Early weight-bearing following surgical fixation of ankle fractures without trans-syndesmotic fixation: safety and early functional outcomes - a systematic review and meta-analysis

Early weight-bearing (EWB) following surgical fixation of malleolar (distal fibula and tibia) fractures in cases without trans-syndesmotic fixation is increasingly advocated, yet clear benefits over delayed weight-bearing (DWB) remain uncertain. We systematically searched PubMed, Embase, and Cochrane CENTRAL through April 2025 for randomised and comparative studies evaluating EWB (≤ 3 weeks) versus DWB (≥ 6 weeks) in operatively treated ankle fractures without trans-syndesmotic fixation. Primary outcomes were functional recovery - measured by each trial’s validated ankle-specific score (OMAS or FAOS) at 12 weeks - and overall complication rate, including loss of reduction/malunion/nonunion rates. Return to work/normal daily activities, and all other outcomes were exploratory. Risk of bias was assessed using RoB 2 and ROBINS-I tools. Eight studies (n = 817; 4 RCTs, 4 comparative cohorts) met inclusion criteria. EWB was associated with a statistically significant improvement in functional recovery at 12 weeks (SMD 0.22; 95% CI 0.07–0.38; I² = 0%) without increasing overall complication risk (RR 0.78; 95% CI 0.53–1.14; I² = 0%), although the magnitude of functional improvement remained below minimal clinically important difference (MCID) thresholds. This small statistical difference persisted at 12 months (SMD 0.17; 95% CI 0.02–0.33), remaining below MCID thresholds. No significant differences were found in individual complication subtypes. EWB was also associated with a 10.8 days (MD − 10.82; 95% CI − 17.61 to − 4.04; P = 0.002; I² = 35%) earlier return to work/normal daily activities. Subgroup analysis suggested greater functional benefit with CAM boots and when weight-bearing began between postoperative days 10–21, though no significant subgroup interactions were observed. In surgically treated ankle fractures without trans-syndesmotic fixation, EWB appears safe and is associated with small improvements in early functional recovery and earlier return to activity, without increasing complications. However, the magnitude of functional improvement remained below established MCID thresholds, indicating limited clinical significance and no clear long-term functional superiority over delayed protocols.