Weightbearing After Internal Fixation of Ankle Fractures

A study purporting to show equivalency for weight-bearing has a lot of chances for positive bias which clouds its message

What’s the Claim?  

The authors of this systematic review of 10 RCTs and 4 cohort studies found that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing at 6-12+ months, but only conferred better outcomes scores in the first six weeks.

How’s It Stack Up?

The topic is controversial coming in, and it may be controversial going back out again; the reason we’re covering it is that the main finding needs a lot of interpretation. There was variability in terms of the amount of weightbearing that was permitted, and exactly when it was allowed, as well as in the type and severity of fracture. Also, the study design itself may tend to make things look better than they are, and so we take these results with a grain of salt. In particular, because of a lack of blinding across the source studies included in the review, the risk of was rated as high (4 RCTs, 2 cohort studies) and moderate (the rest); that kind of bias could, once again, make the findings reported in the study look better than one might see in real-world practice.

What’s Our Take?

Be a little cautious applying the top-line finding across your practice. First of all, protected weightbearing in this study really meant protected — as little as 15% of body weight or 15 kg early on. Many source studies in this systematic review excluded the tougher fractures, some excluded patients over 65, and a couple of retrospective studies were in there. These in particular could make the more-aggressive intervention — early weightbearing — look better than it is.


Khojaly R, Rowan FE, Hassan M, Hanna S, Niocail RM. Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systemic Literature Review and Meta-Analysis. Foot Ankle Int. 2022;43:1143-1156.