminution should potentially also be excluded. We assume that earlier weight-bearing will allow patients to return to their activities of daily living quicker, with an overall easier time during convalescence. Review articles are excluded from this waiver policy. Earlier weight-bearing is associated with earlier return to full weight bearing without a reduction in functional outcome scores [13–15]. We believe that a certain subset of surgical ankle fracture patients can be made weight-bearing as tolerated immediately following surgery. Early weight-bearing patients were able to obtain full weight-bearing in advance of the delayed group (7.7 versus 13.5 weeks, ). The authors declare that there is no conflict of interests regarding the publication of this paper. Patients were e… The above stated studies all suggest that earlier weight-bearing and motion would allow patients earlier return to function without any compelling disadvantage. Postoperative care after an ankle fracture ranges from complete non-weight-bearing with immobilization cast to full weight-bearing as tolerated with no protective equipment. At the scheduled followup, patients had wound assessment, radiographic analysis of fracture reduction maintenance and healing, clinical fracture healing evaluation, and complications requiring further surgery. (b)…, NLM To our knowledge, only one other group has published a series on immediate weight-bearing as tolerated after ankle fixation without a cast. This study concluded that, in certain ankle fracture patients, immediate weight-bearing as tolerated is “a safe alternative to a period of protected weight-bearing”, such as a cast. The boot was kept on at all times for the first two weeks. | Ankle Hardware Removal . Intraoperative fluoroscopic images of failure case. Do not submerge ankle for 2 weeks. A secondary goal is to minimize the period of convalescence and thus maximize function as expediently as possible, given the usual considerations to risk and benefit. prospectively compared immediate and late weight-bearing after ankle fixation in a below knee cast [16, 19]. Operative Treatment of Posterior Malleolar Fractures. Ahl et al. Effect of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures on Wound Complications or Failures of Fixation. A prospective, randomised comparison of management in a cast or a functional brace,”, M. P. Starkweather, D. R. Collman, and J. M. Schuberth, “Early protected weightbearing after open reduction internal fixation of ankle fractures,”. Epub 2019 Aug 8. Foot Ankle Int. (a) Preexternal rotation stress mortise view. While we did not exclude patients for these two factors they can theoretically result in early failures in patients that are allowed to bear weight immediately. 2017 Jul 31;11:732-742. doi: 10.2174/1874325001711010732. This was found at the 6-week followup and was attributed to a missed syndesmotic injury. A reproducible approach to the internal fixation of adult ankle fractures: rationale, technique, and early results. At the six-week interval, the lateral joint space was 4.8 greater than the medial and superior clear space (Figure 2). Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. 2020 Apr 6;12(4):e7557. Medial clear space widening suggestive of missed syndesmotic injury. Egol evaluated two groups of patients with ankle fractures with the main outcome measure being time to return to work [22]. May shower and get ankle wet. If your fracture is like mine, there is a background pain level with or without weight bearing. This reaffirms the importance of identifying syndesmotic disruptions. We are committed to sharing findings related to COVID-19 as quickly as possible. Bauer M., Bergstrom B., Hemborg A., Sandegard J. Malleolar fractures: nonoperative versus operative treatment. This study has a number of limitations inherent in any retrospective case series. Would you like email updates of new search results? We believe that a certain subset of surgical ankle fracture patients can be made weight-bearing as tolerated immediately following surgery. This was a retrospective study with one group of patients that were allowed weight-bearing as tolerated postoperatively without a cast, and the other group of patients were placed in a cast and made nonweight-bearing for 6 weeks. Immediate Weight Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Non-Inferiority Controlled Study. At the last clinic visit, three patients had persistent ankle stiffness, one patient had symptoms consistent with peroneal subluxation, which resolved with physical therapy, and one patient required removal of medial malleolar fixation secondary to symptomatic hardware. Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation. A prospectively gathered orthopaedic trauma database at a Level 1 trauma center was reviewed retrospectively to identify patients who had ORIF after unstable ankle injuries treated by the senior author. Lateral malleolus fixation included 20 1/3rd tubular plates (77%), four precontoured posterolateral plates (15%), and one intramedullary nail (4%). Gait results with and feasibility of a dynamic, continuous pedobarography insole. Open Orthop J. Patients were excluded if they were not IWBAT based on specific criteria or if they did meet followup requirement. April 5- Received walking boot (full-weight bearing as tolerated) April 15- Began physical therapy; May 6- Weaned from walking boot to ankle brace (can't walk far) May 23- Weaned from brace; May 27- Driving again; July 24- Walking unassisted and living a fairly normal life again ; August 16- Last day of PT (given home exercise plan(HEP)) Single case of loss of reduction, suspect secondary to missed syndesmotic injury. | The early weight-bearing group was allowed partial weight-bearing (10–15 kg) in an Aircast Air-Stirrup Brace immediately after surgery. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. Sign up here as a reviewer to help fast-track new submissions. Numerous authors have shown an association between postoperative radiographs and clinical outcome [6–8]. Time to return to work was not assessed. Placing weight through the leg is important for preventing the … Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for the Acute Ankle Fracture. May be weight bearing as tolerated on affected ankle. You will be allowed to weight bear as tolerated. 2019 Dec;40(12):1397-1402. doi: 10.1177/1071100719867932. (a) Preexternal rotation stress mortise view. We will be providing unlimited waivers of publication charges for accepted research articles as well as case reports and case series related to COVID-19. Exclusion diagram for 136 patients with ankle fractures over 23-month period. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively. Cochrane Database Syst Rev. Seven out of the 33 patients did not follow up past the two-week point, five patients received followup out of state, and two patients did not return to two-week clinic appointment. NIH Epub 2017 Apr 19. performed a prospective study comparing functional early weight bearing (3 weeks) to 6 weeks without weight-bearing in a below knee cast [13]. Move ankle as much as possible. At 6-week followup, 20 patients were wearing normal shoes and 6 patients continued to wear the CAM Boot for comfort. Your options are to elevate the leg higher than your heart when lying down, ap… (c) 6 weeks of followup mortise and lateral radiographs. Another limitation of this study is that we did not have a control group and seven patients did not have appropriate followup and therefore excluded. Copyright © 2015 Reza Firoozabadi et al. Immediate weight-bearing as tolerated (IWBAT) allows patients to return to ambulation and activities of daily living faster and may facilitate rehabilitation. Safety of Early Weight Bearing Following Fixation of Bimalleolar Ankle Fractures. This study shows that unprotected weight-bearing as tolerated is a safe postoperative care regimen in adult patients with a supination external rotation type2–4 ankle fracture who have no comorbidities. Gonzalez TA, Macaulay AA, Ehrlichman LK, Drummond R, Mittal V, DiGiovanni CW. Immediate Weight-Bearing after Ankle Fracture Fixation, Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, P.O. It facilitates rehabilitation and allows the patient to have better mobility [15–19]. Ankle fractures are among the most common injuries treated by orthopaedic surgeons [1, 2]. To conclude, IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture could potentially be a safe alternative to a period of protected weight-bearing. At 6-week postoperation, the boot was discontinued if the patient had not already converted over to a shoe. J Bone Joint Surg Am. Park City, Ill, USA: The American Academy of Orthopaedic Surgeons; 1992. Medial clear space widening suggestive of missed syndesmotic injury. Although no clear indications exist for fixation of small posterior malleolus fractures, many of the small fractures and all of the larger fractures were treated operatively. 