Early Unprotected Weight Bearing and Pre-Scheduled Supervised Rehabilitation Program after Surgical Treatment of Ankle Fractures

Document Type : RESEARCH PAPER

Authors

1 Pamukkale University, Orthopedics and Traumatology Department, Denizli, Turkey

2 Pamukkale University, School of Physical Therapy and Rehabilitation, Denizli, Turkey

Abstract

Background: Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weightbearing
and rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditional
methods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearing
along with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotected
immediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the midterm
clinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with the
unaffected side.
Methods: Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included
(mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluate
and classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, Pain
Disability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-
36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative period
and a standardized supervised prescheduled rehabilitation program was undertaken following surgery.
Results: The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supinationexternal
rotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronationexternal
rotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid union
was achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was
80.93±17.24. Although patients’ health-related quality of life was at a good level, the injured-side ankle ROM was lower
than the healthy side (P≤ 0.05).
Conclusion: Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearing
as tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of ankle
fractures. However, this protocol is not studied in patients with associated comorbidities.
Level of evidence: III

Keywords

References

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Galos DK, Taylor B. Safety of Early Weight Bearing 
Following Fixation of Bimalleolar Ankle Fractures. 
Cureus. 2020; 12(4):e7557. 
16.Smeeing DPJ, Houwert RM, Briet JP, Groenwold RHH, 
Lansink KWW, Leenen LPH, et al. Weight-bearing or 
non-weight-bearing after surgical treatment of ankle 
fractures: a multicenter randomized controlled trial. 
Eur J Trauma Emerg Surg. 2020; 46(1):121-30. 
17.Smeeing DPJ, Briet JP, van Kessel CS, Segers MJM, 
Verleisdonk EJMM, Leenen LPH, et al. Factors 
associated with wound- and implant related 
complications following surgical treatment of ankle 
fractures. J Foot Ankle Surg. 2017; 57(5):942-47. 
18.Lauge-Hansen N. Fractures of the ankle. II. 
Combined experimental-surgical and experimentalroentgenologic investigations. Arch Surg. 1950; 
60(5):957-85. 
19.Chibnall JT, Tait RC. The pain disability index: Factor 
structure and normative data. Arch Phys Med Rehabil. 
1994; 75(10):1082-86. 
20.Analay Akbaba Y, Celik D, Ogut RT. Translation, crosscultural adaptation, reliability, and validity of Turkish 
version of the American Orthopaedic Foot and Ankle 
Society Ankle-Hindfoot Scale. J Foot Ankle Surg. 2016; 
55(6):1139-42. 
21.Ware JE Jr, Sherbourne CD. The MOS 36-item shortform health survey (SF-36). I. Conceptual framework 
and item selection. Med Care. 1992; 30(6):473-83. 
22.Sernandez H, Riehl J, Fogel J. Do Early Weight-Bearing 
and Range of Motion Affect Outcomes in Operatively 
Treated Ankle Fractures: A Systematic Review and 
Meta-Analysis. Journal of Orthopaedic Trauma. 2021; 
35(8):408-13.
23.Simanski CJP, Maegele MGR, Lefering R, Lehnen DM, 
Kawel N, Riess P, et al. Functional treatment and early 
weight bearing after an ankle fracture: a prospective 
study. J Orthop Trauma. 2006; 20(2):108-14. 
