In 2005, JBJS published an article by Tongue et al. highlighting the importance of patient-centered care by orthopaedic surgeons1; Tongue et al. noted that understanding the patient’s needs is central to quality care. In the current study, Choido et al. carried out a moderately sized study of their own patients following an undefined range of ankle and foot surgical procedures. Inherent biases can, in part, be gleaned from the title, which indicates a presumption that complete non-weight-bearing is the ideal to be gained.
As Bhandari et al. noted over a decade ago, social factors are important determinants of successful outcomes following ankle fracture2. Arnold et al.3 reported that even functional ankle instability has a measureable impact on health-related quality of life. In a Cochrane Review of hip fractures, Crotty et al.4 recommended that core outcomes should include patient-reported factors such as quality of life and adherence. The same principles no doubt hold for ankle and foot surgical outcomes.
In the current article, Chiodo et al. did not assess relevant social factors such as living status and underplay their own outcome that lack of adherence to non-weight-bearing had no significant impact on complication rates in their study cohort. This patient-centered outcome is barely mentioned, whereas the observation that there is seasonal impact on adherence rates is presented as a novel and important finding. Use of a pressure-sensitive film under the cast provided a dichotomous measure of weight-bearing. The amount of color change at reevaluation provided a semiquantitative measure of adherence to the non-weight-bearing requirement of the treating surgeon. However, there was no way to determine if weight-bearing occurred once or several times. It would have been of interest to see if there were a dose response with respect to healing outcomes.
Chiodo et al. appear to be unaware of reports that prolonged postoperative non-weight-bearing may be suboptimal because of the risks associated with prolonged immobility, including, but not limited to, muscle atrophy and deep venous thrombosis. In a cross-sectional expert opinion survey of 705 members of the American Orthopaedic Foot & Ankle Society and Orthopaedic Trauma Association, Swart et al.5 asked orthopaedic surgeons how long they would instruct patients to be non-weight-bearing after open reduction and internal fixation of ankle fractures. Three different injury characteristics were described: supination external rotation type-4 equivalents, bimalleolar patterns, and trimalleolar patterns. These patterns were combined with three different medical statuses: young and healthy, older and healthy, and older with significant medical comorbidity. Swart et al. found significant variations among orthopaedic surgeons when prescribing non-weight-bearing after ankle fracture fixation. Both injury pattern and medical comorbidity were considered to play a role in deciding how long to keep the patient non-weight-bearing.
A 2012 Cochrane Review by Lin et al.6 found limited evidence supporting early commencement of weight-bearing following ankle fracture treatment. A meta-analysis by Keene et al.7 showed that the impact of early movement after an ankle surgical procedure was unclear. However, Keene et al. did find that there was a small reduction in the risk of postoperative thromboembolism with early full weight-bearing.
In other studies, partial weight-bearing or even full weight-bearing has been found to improve recovery time and to increase patient satisfaction. In 2015, Berwin et al. reported on a load-bearing frame that enabled early ankle movement and produced favorable outcomes8. Kayalı et al. found no unfavorable effect of early weight-bearing after a surgical procedure to treat calcaneal fracture in a small study of middle-aged patients9. A recent meta-analysis by Smeeing et al.10 found that active exercise accelerates return to work and daily activities compared with immobilization. Smeeing et al. concluded that active exercises in combination with immediate weight-bearing may be a safe option.
The WOW! study is a prospective, multicenter study currently in progress that seeks to unravel the conundrum of the effectiveness and safety of unprotected weight-bearing by comparing two commonly used postoperative treatment regimens after internal fixation of specified, intrinsically stable but displaced ankle fractures11. The group expects to have enrolled 225 participants by the third quarter of 2016, with preliminary outcomes to be presented in 2017. It is to be appreciated that there appear to be differences in opinion and that the postoperative pathway may need to be adapted to the patient’s medical and social characteristics.
↵* The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article.
- Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated