This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
After surgery for a broken ankle, it is common practice for people to be told to keep weight off their ankle for 6 weeks. However, some surgeons encourage people to walk again after 2 weeks. This trial compared the safety of walking after 2 weeks with waiting 6 weeks.
Researchers found that 4 months after surgery, people in both groups had:
- similar ankle function (including pain, stiffness, and walking ability)
- a similar number of complications.
This research found that walking earlier is safe for many people. Encouraging people to walk earlier after ankle surgery could help them get back to normal activities sooner and save the NHS money.
More information on broken ankles can be found on the NHS website.
The issue: when can I safely walk after surgery for a broken ankle?
Ankle fractures are a common injury; in the UK, around 190 people break their ankle every day. Some can be treated with a cast or a boot alone, but others need surgery to ensure their bones heal correctly.
After surgery for a broken ankle, most people are told to avoid putting weight on their ankle for 6 weeks (delayed weight-bearing). This can mean that they have extended hospital stays, need help getting around, face delays in returning to work, and rely on social care more. Other people are encouraged to walk only 2 weeks after surgery (early weight-bearing).
There are concerns that early weight-bearing might lead to healing problems, misaligned bones, and an increase in the need for further operations. Others argue that delayed weight-bearing increases the risk of blood clots and muscle wasting.
This study compared the safety of waiting 2 weeks to walk after surgery for a broken ankle with waiting 6 weeks. It also analysed hospital and social care costs.
What’s new?
The study involved 561 adults who had surgery for a broken ankle at 23 UK hospitals. Half were encouraged to walk 2 weeks after surgery, the others to wait 6 weeks. The groups had similar characteristics, most participants (64%) were women, and their average age was 50 years.
The main outcome at 4 months was a measure of ankle function, including symptoms (such as pain and stiffness) and people’s ability to put weight on their ankle (climbing stairs and running, for example). Scores within 6 points (out of 100) of each other were considered equal. 243 in the 2-week group and 237 in the 6-week group provided data for this outcome.
The researchers found that at 4 months, the 2-week group:
- had similar ankle function (score: 66) to the 6-week group (61)
- had a similar likelihood of complications (16% people) as the 6-week group (14%)
- had a similar number of unplanned surgeries due to complications (8%) as the 6-week group (6%)
- cost the NHS and social services less (£725) than the 6-week group (£785; based on 2021/22 costs).
Ankle function was similar between groups for different ages, sexes, and types of ankle surgery. After 1 year, there was no difference between groups in ankle function.
People in the 2-week group had slightly (but not significantly) less time off work in the 6 weeks after surgery. This saved society an average of £722 per person. Years of life in good health (QALYs) were also higher for people in the 2-week group.
Interviews with 29 participants found that recovery took longer than people expected. They were unsure if their symptoms were normal; many wanted more information: “Even just a little leaflet would be good… To say you're getting back on your feet.” People valued spending time with physiotherapists but access to physiotherapy varied between hospitals. For most, pain did not greatly limit their recovery, but the fear of pain and injury did: “When you've been in the cast for a few weeks and then you get transferred into the boot…it is quite frightening.”
Why is this important?
The study suggests that walking 2 weeks after surgery for a broken ankle is as safe as waiting 6 weeks and costs the NHS and social care less. This means that people could return to normal activities earlier.
Clinicians could inform patients of the findings when discussing their rehabilitation. Policymakers could consider ways to encourage more clinicians to recommend a 2-week waiting period; from 2019 to 2021, just 11% of people were recommended this approach.
The authors stress that surgeons considered that many people (42% of the 2,218 assessed) needed to wait for the full 6 weeks after surgery before walking; these people were therefore ineligible for inclusion in this study. This means the findings may be less generalisable to people with more serious fractures. In addition, many people in the 6-week group (38%) did not wait the full period before walking, which may have affected the findings.
What’s next?
The findings from the study have been included in a Cochrane review on rehabilitation after ankle fractures. The researchers hope the findings will inform National Institute for Health and Care Excellence (NICE) guidelines on fractures. The researchers plan to audit UK practice for ankle fracture recovery in 2025.
You may be interested to read
This is a summary of: Bretherton CP, and others. Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial. The Lancet 2024; 403: 2787 – 2797.
A podcast about the study from Cochrane.
Information on recovering from a broken ankle from the NHS.
Information on taking part in NIHR research on ankle fracture.
Funding: This study was funded by the NIHR Research for Patient Benefit programme. It was also supported by the NIHR Barts Biomedical Research Centre, the NIHR Applied Research Collaboration Oxford and Thames Valley, and an NIHR Senior Investigator award.
Conflicts of Interest: None relevant.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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