Early weight-bearing after ankle fracture surgery: a systematic review and meta-analysis of functional outcomes and safety

Abstract

Background: Early weight-bearing (EWB) following ankle fracture surgery represents a paradigm shift from traditional rehabilitation protocols. This systematic review and meta-analysis evaluated the efficacy and safety of early versus delayed weight-bearing following operative treatment of ankle fractures.

Methods: We systematically searched six databases (PubMed, EMBASE, Cochrane CENTRAL, Web of Science, CINAHL, PEDro) from January 2015 to February 2025. Twelve studies (1,847 participants) comparing early (≤ 2 weeks) versus delayed weight-bearing protocols were included. Primary outcomes included functional scores, pain, range of motion, and complications. Random-effects meta-analyses used standardized mean differences for continuous outcomes and risk ratios for dichotomous outcomes.

Results: Early weight-bearing demonstrated significant advantages in pain reduction (SMD: +0.32, 95% CI: 0.21-0.43) and ankle dorsiflexion (SMD: +0.38, 95% CI: 0.26-0.50). Patients with EWB returned to work 12.3 weeks earlier and achieved clinically significant pain reduction 6 weeks sooner than delayed weight-bearing patients. Complication risk favored EWB (RR: 0.89, 95% CI: 0.69-1.14), with fewer immobilization-related complications (DVT: 2.5% vs. 6.3%; CRPS: 1.8% vs. 4.7%). Weber B fractures, younger age (< 45 years), and absence of syndesmotic injury predicted optimal EWB outcomes. Diabetic patients showed enhanced benefits from early mobilization compared to delayed protocols.

Conclusions: Early weight-bearing following ankle fracture surgery results in superior functional outcomes and equivalent safety compared to delayed protocols. Implementation within two weeks post-surgery appears optimal, with benefits most pronounced in Weber B fractures and younger patients. Syndesmotic injuries and diabetes require individualized assessment for optimal rehabilitation timing.

Keywords: Ankle fracture; Early weight-bearing; Functional recovery; Meta-analysis; Rehabilitation.

Fig. 1

Study Characteristics and Quality Assessment Overview of Included Literature on Early vs. Delayed Weight-Bearing in Ankle Fracture Rehabilitation. (a) PRISMA flow diagram detailing the screening, exclusion, and inclusion process. (b) Geographical distribution of included studies, presented as a bubble chart reflecting country-specific publication counts. (c) Risk of bias heatmap across multiple domains based on the Cochrane assessment tool. (d) Publication type distribution of the included studies, including RCTs, cohort studies, and meta-analyses. (e) Density distribution of study follow-up durations, with a dashed line marking the median follow-up time. (f) Density distribution of sample sizes across included studies, highlighting the median participant number

Fig. 2

Characteristics, Timing, and Trends of Early vs. Delayed Weight-Bearing Interventions in Ankle Fracture Rehabilitation. (a) Bar chart comparing early and delayed weight-bearing protocols in terms of initiation timing, type of weight-bearing, and rehabilitation activity formats. (b) Density plots of postoperative weight-bearing initiation time, stratified by early and delayed groups, with respective median time points marked. (c) Heatmap detailing the initiation timing, weight-bearing modality, and activity type of early weight-bearing interventions across individual studies. (d) Dot-line plot visualizing the comparative postoperative initiation week for early vs. delayed groups in each study. (e) Timeline trajectory of early weight-bearing intervention characteristics from 2015–2025, annotated by publication year, sample size, and intervention type

Fig. 3

Functional Outcomes and Clinically Meaningful Improvements Following Early vs. Delayed Weight-Bearing After Ankle Fracture Surgery. (a) Forest plot comparing pooled mean differences in functional scores across short-term, mid-term, and long-term follow-ups. (b) Longitudinal recovery trajectories of functional outcomes over time, highlighting group-wise trends and confidence intervals. (c) Bubble plot of MCID (Minimal Clinically Important Difference) differences across studies, scaled by sample size and stratified by follow-up time. (d) Bar plot comparing average functional outcomes by specific weight-bearing method categories and follow-up durations. (e) Subgroup forest plot analyzing functional outcome differences at 12 weeks across different fracture classifications (e.g., SER, Weber types). (f) Bubble plot of MCID achievement rates by study, emphasizing clinical impact distribution across interventions

Fig. 4

Integrated Comparative Analysis of Early vs. Delayed Weight-Bearing on Pain and ROM After Ankle Fracture Surgery. (a) Forest plot of standardized mean differences (SMDs) for post-operative pain scores across included studies. (b) Line plots showing temporal trends in pain relief under early vs. delayed weight-bearing regimens. (c) Forest plot of SMDs for ankle range of motion (ROM) recovery by study and movement type. (d) Time-based recovery trajectories of ankle ROM under different weight-bearing strategies. (e) Paired SMD comparisons of pain and ROM at 6 and 12 weeks postoperatively, categorized by outcome and study. (f) Bubble plot assessing the correlation between pain relief and ROM improvement (r = 0.61), with study weight reflected in bubble size

Fig. 5

Meta-Analysis of Complication Risks and Publication Bias Assessment for Early vs. Delayed Weight-Bearing in Ankle Fracture Management. (a) Forest plot summarizing the pooled risk ratios for overall postoperative complications. (b) Risk ratio forest plot for reoperation-related complications. (c) Forest plot of infection-related complication risks. (d) Risk ratio estimates for implant-related complications. (e) Contour-enhanced funnel plot evaluating small-study effects and asymmetry for overall complication data. (f) DOI (Doi plot) with Luis Furuya-Kanamori (LFK) index for quantitative publication bias detection

Fig. 6

Comparative Recovery Outcomes and Patient-Centered Metrics Following Early vs. Delayed Weight-Bearing After Ankle Fracture Surgery. (a) Dot plot showing return-to-work time comparisons across studies, with significance levels indicated. (b) Line charts depicting OMAS score trajectories at multiple postoperative timepoints. (c) Bar chart comparing quality-of-life outcomes (EQ-5D, SF-36, FAOS, etc.) between early and delayed weight-bearing. (d) Dot-whisker plots summarizing patient satisfaction outcomes, including pain relief, mobility satisfaction, and overall experience. (e) Forest-style panel plot illustrating differences in return time to ADL, sports, and work across studies, with effect size and statistical significance labeled

Fig. 7

Comparative Analysis of Radiographic and Functional Outcomes Between Early and Delayed Weight-Bearing After Ankle Fracture Surgery. (a) Proportion plot comparing radiographic outcomes (fracture healing, reduction maintenance, fixation failure) between groups across studies. (b) Effect size estimates for range of motion (ROM) recovery stratified by movement direction and timepoint. (c) Forest plot of complication risk ratios for radiographic and implant-related adverse events. (d) Percentage-point difference bar chart for radiographic outcomes, showing success rate gaps between groups. (e) Cohort-level comparison of radiographic and ROM outcomes, displayed as effect sizes (Cohen’s d) with 95% CIs. (f) Kaplan-Meier curve comparing time to radiographic healing between early and delayed weight-bearing patients