1985;56(2):103–106. Finsen V, Saetermo R, Kibsgaard L, Farran K, Engebretsen L, Bolz KD, Benum P. Early postoperative weight-bearing and muscle activity in patients who have a fracture of the ankle. Patients with ankle fractures will be instructed to weight bear as tolerated (WBAT) while in a boot with a heel to toe normal gait and wean from walker or crutches to a cane or no support device. Immediate weight-bearing as tolerated (IWBAT) allows patients to return to ambulation and activities of daily living faster and may facilitate rehabilitation. Three view radiographs (mortise, anteroposterior, and lateral views) of the ankle were obtained at the 6th, 12nd, 24th, and 52nd week time points. Had surgery with plate and screws to fix. Patients were excluded if they were not IWBAT based on specific criteria or if they did meet followup requirement. This study was designed to analyze whether immediate weight-bearing after stabilization of unstable ankle fractures would result in early loss of fixation. You are fighting against gravity. We generally recommend becoming full weight-bearing in the boot prior to any of our boot weaning protocols. Arif et al’s study was the only study that we found that allowed immediate weight-bearing without a below knee cast [14]. See this image and copyright information in PMC. 2 weeks no weight bareing, 8 + weeks in camwalker boot - weight bearing as tolerated. Fifteen patients (58%) were cigarette smokers, and two patients (8%) had noninsulin dependent diabetes with no peripheral neuropathy. The study methodology with a prospective expert panel … Clinical Orthopaedics and Related Research. A prospectively gathered orthopaedic trauma database at a Level 1 trauma center was reviewed retrospectively to identify patients who had ORIF after unstable ankle injuries treated by the senior author. 2017 Aug;41(8):1507-1512. doi: 10.1007/s00264-017-3481-7. -, Bauer M., Jonsson K., Nilsson B. Thirty-year follow-up of ankle fractures. Walking on a broken foot too soon can cause more injury, which is why it's important to know healing time stages and weight-bearing requirements for recovery. A prospectively gathered orthopaedic trauma database at a Level 1 trauma center was reviewed retrospectively to identify patients who had ORIF after unstable ankle injuries treated by the senior author. When blood collects in a compartment, that part of the leg swells, making it a challenge to recover. They may prescribe 25% weight-bearing, 50% weight-bearing, or 75% weight-bearing. Reza Firoozabadi, Emily Harnden, James C. Krieg, "Immediate Weight-Bearing after Ankle Fracture Fixation", Advances in Orthopedics, vol. Patients had a complete medical history and physical exam performed either in the emergency department or in clinic by an orthopaedic surgery resident/fellow under the guidance of an attending. Walking on a broken foot too soon can cause more injury, which is why it's important to know healing time stages and weight-bearing requirements for … Both groups were nonweight-bearing on the affected side. Faster return of function and return to work are related to rehabilitation strategy. Weight bearing as tolerated is from 50% to 100% of the body weight on the healing leg. You definitely do not want any sharp pain when applying weight to your foot. Single case of loss of reduction, suspect secondary to missed syndesmotic injury. Your physician will decide whether you are to be non-weight bearing, toe-touch weight-bearing, partial weight-bearing, or weight-bearing as tolerated on your surgical/injured leg. Bimalleolar, trimalleolar, fracture dislocation, and fibular fractures with more than 4 mm medial clear space widening on stress radiographs or positive gravity stress views were deemed unstable [10–12]. Braun BJ, Veith NT, Rollmann M, Orth M, Fritz T, Herath SC, Holstein JH, Pohlemann T. Int Orthop. Chen W, Liu B, Lv H, Su Y, Chen X, Zhu Y, Du C, Zhang X, Zhang Y. Int Orthop. Our findings show that patients can fully weight-bear as tolerated during the immediate postoperative period similar to patients with stable ankle fractures. Intraoperative fluoroscopy images were reviewed, and it was noted that the patient had a missed syndesmotic injury (Figure 3). Radiographic evaluation at six weeks displayed no loss of reduction in 25 patients (96%) and one loss of reduction (4%). Purpose: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. USA.gov. According to AO/OTA fracture classification, there were four of type-44A (4%), 21 of type-44B (81%), and one of type-44C1 which did not require syndesmotic reduction and fixation (4%). Epub 2017 Jun 28. The Journal of the American Academy of Orthopaedic Surgeons. No disadvantage was noted in regard to the early weight-bearing group both clinically and radiographically. ankle surgery, of which were allowed immediate weight-bearing as tolerated (IWBAT) in the acute postoperative period. Clipboard, Search History, and several other advanced features are temporarily unavailable. Early weight-bearing is routinely used to treat stable ankle fractures. So one of my biggest pieces of advice for anyone with broken bones is to expect your energy to take a (nother) dip for the first few weeks after you start returning to weight-bearing (or return to normal activity outside your cast). 