The Effect of Postoperative Weightbearing Protocols on Total Cost and Complications Following Ankle Fracture ORIF: A Systematic Review.

Abstract

Open reduction and internal fixation is often the definitive surgical treatment for unstable ankle fractures, however, there is significant debate regarding the optimal postoperative weight-bearing protocol. This study aims to evaluate the total costs associated with immediate unprotected weight-bearing, immediate protected weight-bearing, early weight-bearing, and delayed weight-bearing protocols following ankle fracture ORIF. A search of the PubMed electronic database was conducted in July 2025. The primary outcomes of interest included the effects of different weight-bearing protocols on healthcare costs and time to return to work. Secondary outcomes included postoperative complications. A total of eleven studies were included. Several studies demonstrated that earlier weight-bearing protocols were associated with a statistically significant decrease in time to return to work (P<0.05). Total cost was found to be lower in protocols allowing quicker return to weight-bearing, with a cost reduction as high as $928.29 for immediate protected weight-bearing compared to delayed weight-bearing protocols. No clinically significant differences in postoperative complications were noted, although four studies reported consistently fewer complications in the immediate protected weight-bearing group. This systematic review highlights the potential utility of immediate protected weight-bearing strategies following surgical repair of ankle fractures. These protocols demonstrate potential to decrease return to work and cost with no increase in postoperative complications. However, future studies are still needed to evaluate wearable monitoring solutions to quantify actual weight-bearing adherence. Further studies should evaluate comparisons between immediate protected weight-bearing, immediate unprotected weight-bearing, and early weight-bearing protocols, standardize reporting of outcomes, and stratify findings by fracture classification and fixation construct. Level of Evidence: Level III, systematic review of comparative studies.