To unlock this feature and to subscribe to our weekly evidence emails, please create a FREE orthoEvidence account.


Already Have an Account?

Visit our Evidence-Based Covid-19 Website and Stay Up to Date with the latest Research.
Ace Report Cover

Safety, efficacy of early weight-bearing and mobilization after ORIF for ankle fractures

Cite This
+ Favorites
Cite This
+ Favorites
Author Verified
Ace Report Cover
April 2015

Safety, efficacy of early weight-bearing and mobilization after ORIF for ankle fractures

Vol: 4| Issue: 4| Number:52| ISSN#: 2564-2537
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:2
Journal Level of Evidence:N/A

Weight-Bearing and Mobilization in the Postoperative Care of Ankle Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Cohort Studies

PLoS One. 2015 Feb 19;10(2):e0118320.

Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here


A total of 25 studies (randomized controlled trials and cohort studies) were included in this systematic review and meta-analysis investigating mobilization and weight-bearing following open reduction and internal fixation of ankle fractures. The purpose of this study was to examine the effectiveness of different postoperative rehabilitation protocols. The results of this review found that early weight-bearing and active mobilization did not cause a significant increase in incidence of complications and accelerated patients’ return to work and daily activities.

Publication Funding Details +
None disclosed

Risk of Bias


Reporting Criteria


Fragility Index


Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.




Accessing Data


Analysing Data





Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Ankle fractures account for a number of visits to orthopaedic and fracture clinics, commonly occurring in sporting activities. A number of these injuries are treated surgically, particularly open reduction and internal fixation (ORIF), though there has been debate about optimal postoperative rehabilitation in these cases, with no conclusive standard of postoperative care. As a result, this systematic review and meta-analysis aimed to compare the efficacy and safety of current rehabilitative interventions used in patients who undergo ORIF for ankle fractures.

What was the principal research question?

How effective and safe are current rehabilitative interventions following open reduction and internal fixation of ankle fractures?

Study Characteristics -
Data Source:
Online databases EMBASE and MEDLINE were consulted in January, 2014. In addition, reference lists of selected articles and the Google database were used for further manual search of applicable literature
Index Terms:
The search string used was: [ankle fracture OR Lauge Hansen OR Weber] AND [cast OR orthosis OR weight-bearing] AND [Olerud Molander OR follow-up].
Study Selection:
Studies in any language were selected for inclusion if they were a randomized controlled trial or cohort study assessing postoperative rehabilitation programmes for ankle fractures. Study selection was performed independently by two reviewers, with discord being resolved through discussion. In total, 25 studies were included, with data sampled from 1376 participants. Of the included studies, 12 were randomized controlled trials, 7 were prospective cohort studies, 1 was a retrospective study, and 5 were partial prospective and retrospective studies..
Data Extraction:
Two authors independently extracted data from selected studies and discrepancies were resolved by discussion. Demographic information of the studies including design and treatment groups, Olerud Molander score, time to return to work and activities, and incidence of complications arising from postoperative care, short-term results (6-12 weeks), and long-term returns (>6 months) were extracted from the studies. Missing data was procured by contacting the publication's author.
Data Synthesis:
Pooling and statistical analysis was performed by Review Manager (version 5.2). Mean differences were calculated for continuous data with 95% confidence intervals (CI) generated through inverse variance in a fixed-effects model. Risk ratios (RR) were calculated for dichotomous outcomes, and associated 95% confidence intervals (CI) were found through the Mantel-Haenszel method utilizing a fixed- or random-effects model. Forest plots and I-squared statistic determined through Tau and Chi square standard testing were used to assess statistical heterogeneity where and I>25% was considered substantial heterogeneity.

What were the important findings?

  • In total, 19 studies provided comparison between mobilization (ie. exercises) versus immobilization after ORIF, and 11 studies provided comparison between early weight-bearing and delayed weight-bearing after ORIF.
  • In comparing mobilization versus immobilization postoperatively, no statically significant differences were noted in functional outcome through Olerud Molander score in the short- and long-term (9 studies: Short-term MD -6.88 [95%CI: -17.66, 3.91]; Long-term MD -1.05 [95% CI: -4.11, 2.00]) or incidence of complications (12 studies: RR 1.22 [95%CI: 0.60, 2.45]). Mobilization demonstrated significantly earlier return to work/ daily activities (7 studies: MD -20.76 days [95%CI -40.02, -1.50]).
  • In comparing early weight-bearing versus delayed weight-bearing, early weight-bearing groups demonstrated a mean 20.62-day earlier to work/daily activities as compared with delayed weight-bearing, though the difference did not reach statistical significance (3 studies: [95%CI -42.46, 1.22]; p=0.06). The incidence of complications did not significantly differ between early and delayed weight-bearing (8 studies: RR 1.26 [95%CI 0.56, 2.85]).
  • Sub-group analysis of studies which featured immediate weight-bearing as tolerated as the early weight-bearing group also demonstrated no significant differences in complication risk (2 studies: RR 0.69 [95%CI 0.28, 1.73]).

What should I remember most?

In rehabilitation after open reduction and internal fixation (ORIF) for ankle fracture, earlier return to work and daily activities was noted with exercise versus immobilization, as well as early weight-bearing versus delayed weight-bearing, though the latter did not reach statistical significance. No protocol demonstrated a significantly higher incidence of complications than its comparator. Short- and long-term functional outcome also appeared similar between exercise and immobilization protocols.

How will this affect the care of my patients?

The results this study suggest that exercise therapy, as opposed to immobilization, after ankle fixation surgery may facilitate an earlier return to activities without increasing the risk of complications. Early weight-bearing also does not appear to increase risk for complications when compared to delayed weight-bearing, with a trend toward to earlier return to activities. Given the ongoing trials currently being performed with respect to postoperative rehabilitation after ankle fracture fixation, a re-evaluation in the near future with the addition of ongoing and planned randomized controlled trials may further define the roles of different postoperative care methods as they pertain to patient outcome.

CME Image

Did you know that you’re eligible to earn 0.5 CME credits for reading this report!


Join the Conversation

Please Login or Join to leave comments.

Learn about our AI Driven
High Impact Search Feature

High Impact Icon

The OE High Impact metric uses AI to determine the impact a study will have by considering the content of the article itself. Built using the latest advances of natural language processing techniques. OE High Impact predicts an article’s future number of citations than impact factor alone.