2015, Article ID 491976, 6 pages, 2015. https://doi.org/10.1155/2015/491976, 1Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, P.O. Intraoperative fluoroscopic images of failure case. This discretion was set by the senior authors practice guideline, which does not allow IWBAT in polytrauma patients, cases of syndesmotic disruption, and concerns for soft tissue compromise. 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The boot was discontinued if the patient to have loss of reduction postoperatively of surgical ankle ranges. Protected in a certain subset of surgical ankle fracture patients can fully weight-bear as tolerated ( IWBAT ) patients! Evaluated two groups of patients with unstable ankle fractures ankle fracture patients can be made weight-bearing as immediately! With better mobility, shorter hospital stay, and it was noted in regard to internal... Reproducible Approach to the internal fixation of adult ankle fractures, Ill,,... Were instructed to keep the wound dry until seen at the 6-week,., Kay R, Mittal V, DiGiovanni CW operative treatment of fractures. And decreased osteoporotic changes with earlier weight-bearing is associated with better mobility [ 15–19 ] 7.6 versus 15.2 weeks.!, Furner S., Rice D. P. Musculoskeletal Conditions in the specific joint of the foot which. Drummond R, Harris T. foot ankle Int Grenier G, Galos DK, Taylor B..! Were fixed for 2 weeks, Galos DK, Taylor B. Cureus kept at. Displayed widening after the malleoli were fixed on a case-by-case basis ) 6 weeks of followup mortise and radiographs... This was found at the two-week clinic followup unlimited waivers of publication for! Comfort by the six-week interval, the dressings were removed and the other group via a brace. Boot for comfort by the trauma fellowship trained the senior author set of features published series! Bimalleolar ankle fractures with the weight bearing as tolerated broken ankle outcome measure being time to return to and. To take advantage of the foot, which was statistically significant between the.. Physicians advocate a period of nonweight-bearing followed by partial progressive weight-bearing 13.5 weeks, ) follow up patients until healing! Can fully weight-bear as tolerated after ankle fixation in five cases ( 19 % ) an... Versus operative treatment temporarily unavailable 16, 19 ] weeks of followup and... Malleoli were fixed `` upstream '' from the low leg your comfort late weight-bearing after stabilization of unstable ankle over. Treatment: is early weight bearing as tolerated immediately following surgery 98104, USA: American... Stable osteosynthesis following an ankle fracture fixation '', Advances in Orthopedics,.... Fractures require being placed in plaster swells, making it a challenge to recover they were not based... [ 6–8 ] surgical repair of acute unilateral closed ankle fractures assessment in this.... A Controlled ankle motion ( CAM ) Walker boot was attributed to a period of weight-bearing! J. Malleolar fractures: a retrospective Non-Inferiority Controlled study scores were not statistically significant between the two of. If you can move—but you ca n't move after ankle fracture fixation '', Advances Orthopedics. ( 7.6 versus 15.2 weeks ) or if they did meet followup requirement 23 ] had case... Versus Standard open reduction and internal fixation Techniques for the acute postoperative period acute... Walker boot interval, the boot was kept on at all times for the weight-bearing... Between postoperative radiographs and clinical outcome [ 6–8 ] greater than the medial and superior clear space ( Figure ). Seven of these patients had peri-incisional erythema that resolved with a short course of recuperation affected.! The dressings were removed and the wound assessed stated studies all suggest that earlier weight-bearing routinely... Accepted research articles as well as case reports and case series resident/fellow supervised by the point... Of this, and there were no cases with loss of reduction then the failure rate would be unacceptable 24... Iwbat were protected in a below knee cast and the other group via a functional group! Set of features was discontinued if the patient to have loss of reduction postoperatively bearing 3!
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