Ankle fractures are common injuries that often require open reduction and internal fixation surgery. Post-operative rehabilitation protocols traditionally recommend late weight-bearing to avoid complications. Recently, early weight-bearing has been explored as an alternative approach to potentially accelerate recovery. This systematic review aimed to examine the effects of early weight-bearing compared to late weight-bearing on function, time to return to daily life, and safety outcomes following ankle fracture surgery.
Seven electronic databases were searched for randomized controlled trials published in English and Chinese. Eligible studies included people recovering from ankle fracture surgery of any age, with no significant co-morbidities (e.g., severe cardiovascular disease, unstable chronic conditions, or acute neurological impairments). The intervention was defined as early weight-bearing protocols, encompassing both partial and complete weight bearing, initiated within six weeks post-surgery. The comparator was late weight-bearing, starting six weeks or more post-surgery. Primary outcomes were 1) ankle function, 2) time to return to daily life and 3) complication rates. (e.g., re-fracture, wound infection). A primary timepoint post-surgery was not specified. Risk of bias was assessed using the Cochrane Risk of Bias 1.0 tool. Meta-analyses were applied using fixed effects model (if I2 < 50%) or random-effects model (if I2 > 50%). There was no assessment of the certainty of evidence.
There review included 11 trials (862 participants). Eight (73%) trials initiated early weight-bearing within six weeks post-surgery. Some trials presented an unclear or high risk of bias due to lack of concealed allocation (5 trials), blinding of participants or personnel (7 trials), and blinding of outcome assessors (4 trials).
Compared to late weight-bearing, early weight-bearing improved ankle function scores at 6 weeks (SMD 0.69, 95% CI 0.49 to 0.88, I2 = 0%), 12 weeks (SMD 0.57, 95% CI 0.22 to 0.92, I2 = 75%), 24-26 weeks post-surgery (SMD 0.52, 95% CI 0.20 to 0.85, I2 = 51%), although ankle function was not improved 1-year post-surgery (SMD 0.21, 95% CI -0.01 to 0.42). Time to return to daily life was significantly shorter in patients who received early weight-bearing (MD -2.74 weeks, 95% CI -3.46 to -2.02, I2 = 0%). Early weight-bearing did not significantly increase complications compared to late weight-bearing (RR 1.30, 95% CI: 0.85 to 1.98).
Early weight-bearing after ankle fracture surgery improves ankle function more than late weight bearing in the short term but not at 1-year post-surgery. People who receive early weight-bearing have less time away from daily life without an increase in complication rates. These findings suggest that early weight-bearing could be used instead of late weight bearing post-operative ankle fracture.
