European Journal of Cardiovascular Medicine

Ankle fractures are among the most frequently encountered injuries in orthopedic practice and represent a major source of short-term disability and prolonged functional limitation in adults. They occur across a wide age spectrum, from high-energy trauma in younger individuals to low-energy rotational injuries in older patients. Because the ankle is a weight-bearing joint with a complex articular surface and ligamentous stability, even minor malreduction can lead to altered tibiotalar contact mechanics, persistent pain, stiffness, and progression to posttraumatic osteoarthritis. In many unstable fracture patterns—particularly bimalleolar and trimalleolar fractures or those with syndesmotic disruption— operative treatment is recommended to restore mortise congruency, obtain stable fixation, and allow rehabilitation aimed at early restoration of function.¹ Open reduction and internal fixation (ORIF) has therefore become the standard approach for displaced or unstable ankle fractures in many centers. While ORIF is effective at achieving anatomical alignment, the overall recovery trajectory depends not only on surgical technique but also on postoperative management, including immobilization duration, initiation of ankle motion, and timing of weightbearing. Complications after ankle ORIF remain clinically important and include wound problems, infection, venous thromboembolism, malreduction, implant irritation or failure, delayed union or nonunion, and long-term stiffness. Large populationbased analyses have demonstrated that even with modern techniques, adverse events after ankle ORIF are not rare and are influenced by patient comorbidities and injury factors, underscoring the need to refine postoperative protocols to maximize functional recovery while minimizing risk.² Historically, many surgeons have preferred delayed weight-bearing (often for six weeks or longer) following ORIF due to concerns about loss of reduction, implant failure, or compromised fracture healing. This conservative approach is intuitive, especially for fractures with comminution, osteopenia, or syndesmotic fixation. However, prolonged non– weight-bearing and extended immobilization can contribute to muscle atrophy, reduced proprioception, joint stiffness, gait abnormalities, and delayed return to work. From a rehabilitation perspective, early, controlled mechanical loading may facilitate cartilage nutrition, enhance neuromuscular function, and improve patient confidence and mobility. Yet, the challenge remains to balance potential functional benefits against biomechanical risks to fixation stability. The available evidence regarding early postoperative motion and loading has historically been heterogeneous, with variation in fracture types, fixation methods, and definitions of “early” mobilization or weight-bearing, making it difficult for clinicians to adopt a uniform, evidence-based policy.³Syndesmotic injury adds further complexity to postoperative decision-making. When the distal tibiofibular syndesmosis is disrupted and stabilized with screws, traditional teaching often recommends delayed weight-bearing until sufficient healing or screw removal, because early loading may theoretically risk syndesmotic diastasis, screw breakage, or malreduction. Nevertheless, clinical practice varies widely, with differences in whether syndesmotic screws are removed routinely, retained, or allowed to break, and when unprotected weightbearing is permitted. Reviews focused on syndesmotic screw management have highlighted this variability and have emphasized that weight-bearing timing is often dictated more by tradition than by strong comparative evidence, thereby reinforcing the importance of local prospective evaluation to guide protocol selection in real-world tertiary care settings.⁴ Another important consideration is that outcomes after ankle fracture fixation may differ across patient subgroups. Elderly patients often have lower baseline physiological reserve, higher prevalence of osteoporosis and comorbidities, and comparatively fragile soft tissues, which can increase the likelihood of wound complications and delayed functional recovery. Studies evaluating older populations undergoing ankle fracture ORIF suggest that while acceptable outcomes are achievable, complication rates may rise with increasing age and systemic disease burden. These observations are clinically relevant because early weight-bearing protocols, if safe, could potentially reduce deconditioning and improve mobility in older adults, but must be evaluated carefully against wound and fixation-related risks.⁵ Similarly, metabolic disease states such as diabetes mellitus are associated with elevated rates of postoperative complications, including infection and impaired wound healing. This subgroup is frequently managed more cautiously with prolonged immobilization and delayed weightbearing, which may itself worsen functional outcomes through stiffness and delayed rehabilitation. Evidence describing outcomes in diabetic patients after ankle fracture surgery emphasizes the high complication burden in complicated diabetes and the need for individualized rehabilitation strategies. These considerations suggest that even in mixed general populations, weight-bearing policies should be informed by both fracture stability and patient risk profile, and that prospective studies should report both functional recovery and complication patterns to provide a balanced assessment.⁶ Despite growing clinical interest in accelerated rehabilitation pathways, there remains no universal consensus on the optimal timing of weight-bearing after ankle ORIF, particularly in resource-constrained settings where prolonged immobilization can have socioeconomic consequences for patients and families. Early mobilization and early weight-bearing protocols may shorten dependence, improve range of motion, reduce stiffness, and enable faster return to daily activities, but concerns persist regarding wound complications, loss of reduction, and hardware problems. Systematic evaluations of early motion strategies have noted that, while earlier functional recovery is possible in appropriately selected patients, the evidence base has historically been limited by small trials and varying complication reporting, leaving room for well designed prospective comparative studies to clarify the trade-off between benefit and risk.³

This prospective comparative study was conducted at a tertiary care hospital to evaluate the functional outcomes of early versus delayed weight-bearing following operative fixation of ankle fractures. The study was designed to assess clinical, functional, and radiological outcomes after open reduction and internal fixation (ORIF) of ankle fractures managed with two different postoperative weight-bearing protocols. A total of 58 patients with ankle fractures who underwent ORIF were included in the study. Patients of either gender presenting with closed ankle fractures requiring surgical fixation were enrolled. Only skeletally mature patients who were able to comply with postoperative rehabilitation and followup protocols were considered. Patients with open fractures, pathological fractures, associated ipsilateral lower limb injuries, polytrauma, neurovascular compromise, pre-existing ankle pathology, or systemic conditions affecting bone healing were excluded. Methodology All patients underwent open reduction and internal fixation under standardized surgical principles. Fractures were classified based on radiographic evaluation, and fixation was performed using appropriate implants such as plates, screws, or tension band wiring depending on fracture pattern. Syndesmotic injuries, when present, were stabilized using syndesmotic screws. All procedures were performed by experienced orthopedic surgeons following uniform operative protocols to minimize variability. Postoperative Weight-Bearing Protocol Following surgery, patients were divided into two groups based on postoperative weight-bearing strategy. The early weight-bearing group was allowed to commence partial weight-bearing after initial wound healing, progressing to full weight-bearing as tolerated under supervision. The delayed weightbearing group remained non–weight-bearing for a longer postoperative period before gradually progressing to partial and then full weight-bearing. Both groups received identical postoperative care in terms of immobilization, analgesia, wound management, and physiotherapy protocols apart from weight-bearing status. Outcome Measures Patients were evaluated using a combination of functional, clinical, and radiological parameters. Functional outcome was assessed using a standardized ankle scoring system that evaluated pain, walking ability, range of motion, stability, and daily activity performance. Pain intensity was measured using the Visual Analog Scale (VAS). Ankle range of motion was assessed using a goniometer. Radiological evaluation was performed using serial ankle radiographs to assess fracture union, implant position, and alignment. Complications such as wound infection, delayed union, nonunion, implant failure, ankle stiffness, and post-traumatic arthritis were also recorded. Statistical Analysis Collected data were compiled and analyzed using appropriate statistical software. Continuous variables were expressed as mean and standard deviation, while categorical variables were expressed as frequencies and percentages. Comparative analysis between early and delayed weight-bearing groups was performed using suitable statistical tests, with a p-value of less than 0.05 considered statistically significant.

Table 1 describes the demographic characteristics of the study population. The mean age of patients in the early weight-bearing group was 41.32 ± 10.24 years, while in the delayed weight-bearing group it was 42.18 ± 9.86 years. The overall mean age of the study population was 41.75 ± 10.03 years. The difference in age distribution between the two groups was not statistically significant (p = 0.734), indicating that both groups were comparable with respect to age. Male patients constituted the majority in both groups, with 62.07% males in the early weight-bearing group and 58.62% in the delayed weight-bearing group. Females accounted for 37.93% and 41.38% of patients in the early and delayed weight-bearing groups respectively. There was no statistically significant difference in gender distribution between the groups (p = 0.789). Regarding the side of injury, the right ankle was involved in 55.17% of patients in the early weight-bearing group and 51.72% in the delayed weight-bearing group, while left ankle involvement was seen in 44.83% and 48.28% respectively. This difference was also not statistically significant (p = 0.794). Table 2 presents the distribution of fracture types in the study population. Unimalleolar fractures were the most common type overall, accounting for 39.66% of cases, followed equally by bimalleolar fractures at 39.66%. Trimalleolar fractures constituted 20.69% of the total cases. In the early weight-bearing group, 41.38% had unimalleolar fractures, 37.93% had bimalleolar fractures, and 20.69% had trimalleolar fractures. Similarly, in the delayed weight-bearing group, unimalleolar fractures were seen in 37.93%, bimalleolar fractures in 41.38%, and trimalleolar fractures in 20.69% of patients. The difference in fracture pattern distribution between the two groups was not statistically significant (p = 0.812). Syndesmotic injuries were observed in 27.59% of patients in the early weight-bearing group and 31.03% in the delayed weight-bearing group, with no significant difference between the groups (p = 0.771). Table 3 compares the functional outcome scores, pain levels, and ankle range of motion between the two groups. The mean functional ankle score was significantly higher in the early weight-bearing group (88.24 ± 6.18) compared to the delayed weightbearing group (80.67 ± 7.42), and this difference was statistically significant (p = 0.001). Pain assessment using the Visual Analog Scale showed significantly lower pain scores in the early weight-bearing group (1.84 ± 0.92) compared to the delayed weight-bearing group (2.96 ± 1.12), with a statistically significant difference (p = 0.002). Range of motion assessment revealed that patients in the early weight-bearing group achieved greater ankle dorsiflexion (16.42 ± 3.12 degrees) than those in the delayed weightbearing group (13.68 ± 3.46 degrees), and this difference was statistically significant (p = 0.004). Similarly, ankle plantarflexion was significantly better in the early weight-bearing group (33.86 ± 4.91 degrees) compared to the delayed weight-bearing group (29.47 ± 5.28 degrees) (p = 0.003). Table 4 outlines the radiological outcomes and fracture union status in both groups. Radiological union was achieved in 96.55% of patients in the early weight-bearing group and 93.10% of patients in the delayed weight-bearing group. The difference in union rates between the two groups was not statistically significant (p = 0.553). Delayed union was observed in one patient (3.45%) in the early weight-bearing group and two patients (6.90%) in the delayed weight-bearing group. Malalignment was noted in 3.45% of patients in the early weight-bearing group and 6.90% in the delayed weight-bearing group, with no significant difference between the groups (p = 0.553). Implant failure was observed in one patient (3.45%) in the delayed weight-bearing group, while no implant failure was reported in the early weightbearing group; however, this difference was not statistically significant (p = 0.312).  Table 5 shows the comparison of postoperative complications between the two groups. Superficial surgical site infection was observed in 6.90% of patients in the early weight-bearing group and 10.34% in the delayed weight-bearing group, with no statistically significant difference (p = 0.640). Ankle stiffness was significantly more common in the delayed weight-bearing group, occurring in 24.14% of patients compared to 10.34% in the early weightbearing group, and this difference was statistically significant (p = 0.041). Post-traumatic arthritis developed in 3.45% of patients in the early weightbearing group and 10.34% in the delayed weightbearing group, though this difference was not statistically significant (p = 0.301). Nonunion was observed in one patient (3.45%) in the delayed weight-bearing group, while no cases were reported in the early weight-bearing group; this difference was not statistically significant (p = 0.312). Overall complications were significantly higher in the delayed weight-bearing group (48.28%) compared to the early weight-bearing group (20.69%), and this difference was statistically significant (p = 0.028).

Table 1. Demographic Profile of the Study Population (n = 58)

Table 2. Distribution of Fracture Types

Table 3. Functional Outcome Scores and Pain Assessment

Table 4. Radiological Outcome and Fracture Union

Table 5. Postoperative Complications

In the present study, both groups were comparable at baseline, which strengthens the validity of the functional comparisons. The mean age was 41.75 ± 10.03 years overall (early: 41.32 ± 10.24 vs delayed: 42.18 ± 9.86; p = 0.734) with male predominance (60.34% overall) and a slightly higher right-sided involvement (53.45%). A similar middle-aged profile has been reported in early weight-bearing cohorts such as Gul et al (2007), where the mean age was approximately 44 years in their operated ankle fracture population managed with immediate unprotected weight bearing versus casting, supporting that our study population reflects the typical demographic seen in operatively treated ankle fractures.7 Fracture morphology was also well balanced between protocols in our series, with unimalleolar and bimalleolar fractures each contributing 39.66% and trimalleolar fractures 20.69%, while syndesmotic injury was present in 29.31% overall (early: 27.59% vs delayed: 31.03%; p = 0.771). This distribution indicates inclusion of a meaningful proportion of more complex injuries (bi-/trimalleolar and syndesmotic involvement) in both arms. Ahl et al (1987) similarly focused on unstable displaced patterns—53 dislocated bimalleolar and trimalleolar fractures—and reported comparable clinical results between immediate and late weight-bearing protocols at 3 and 6 months, supporting the concept that, when fixation restores stability, earlier loading does not necessarily worsen clinical recovery.8 Functionally, our early weight-bearing group achieved significantly superior recovery, demonstrated by a higher mean functional ankle score (88.24 ± 6.18 vs 80.67 ± 7.42; p = 0.001) and lower pain (VAS 1.84 ± 0.92 vs 2.96 ± 1.12; p = 0.002). These values suggest that permitting earlier loading may accelerate restoration of daily activities and reduce pain-related disability. Comparable long-term function has been shown in randomized postoperative rehabilitation comparisons; for example, Lehtonen et al (2003) reported Olerud–Molander scores of 87 ± 8 (cast) versus 87 ± 9 (functional brace) at two years, indicating that stable fixation can allow functional protocols without compromising final outcome, consistent with our finding of better early function without evidence of harm.9

Range of motion outcomes in our study also favored early weight-bearing, with significantly greater dorsiflexion (16.42 ± 3.12° vs 13.68 ± 3.46°; p = 0.004) and plantarflexion (33.86 ± 4.91° vs 29.47 ± 5.28°; p = 0.003). This likely reflects reduced stiffness due to earlier functional use and less prolonged immobilization. In the Cochrane review by Lin et al (2012), rehabilitation strategies allowing earlier exercise/weight-bearing during or soon after immobilization were associated with improvements in ankle motion in several trials, supporting our observation that earlier functional loading can translate into measurable gains in ROM following ankle fracture treatment.10

The specific advantage seen in dorsiflexion in our early weight-bearing group is clinically relevant because dorsiflexion limitation is strongly associated with gait compromise and persistent functional restriction after ankle fractures. Our cohort achieved a mean dorsiflexion of 16.42° with early loading compared with 13.68° in delayed loading. Tropp et al (1995) likewise observed that although overall ROM recovered by 12 months, dorsiflexion remained better in the brace (early mobilization) group, and early deficits in torque and ROM were significantly less in that group at 10 weeks, paralleling the directional benefit we observed with early weight-bearing protocols.11

Radiological safety is a key concern when adopting early weight-bearing. In our study, union was high in both groups (96.55% early vs 93.10% delayed; p = 0.553), with low rates of malalignment (3.45% vs 6.90%) and minimal delayed union (3.45% vs 6.90%). These findings indicate that earlier loading did not compromise stability or healing in a meaningful way. This aligns with Ahl et al (1993), who compared active ankle movement with weight-bearing in an orthosis versus active movement without weightbearing and reported no fracture redislocation on conventional radiography, reinforcing that, when fixation and mortise stability are adequate, controlled early weight-bearing can be radiographically safe.12 From a principles standpoint, early motion and loading after rigid internal fixation has historical support, provided anatomical reduction and stable fixation are achieved. Our data demonstrate no meaningful increase in implant failure (0.00% early vs 3.45% delayed; p = 0.312) and no signal of increased nonunion with early loading (0.00% vs 3.45%). Burwell et al (1965) emphasized the role of rigid internal fixation to permit early joint movement as a core concept in managing displaced ankle fractures, and the low mechanical complication rates in our early weight-bearing arm are consistent with this foundational rationale for stable fixation enabling earlier functional recovery.13  Complication patterns in our study further favor early weight-bearing, particularly for stiffness: ankle stiffness occurred in 10.34% with early loading versus 24.14% with delayed loading (p = 0.041), and overall complications were significantly lower in the early group (20.69% vs 48.28%; p = 0.028). While superficial infection was similar (6.90% vs 10.34%; p = 0.640), the marked reduction in stiffness supports limiting prolonged non–weight-bearing where safe. Cimino et al (1991) similarly found that early mobilization with unrestricted weight-bearing did not increase morbidity or loss of reduction and reported a higher proportion achieving dorsiflexion >15° in the orthosis group (72% vs 37%; p = 0.014), which matches our observation of superior ROM and lower stiffness with earlier functional progression.14 In our cohort, early weight-bearing improved functional score (88.24 vs 80.67), reduced pain (VAS 1.84 vs 2.96), improved dorsiflexion/plantarflexion, and did not worsen union or mechanical failure. Black et al (2012) concluded that available studies generally showed no evidence that early weight-bearing is harmful compared with delayed weight-bearing, and noted trends favoring early weight-bearing for ROM and earlier return to work, which supports adopting early weight-bearing in appropriately selected patients with stable fixation and good compliance—conditions that reflect the clinical pathway used in our study.15

Early weight-bearing after ankle fracture fixation (ORIF) resulted in significantly better functional outcomes, lower pain scores, and improved ankle range of motion compared to delayed weight-bearing. Radiological union rates and implant stability were comparable between both groups, indicating that early loading did not compromise fracture healing. The delayed weight-bearing group showed a significantly higher incidence of ankle stiffness and overall postoperative complications. Therefore, early weightbearing can be safely recommended in appropriately selected patients with stable fixation and good compliance to rehabilitation protocols.

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2. SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am. 2009;91(5):1042-1049. doi:10.21 06/JBJS.H.00653. Link: https://pubmed.ncbi.nlm.nih.gov/19411451/

3. Thomas G, Whalley H, Modi C. Early mobilization of operatively fixed ankle fractures: a systematic review. Foot Ankle Int. 2009;30(7):666-674. doi:10.3113/FAI.2009.0666. Link: https://pubmed.ncbi.nlm. nih.gov/19589314/

4. Schepers T. To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg. 2011;131(7):879-883. doi:10.1007/s00402-010- 1225-x. Link: https://pmc.ncbi.nlm.nih.gov/ articles/PMC3117259/

5. Lynde MJ, Sautter T, Hamilton GA, Schuberth JM. Complications after open reduction and internal fixation of ankle fractures in the elderly. Foot Ankle Surg. 2012;18(2):103-107. doi:10.1016/j.fas.2011 .03.010. Link: https://pubmed.ncbi.nlm.nih.gov/22443995/

6. Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011;32(2):120-130. doi:10.3113/FAI.2011. 0120.Link:https://www.frischortho.com/pdf/outcomes-of-anklefractures - in-patients-with uncomplicat- ed -versuscomplicated-diabetes.pdf

7. Gul A, Batra S, Mehmood S, Gillham N. Immediate unprotected weight-bearing of operatively treated ankle fractures. Acta Orthop Belg. 2007;73(3):360-365. Link: https://www.actaorthopaedica.be/assets /1381/11- Gul_et_al.pdf

8. Ahl T, Dalén N, Holmberg S, Selvik G. Early weight bearing of displaced ankle fractures. Acta Orthop Scand. 1987;58(5):535-538. doi:10.3109/17453678709146394. Link: https://pubmed.ncbi.nlm. nih.gov /3425284/

9. Lehtonen H, Järvinen TLN, Honkonen S, Nyman M, Vihtonen K, Järvinen M. Use of a cast compared with a functional ankle brace after operative treatment of an ankle fracture: a prospective, randomized study. J Bone Joint Surg Am. 2003;85(2):205-211. doi:10.2106/00004623-200302000-00004. Link: https://pubmed.ncbi.nlm.nih.gov/12571295/

10. Lin CWC, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012;11:CD005595. doi:10.1002/14651858.CD 005595.pub3. Link: https://pubmed.ncbi.nlm.nih.gov/23152232/

11. Tropp H, Norlin R. Ankle performance after ankle fracture: a randomized study of early mobilization. Foot Ankle Int. 1995;16(2):79-83. doi:10.1177/107110079501600205. Link: https://pubmed.ncbi.nlm. nih.gov/7767451/

12. Ahl T, Dalén N, Lundberg A, Bylund C. Early mobilization of operated on ankle fractures: prospective, controlled study of 40 bimalleolar cases. Acta Orthop Scand. 1993;64(1):95-99. doi:10.3109/174536793 08994541.Link: https://pubmed.ncbi.nlm.nih.gov/8451961/

13. Burwell HN, Charnley AD. The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg Br. 1965;47(4):634-660. Link: https://pubmed.ncbi.nlm .nih.gov/5846764/

14. Cimino W, Ichtertz D, Slabaugh P. Early mobilization of ankle fractures after open reduction and internal fixation. Clin OrthopRelat Res. 1991;(267):152-156. Link: https://pubmed.ncbi.nlm.nih.gov/ 2044269/

15. Black JDJ, Bhavikatti M, Al-Hadithy N, Hakmi A, Kitson J. Early weight-bearing in operatively fixed ankle fractures: a systematic review. Foot (Edinb). 2012;23(2-3):78-85. doi:10.1016/j.foot.2012.05.002. Link: https://pubmed.ncbi.nlm.nih.gov/23725766/