A Prospective Randomized Trial to Assess Early versus Delayed Weight Bearing Following Operatively Treated Ankle Fractures in the United States
In brief
Early weight bearing after ankle repair kept reoperations below 3%
In a 418-patient randomized trial, starting weight bearing two weeks after surgery led to reoperation in 2.3% of patients, compared with 3.4% when weight bearing began at six weeks. Early weight bearing was no less safe, but did not significantly speed return to work; the findings apply to selected fractures without syndesmotic fixation.
- Journal
- Journal of orthopaedic trauma (Q1)
- Published
- 14 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- William T Obremskey, Kristin R Archer, Greg E Gaski, Ida Leah Gitajn, Roman M Natoli, Clay A Spitler, et al.
- PMID
- 42873990
- DOI
- 10.1097/BOT.0000000000003299
Why clinicians should know about it
- Picked for Orthopedics and Sports Medicine (paper of the day, 15 October 2026): Early weight bearing non-inferior, not superior for return-to-work
Abstract
OBJECTIVES: To determine the safety of early versus delayed weight bearing and effectiveness for improving return-to-work following ankle fracture repair. METHODS: Design: Prospective randomized study. SETTING: 19 United States Trauma Centers. PATIENT SELECTION CRITERIA: Adult patients (≥18 years) with ankle fracture (OTA/AO 44 A, B or C) undergoing surgical fixation were included. Open Gustilo-Anderson (G-A) Type IIIB, IIIC, syndesmotic injuries with fixation, and injuries with arterial impaction that surgeons felt unsafe to weight were excluded. OUTCOME MEASURES AND COMPARISONS: The co-primary outcomes were (1) non-inferiority of early versus delayed weight bearing for reoperation for complications of hardware failure, non-union, loss of reduction, infection, or fusion; and (2) gated superiority of early versus delayed weight bearing for time to return-to-work, both within 365 days of randomization. Reoperation and time to return-to-work was compared between patients assigned to early (2 weeks post-operatively) versus delayed (6 weeks post-operatively) weight bearing. RESULTS: The modified intent to treat sample included 418 patients enrolled between January 2020 through October 2023; 214 early (mean age: 47; SD (15) range (18-84); 35% male); 204 delayed (mean age: 43; SD (15); 36% male). Reoperation for complication occurred in 5 early (2.3%, 95% Confidence Interval (CI): 0.3%, 4.4%), and 7 delayed patients (3.4%, 95% CI: 0.9%, 5.9%). Median time to return-to-work (95% CI) was 54 (42, 77) days and 69 (47, 89) days for the early and delayed groups, respectively. Early weight bearing was non-inferior to delayed weight bearing for reoperation (difference in complication free survival (early - delayed): 1.5 percentage points; 90% two sided CI: -1.7%, 4.8% which excluded the non-inferiority tolerance of -5.0%) and not superior for return-to-work (Hazard Ratio 1.1, 95% CI: 0.8, 1.6, p=0.475). CONCLUSIONS: Trial findings add to the growing evidence demonstrating the safety of early weight bearing after fixation of bimalleolar and trimalleolar ankle fracture without syndesmotic disruption, a key concern for both clinicians and patients. However, no statistically significant benefit of earlier return-to-work was found. LEVEL OF EVIDENCE: I.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.