24.Bäcker HC, Konigsberg M, Freibott CE, Rosenwasser 
MP, Greisberg JK, Vosseller JT. Radiographic results of 
unitcortical medial malleolar fracture fixation. Foot 
Ankle Int. 2019; 40(4):398-401. 
25.Lorente A, Palacios P, Lorente R, Mariscal G, Barrios 
C, Gandí�a A. Orthopedic treatment and early weightbearing for bimalleolar ankle fractures in elderly 
patients: Quality of life and complications. Injury. 
2020; 51(2):548-53. 
26.Chang G, Henry T, Sobol K, Krieg J. Short term 
complications in geriatric ankle fractures using 
a protocolized approach to surgical treatment: is 
early weight bearing safe? Iowa Orthop J. 2020; 
40(1):159-65. 
27.Del Buono A, Smith R, Coco M, Coco M, Woolley L, 
Denaro VGait results with and feasibility of a dynamic, 
continuous pedobarography insole. Int Orthop. 
2017; 41(8):1507-12. 
15.Passias BJ, Korpi FP, Chu AK, Myers DM, Grenier G, 
Galos DK, Taylor B. Safety of Early Weight Bearing 
Following Fixation of Bimalleolar Ankle Fractures. 
Cureus. 2020; 12(4):e7557. 
16.Smeeing DPJ, Houwert RM, Briet JP, Groenwold RHH, 
Lansink KWW, Leenen LPH, et al. Weight-bearing or 
non-weight-bearing after surgical treatment of ankle 
fractures: a multicenter randomized controlled trial. 
Eur J Trauma Emerg Surg. 2020; 46(1):121-30. 
17.Smeeing DPJ, Briet JP, van Kessel CS, Segers MJM, 
Verleisdonk EJMM, Leenen LPH, et al. Factors 
associated with wound- and implant related 
complications following surgical treatment of ankle 
fractures. J Foot Ankle Surg. 2017; 57(5):942-47. 
18.Lauge-Hansen N. Fractures of the ankle. II. 
Combined experimental-surgical and experimentalroentgenologic investigations. Arch Surg. 1950; 
60(5):957-85. 
19.Chibnall JT, Tait RC. The pain disability index: Factor 
structure and normative data. Arch Phys Med Rehabil. 
1994; 75(10):1082-86. 
20.Analay Akbaba Y, Celik D, Ogut RT. Translation, crosscultural adaptation, reliability, and validity of Turkish 
version of the American Orthopaedic Foot and Ankle 
Society Ankle-Hindfoot Scale. J Foot Ankle Surg. 2016; 
55(6):1139-42. 
21.Ware JE Jr, Sherbourne CD. The MOS 36-item shortform health survey (SF-36). I. Conceptual framework 
and item selection. Med Care. 1992; 30(6):473-83. 
22.Sernandez H, Riehl J, Fogel J. Do Early Weight-Bearing 
and Range of Motion Affect Outcomes in Operatively 
Treated Ankle Fractures: A Systematic Review and 
Meta-Analysis. Journal of Orthopaedic Trauma. 2021; 
35(8):408-13.
23.Simanski CJP, Maegele MGR, Lefering R, Lehnen DM, 
Kawel N, Riess P, et al. Functional treatment and early 
weight bearing after an ankle fracture: a prospective 
study. J Orthop Trauma. 2006; 20(2):108-14. 
24.Bäcker HC, Konigsberg M, Freibott CE, Rosenwasser 
MP, Greisberg JK, Vosseller JT. Radiographic results of 
unitcortical medial malleolar fracture fixation. Foot 
Ankle Int. 2019; 40(4):398-401. 
25.Lorente A, Palacios P, Lorente R, Mariscal G, Barrios 
C, Gandí�a A. Orthopedic treatment and early weightbearing for bimalleolar ankle fractures in elderly 
patients: Quality of life and complications. Injury. 
2020; 51(2):548-53. 
26.Chang G, Henry T, Sobol K, Krieg J. Short term 
complications in geriatric ankle fractures using 
a protocolized approach to surgical treatment: is 
early weight bearing safe? Iowa Orthop J. 2020; 
40(1):159-65. 
27.Del Buono A, Smith R, Coco M, Coco M, Woolley L, 
Denaro V, Maffulli N. Return to sports after ankle 
fractures: a systematic review. Br Med Bull. 2013; 
106:179-91.
The Archives of Bone and Joint Surgery
Volume 10, Issue 2
February 2022
Pages 183-189

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History

  • Receive Date: 20 February 2021
  • Revise Date: 06 May 2021
  • Accept Date: 21 August 2021

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