Weight-bearing Status After Foot & Ankle Surgery

Introduction

Restriction of weight-bearing following foot and ankle surgery is commonly used to protect the surgical site and allow soft tissues and wounds to settle
However, not all patients are able to comply with this instruction and, at the very least, find it inconvenient
This can lead to delayed hospital discharge and increased length of stay
In addition, non-weight-bearing (NWB) and casting can potentially lead to a higher risk of complications such as muscle atrophy and venous thromboembolic events
Therefore, earlier weightbearing and rehabilitation would be advantageous if they do not increase adverse outcomes of surgery
There has been increasing interest in this issue, both in the elective and trauma situation

1st MTPJ fusion

Post-operative weightbearing status and splints have been variously described, with use of surgical shoes, cast boots and heel or flat weightbearing
A recent systematic review found 17 articles with suitable criteria where weightbearing was initiated within 2 weeks of surgery encompassing 898 arthrodesis
Pooling these results showed a total of 57 described non-unions (6.35%)
This compares with an earlier systematic review showing a non-union rate of 5.4% when weightbearing status was not a criteria of the review
Caution is required, however, as none of the studies were controlled trials comparing post-operative weightbearing status; the definition of non-union was varied between trials; the groups were heterogenous
Overall, however, it is suggested that early weightbearing may not result in an adverse outcome, and may be a suggested avenue for further investigation

1st TMTJ fusion

Traditionally accompanied by cast immobilisation and non-weightbearing status for 6 weeks
Some studies have reported on earlier weightbearing ranging from partial to full weightbearing within 2 weeks of surgery
A recent systematic review found 7 suitable papers with early weightbearing protocols, with a total of 443 arthrodesis; 16 (3.61%) non-unions were described
Again, caution is recommended as no studies were controlled trials comparing post-operative weightbearing and there is significant heterogenicity of the papers
However, early weightbearing for this procedure has shown promising results and may be a consideration for further study

Ankle fusion

Post-operative regimens vary, but typically involve immobilisation in cast, non-weightbearing for 6 weeks
A recent systematic review looked at the evidence for weightbearing encompassing 60 studies deemed suitable for review, with a total of 2426 ankle arthrodesis
Only 1 study compared outcomes of weightbearing status and was retrospective in nature
The studies were grouped dependent on length of time kept non-weightbearing: 0-1 week, 2-3 weeks, 4-5 weeks, 6 weeks and beyond
Overall union rate was 93%
There were comparable union rates, complication rates and time to union between groups
However, caution again is required on study interpretation due to the highlighted heterogenicity of the groups, the consistency of reporting between the studies and the overall lack of high-quality evidence
The results of early weightbearing are promising and would be a valuable area for a further high-quality study

Ankle fractures

Ankle fracture management has been an area of increased interest in recent years
Early and immediate weightbearing and early range of motion have both been proposed to improve outcomes, both separately and in combination
Benefits suggested include improved range of motion, and early return to work
A Cochrane review in 2012 found 30 trials that met the criteria to be assessed following surgical management of ankle fractures
It concluded that the evidence was limited, due to heterogenicity and bias, however early weightbearing may show an improvement in ankle range of motion
However, a further systematic review in 2016 indicated that active mobilisation and early weightbearing was advantageous and resulted in an earlier return to work, without increasing complications
Overall, there is a trend towards early weightbearing and early range of motion; further evidence is likely to be produced as study protocols for randomised control trials looking at weightbearing status and exercise in the post-operative period have been recently submitted

References

Crowell, A. Early Weight-Bearing After Arthrodesis of the First Metatarsal-Phalangeal Joint: A Systematic Review of the Incidence of Non-Union. J Foot Ankle Surg. Nov-Dec 2018;57(6):1204-1206.doi: 10.1053/j.jfas.2018.06.011. Epub 2018 Sep 22

RoukisTS. Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. JFootAnkleSurg2011;50(6):710–713

Crowell A, Van JC, Meyr AJ. Early Weightbearing After Arthrodesis of the First Metatarsal-Medial Cuneiform Joint: A Systematic Review of the Incidence of Nonunion. J Foot Ankle Surg. 2018 Nov-Dec;57(6):1204-1206. doi: 10.1053/j.jfas.2018.06.011. Epub 2018 Sep 22. PMID: 30253966

Potter MJ, Freeman R. Postoperative weightbearing following ankle arthrodesis: a systematic review. Bone Joint J. 2019 Oct;101-B(10):1256-1262. doi: 10.1302/0301-620X.101B10.BJJ-2019-0207.R1. PMID: 31564155

Lin CW, Donkers NA, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012 Nov 14;11:CD005595. doi: 10.1002/14651858.CD005595.pub3. PMID: 23152232

Smeeing DPJ, Houwert RM, Briet JP, Kelder JC, Segers MJM, Verleisdonk EJMM, et al. (2015) 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 10(2): e0118320. doi:10.1371/journal.pone.0118320

Khojaly R, Mac Niocaill R, Shahab M, Nagle M, Taylor C, Rowan FE, Cleary M. Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture. Trials. 2021 May 27;22(1):369. doi: 10.1186/s13063-021-05319-0