1 week post ankle ORIF

Maybe Marie's fracture is not a bimalleolar fracture? My surgeon gave me the same advice as Marie's and I am in a very good place 7 weeks in. He said with certain simple fractures the new guidance is to get movement (as tolerated) much quicker than the antiquated 6 weeks rule. Please read the many, many medical journals on this topic. It is proven there is no benefit (in fact there are detriments) to staying in a hard cast for too long - not only psychologically, but also the length of recovery of soft tissue repair after such long mobilisation, not mentioning the muscular atrophy! 

Marie your surgeon is a specialist, please do not be swayed by people online who think they know best! 

Wish you the best of luck - let me know if you have any questions or want information on the early mobilisation. 

Joe,

Certainly each individual case is different with regard to fracture location, severity, surgery outcomes, and other factors. I think ultimately the timeline for full weight bearing depends on the x-ray evidence and signs of any lingering soft tissue damage (tendons, ligaments, etc.)

Please cite your medical journal articles recommending rapid weight bearing after fractures as the 'new standard of care' in ankle treatment. I doubt it is a given fact as you might suggest. If you were an accomplished ankle orthopedic surgeon speaking from your own experience in practice I would tend to give your opinion more credence (and, no, I am not a doctor either).

My practitioner was a skilled orthopedic surgeon and I don't think he takes his recommendations lightly.

I was hoping you were going to say this! But before I post the medical journals, I will also mention I had my 2nd physio session with Spire in Nottingham today - and the well known physio (who a huge number of very well known professional sports men / women uses), also clarified he has seen a huge improvement with early mobility with ankle fractures. I am now 7 weeks post op, and he said my movement is fantastic, and I am now ready to start driving, and to start using just 1 crutch for outside use. But again - I'm sure you are correct that my surgeon so wrong to allow me to do this. 

Now to the journals (You may have to google them yourself as I cannot send links - however I will include the conclusions of each medical journal for your ease)

1) Fernando A. Peña, MD, of the University of Minnesota - 'compared functional results and level of complications seen with immediate WBAT after ORIF in 159 patients versus 222 patients treated with ORIF and a traditional postoperative protocol of non–weight bearing (NWB) for 6 weeks after surgery'

Conclusions: In patients with a normal sensory exam, it is safe to allow WBAT after undergoing ORIF of an ankle fracture regardless of the fracture pattern. A higher level of function is acquired at an earlier time of the recovery when compared to a protocol of NWB for 6 weeks. An extended period of NWB can have a significant impact on patient satisfaction as well as significant social implications including potentially lost productivity and income for the patient. NWB can also cause transportation challenges for patients, which can cause work limitations, and may increase other indirect costs of these injuries. 

2) Kentaro Amaha and Tatsuya Arimoto -  Asia Pacific Sports Med Arthrosc Rehabil Technol. Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture

Concusion - In conclusion, we compared the functional recovery of patients using a conventional PC with that of patients using a WB after undergoing surgery for ankle fractures. The Weight Bearing group showed a significantly faster functional recovery. A WB has an adjustable heel lift allowing users to change the ankle position to a slightly plantarflexed position that facilitates walking in a postoperative swollen ankle. Furthermore, WBs are easy to slip on and make it easy to adjust the ankle position in conformity with the swelling so that the patient can walk whilst the least painful position is maintained. It is stable enough to allow immediate weight-bearing postoperatively, and no loss of reduction was seen. The Rocker bottom design minimises the sagittal plane motion in specific joints of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activities at a faster rate.

3) Reza Firoozabadi and Emily Harnden Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington - Immediate Weight-Bearing after Ankle Fracture Fixation

Conclusion - IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture is a safe alternative to a period of protected weight-bearing. Earlier weight-bearing has been associated with better mobility, shorter hospital stay, and earlier return to work. Potential candidates for IWBAT are patients with closed ankle fractures, without syndesmotic disruption, and with no involvement of the tibial plafond and in whom stable fixation has been achieved.

Erik N Kubiak - The Journal of the American Academy of Orthopaedic Surgeons - Early Weight Bearing After Lower Extremity Fractures in Adults 

Conclusion - For certain fracture patterns, well-designed trials suggest that patients with normal protective sensation can safely bear weight sooner than most protocols permit. Several randomized, controlled trials of surgically treated ankle fractures have shown no difference in outcomes between immediate and delayed (=6 weeks) weight bearing. Retrospective series have reported low complication rates with immediate weight bearing following intramedullary nailing of femoral shaft fractures and following surgical management of femoral neck and intertrochanteric femur fractures in elderly patients

KPower - I look forward to your response to these. If you want more there are plenty more for you to review. I would certainly welcome some medical journals offering evidence of your opinions? 

I am trying to give Marie some positivity, that I was given the same advice as her - and now 7 weeks later I am in a very good place. I wasn't expecting a huge debate, and to be told mine, and her advice was wrong! (When there is extensive medical evidence - as above, conveying the facts)

Marie if you want any advice please feel free to get in touch - I can also send you a link to my youtube video showing my walking progress which will hopefully spur you on! 

Hey Joe, i have also read the same research the day after my trimall anke fracture. The thing is that this research excluded many types of fractures for lack of eligibility. But nonetheless, it fulled me with hope! The 2 things i considered a drawback from this research was 1. The selection criteria and 2. The fact that 26 of the selected participants did not follow up with the research. And if they would have, and subsequently have had negative results, the failure rate would have went down to an unacceptable 24%. Although wolff's law does state that bones grow stronger based on the stress they receive. My final takeaway from these reseaches was that, on average, early weight bearing allowed patients to return to walking approx. 2 weeks faster, is it really worth it to jeopardize the entire recovery for 2 weeks. Im thinking that the traditional approach of 6 wks NWB and gradual return to FWB afterwards is a safer and likely better approach (again im no professional, and early weight bearing might be a great thing!). Aside from that, i really want to thank you for going above and beyond for providing comfort and reassurance with your post. All the best in your recovery!

Hi Kim, really sorry to hear your situation - I really hope you recover soon, hopefully the exogen works for you! 

In regards to the walking in a few weeks being nutty - I know it might sound it, but there's now lots of medical proof to its benefits. Just for your perusal here are a number of medical journals highlighting the benefits - 

1) Fernando A. Peña, MD, of the University of Minnesota - 'compared functional results and level of complications seen with immediate WBAT after ORIF in 159 patients versus 222 patients treated with ORIF and a traditional postoperative protocol of non–weight bearing (NWB) for 6 weeks after surgery'

Conclusions: In patients with a normal sensory exam, it is safe to allow WBAT after undergoing ORIF of an ankle fracture regardless of the fracture pattern. A higher level of function is acquired at an earlier time of the recovery when compared to a protocol of NWB for 6 weeks. An extended period of NWB can have a significant impact on patient satisfaction as well as significant social implications including potentially lost productivity and income for the patient. NWB can also cause transportation challenges for patients, which can cause work limitations, and may increase other indirect costs of these injuries. 

2) Kentaro Amaha and Tatsuya Arimoto -  Asia Pacific Sports Med Arthrosc Rehabil Technol. Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture

Concusion - In conclusion, we compared the functional recovery of patients using a conventional PC with that of patients using a WB after undergoing surgery for ankle fractures. The Weight Bearing group showed a significantly faster functional recovery. A WB has an adjustable heel lift allowing users to change the ankle position to a slightly plantarflexed position that facilitates walking in a postoperative swollen ankle. Furthermore, WBs are easy to slip on and make it easy to adjust the ankle position in conformity with the swelling so that the patient can walk whilst the least painful position is maintained. It is stable enough to allow immediate weight-bearing postoperatively, and no loss of reduction was seen. The Rocker bottom design minimises the sagittal plane motion in specific joints of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activities at a faster rate.

3) Reza Firoozabadi and Emily Harnden Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington - Immediate Weight-Bearing after Ankle Fracture Fixation

Conclusion - IWBAT in a certain subset of patients with stable osteosynthesis following an ankle fracture is a safe alternative to a period of protected weight-bearing. Earlier weight-bearing has been associated with better mobility, shorter hospital stay, and earlier return to work. Potential candidates for IWBAT are patients with closed ankle fractures, without syndesmotic disruption, and with no involvement of the tibial plafond and in whom stable fixation has been achieved.

Erik N Kubiak - The Journal of the American Academy of Orthopaedic Surgeons - Early Weight Bearing After Lower Extremity Fractures in Adults 

Conclusion - For certain fracture patterns, well-designed trials suggest that patients with normal protective sensation can safely bear weight sooner than most protocols permit. Several randomized, controlled trials of surgically treated ankle fractures have shown no difference in outcomes between immediate and delayed (=6 weeks) weight bearing. Retrospective series have reported low complication rates with immediate weight bearing following intramedullary nailing of femoral shaft fractures and following surgical management of femoral neck and intertrochanteric femur fractures in elderly patients

I am currently doing a UK wide trial (managed by the Poole Hospital trust, but I was at NW Anglia) and was in a walking boot at 2 weeks post op, and now 7 weeks in I am taking my first steps unassisted / driving again etc, so I've personally felt the benefits. 

Away from that though I really hope you recover quickly - stay positive, and things do always get better! xx

Thank you! It's just frustrating as hell. I definitely don't question the literature, I read quite a bit prior to surgery, and I knew there were some conflicting schools of thought. But here's a good question, how did you endure the pain of the boot so soon? My ankle is still so painful and swollen even just laying down with the boot, makes me want to scream.  I'm not a wussy lol, I have been through 7 surgeries in my life prior, and this by far is the worse pain experienced. And this too, they tell me it's ok not to wear the boot in bed, ok great, but even to get on my electric scooter to the bathroom 7 feet away, they want it on. I'm zero weight bearing, balance on my right leg, so why? Aren't the screws holding me together for gentle movement, as long as I don't stand? Can I massage my foot like I am gently, or will I pop a screw?! Massage helps the numbness. 

And by the way, what's a normal sensory pattern, which was outlined as the reasoning for the boot early? I'm trying to figure out if I'm "normal."

Hi kim, really sorry to hear your situation, remember first and foremost that this is ONLY TEMPORARY! Soon enough, youll look back and think "i cant believe its already been X amout of time since this nightmare ended!". Is there a reason why your fracture hasnt healed so well after 8 weeks? Preexisting conditions, or nonunion due to the bones not being aligned correctly? Hope all goes well for you, please keep us updated.

Well I have a bad habit, smoking. He thinks that's a potential. Otherwise, no. Very true, years do pass quickly and when I'm out of this it will just be a bleep in time. Given others were afforded the opportunity to try to walk just a few weeks out, and we know fractures don't heal that quick, I'm not too sure why he's waiting. 10 weeks out from surgery now, c'mon already. Next appt is in 2 weeks, I hope he sees some progress in there. The pain though, even when elevating, still hurts - ridiculous. And my ankle and foot are so huge and numb/tingling. I just want to leave my house lol!! It's 110 out there, I live in the desert, maybe this is a gift lol.