Early versus Delayed Weight-Bearing after Surgical Fixation of Ankle Fractures: A Systematic Review and Meta-Analysis.
DOI:
https://doi.org/10.51168/z0yjky81Keywords:
ankle fracture, early weight-bearing, internal fixation, rehabilitation, Olerud-Molander Ankle Score, postoperative complications, return to work, meta-analysisAbstract
Background:
Prolonged non-weight-bearing after ankle fracture fixation may protect reduction and implants but can delay mobility, increase stiffness, and prolong absence from work. Recent pragmatic trials have questioned the routine six-week restriction.
Objective:
To compare early and delayed weight-bearing after ankle fracture fixation regarding functional recovery, return to activity, mechanical failure, reoperation, and complications.
Methods:
This updated systematic review included reports through 31 December 2025. Adults commencing weight-bearing within three postoperative weeks were compared with those starting at four weeks or later. Evidence from randomised-trial meta-analyses was integrated with the 2024 WAX trial, 2025 INWN trial, and a 2025 syndesmotic-injury cohort. Risk of bias and certainty were assessed using RoB 2, ROBINS-I, and GRADE principles.
Results:
A 2025 meta-analysis of 10 randomised trials involving 1,276 participants showed improved Olerud-Molander Ankle Score with early weight-bearing at six weeks (mean difference [MD] 5.86, 95% confidence interval [CI] 3.64–8.08) and at 12 weeks to four months (MD 3.17, 95% CI 0.84–5.50), but not at 12 months (MD 1.86, 95% CI −0.50–4.22). Return to work or daily activities occurred 1.75 weeks earlier (95% CI 0.98–2.52). Overall complications were not significantly different (risk ratio 1.34, 95% CI 0.96–1.86). The INWN trial reported a 10.4-point adjusted six-week OMAS benefit with immediate protected weight-bearing and favourable cost-utility. A syndesmotic-injury cohort reported earlier recovery without fixation loss.
Conclusions:
Early protected weight-bearing after stable ankle fracture fixation provides modest short-term functional improvement and earlier return to activity, although benefits diminish over time. Evidence does not show a clear increase in complications, but safety remains uncertain in high-risk cases. Protocols should be individualised according to fixation stability, soft-tissue status, comorbidity, protective sensation, and adherence.
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