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The Blackburn Foot and Ankle Hyperbook  
Evidence based education in foot and ankle surgery
  Post-op management

General management after ankle fracture fixation is noncontroversial:

  • reduction of swelling
  • wound care

Traditional management would then be 6 weeks in a below-knee cast with varying amounts of weightbearing. Older series have used up to 12 weeks in a long leg cast.

The issues to be answered include:

  • Does early mobilisation of the ankle followed by a period of casting produce better movement after removal of the cast?
  • Does weightbearing affect the outcome, alone or in combination with mobilisation?
  • Does protected mobilisation affect the outcome, alone or in combination with weightbearing?

Evidence base

Hedstrom et al (1994) presented final data from a series previously reported by Ahl (1988, 1993). 53 patients with a variety of displaced ankle fractures treated by ORIF according to Cedell were randomised to post-op weightbearing in an orthosis allowing active exercises or in a cast. One patient in each group had redisplacement of the lateral malleolus, and 4 patients in the orthosis group had redisplacement of the posterior malleolus. At 18 month follow-up 6/53 were lost to FU. There were no difference in Olerud scores at 3, 6 or 18 months. VAS ankle score was better in the orthosis group at 3 months but not 6 or 18 months. The groups were small, the fractures heterogenous and the fixation method now obsolete.

Cimino et al (1991) reported 63 unstable ankle # stabilised with AO technique + alternately assigned to cast or AFO (like tibial brace). 8 additional AFO cases analysed with AFO trial group. All FWB.

51 FU at 12-14 months: 32 AFO, 19 cast – extensive protocol breaches. 72% of AFO patients and 37% of cast patients regained >15deg dorsiflexion, although total RoM was not different. There were 2 wound problems in each group and a syndesmotic failure in the AFO group. 7 syndesmosis screws were used – no probs with WB + movement

Tropp and Norlin (1995) reported 30 patients with Weber B/C #s fixed according to Cedell or AO randomised to FWB in brace or cast (6 weeks). Olerud scores showed no difference at 10 weeks and 12 months. Dorsiflexion was better in the brace group at each review but no correlated functional impairment. Slow improvement in muscle strength. One third of patients still significantly impaired at 1 year but most recovered by 3 years. The brace was more popular with patients

van Laarhoven et al (1996) reported 81 patients with all AO fracture types and AO fixation randomised to BKW cast or NWB active mobilisation. Review at 6 weeks – small but significant advantage in Olerud score and VAS to BKW group. Review at 12 months. No difference in Olerud scores between groups or AO B vs C. No difference in time off work, complications or OA at 1 year

Dogra and Rangan (1999) reported 52 patients with bimalleolar # and AO fixation randomised to 2 weeks active NWB ankle movements followed by BKW casting (PWB) for 6 weeks, or 2 weeks NWB without exercises followed by casting as before. There were only 26 patients in each group. Review at 12 weeks by blinded observer. No difference in range of dorsiflexion, plantarflexion, Olerud scores or VAS pain scores. Subjectively better gait in early-mobilised. This study does not support the practice of a period of ankle movement followed by casting, although the groups are small.

Egol et al (2000) reported 60 patients with AO fixation randomised to 6 weeks BK NWB cast or 6 weeks NWB bracing and active exercise. Review 6/52, 12/52, 6/12, 1 year with independent 1 year review. 55 finally reviewed. Braced patients had slightly better Mazur scores at 6 weeks. Braced patients had better SF36 scores, though only vitality + general health perception were significant. Time off work was 106 days in the casted group and 54 days in the braced group. this study repeats earlier ground in treatment assignment, but it used more up to date and standardised outcome measures – hopefully this will become a trend.

Summary

Overall, both protected early mobilisation and weightbearing may improve early functional recovery, although there is probably no long-term benefit. However, functional treatment is preferred by most patients and this point is made by Tropp and Norlin. Therefore, it is most important to show that functional treatment causes no detriment to patients, and these studies show no evidence of detriment. It would be useful if further studies could clearly address issues of patient acceptability and convenience.

Currently there seems no reason to restrict weightbearing or mobilisation unless there are specific reasons to do so. Such reasons might include poor bone quality with limited stability of fixation, or patient compliance issues. Our default practice is to mobilise patients post-operatively in ankle braces with weightbearing as tolerated, once the wound has healed.

References

  • Hedstrom M, Ahl T, Dalen N. Early postoperative ankle exercise. A study of postoperative lateral malleolar fractures. Clin Orthop 1994(300):193-6
  • Cimino W et al. Early mobilisation of ankle fractures after open reduction and internal fixation. CORR 1991; 267: 152-6
  • Tropp H, Norlin R. Ankle performance after ankle fracture: a randomized study of early mobilization. Foot Ankle Int 1995;16(2):79-83
  • van Laarhoven CJ, Meeuwis JD, van der Werken C. Postoperative treatment of internally fixed ankle fractures: a prospective randomised study.JBJS 1996;78(3):395-9
  • Dogra AS, Rangan A. Early mobilisation versus immobilisation of surgically treated ankle fractures. Prospective randomised control trial. Injury 1999;30(6):417-9
  • Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. A prospective, randomised comparison of management in a cast or a functional brace. JBJS 2000;82(2):246-9.