What is the recommended postoperative rehabilitation guideline after Open Reduction Internal Fixation (ORIF) of a trimalleolar ankle fracture?

Postoperative Rehabilitation After ORIF of Trimalleolar Ankle Fracture

Early weight bearing at 3 weeks postoperatively combined with functional mobilization is safe and superior to traditional 6-week non-weight bearing protocols, resulting in faster return to function without increased complications.

Weight Bearing Protocol

Begin protected weight bearing at 3 weeks postoperatively if the surgical construct is stable, as determined by the operating surgeon 1, 2, 3. This represents a significant departure from traditional 6-week non-weight bearing protocols.

• Weeks 0-3: Non-weight bearing with crutches 1, 2
• Week 3 onwards: Progressive weight bearing as tolerated with assistive devices 1, 2, 3
• Full weight bearing: Typically achieved by 7-8 weeks postoperatively 1, 2

The evidence strongly supports this approach: early weight bearing at 3 weeks demonstrates significantly lower rates of deep infection (1.7% vs 6.1%) and reoperation (2.0% vs 7.8%) compared to traditional 6-week protocols, with no difference in union rates or implant failure 2. A matched-pair analysis confirmed patients with early weight bearing achieved full weight bearing at 7.7 weeks versus 13.5 weeks in delayed protocols 1.

Critical Caveat

Weight bearing should only progress if the patient demonstrates:

• Correct gait pattern (with crutches if necessary) 4
• No pain during or after walking 4
• No effusion or temperature increase 4
• Stable surgical fixation as confirmed by the surgeon 1, 3

Immobilization and Bracing

Minimize cast immobilization duration to approximately 2 weeks or less 2. Early functional treatment is superior to prolonged immobilization.

• Use a removable walking boot rather than rigid cast when possible 1, 2
• Cast immobilization periods averaging 1.8 weeks show better outcomes than 2.7 weeks 2
• Do NOT use routine postoperative knee bracing, as this is associated with 2.83-fold increased failure rates 5

Range of Motion Protocol

Initiate immediate ankle mobilization with progressive flexion restrictions 5.

• Weeks 0-4: Restrict dorsiflexion/plantarflexion to 90-45° 5
• Week 5: Progress to 90-30° 5
• Week 6: Progress to 90-20° 5
• Week 7: Progress to 90-10° 5
• Week 8: Full ROM 5

For patients with delayed rehabilitation or scar tissue formation, Mulligan's mobilization with movement techniques effectively restore dorsiflexion range 6.

Exercise Progression

Weeks 0-3 (Non-Weight Bearing Phase)

• Initiate isometric quadriceps exercises on postoperative day 1 when pain-free 4, 5
• Begin ankle pumps and gentle ROM within protected ranges 6
• Cryotherapy for pain control in first postoperative week 4
• Ultrasound therapy for scar mobility if needed 6

Weeks 3-6 (Early Weight Bearing Phase)

• Prioritize closed kinetic chain exercises over open kinetic chain 5
• Progress to concentric and eccentric exercises when no effusion or pain increase occurs 4
• Begin proprioception training 6
• Gait training with assistive devices 6, 1

Weeks 6-12 (Advanced Phase)

• Open kinetic chain exercises (90-45°) may begin at 4 weeks, but add no extra weight for first 12 weeks 5
• Progressive strengthening of lower limb muscles 6
• Combine neuromuscular training with strength training for optimal outcomes 4, 5
• Core stability exercises as adjunct 4

Return to Work and Activity

• Return to work: Average 8-9 weeks postoperatively 1, 2
• Return to driving:
  • Right ankle: 4-6 weeks 4
  • Left ankle: 2-3 weeks 4

Return to Sport Criteria

Use objective criteria rather than time alone 5. Minimum discharge criteria include:

• No pain or swelling (trace effusion acceptable) 4, 5
• Full ankle ROM 4, 5
• Limb symmetry index >90% for strength and hop tests 4, 5
• For pivoting/contact sports, LSI of 100% is recommended 4
• Quality of movement assessment during functional activities 4

Common Pitfalls to Avoid

Prolonged non-weight bearing causes muscle wasting and delayed functional recovery 6. The traditional 6-week non-weight bearing protocol is outdated and associated with worse outcomes 1, 2.

Patient fear of pain can lead to excessive non-weight bearing 6. Address psychological factors including fear of reinjury through patient education and gradual progression 4.

Medical comorbidities and older age may require modified protocols 7. However, even in these populations, aim for weight bearing by 6-8 weeks maximum rather than prolonged immobilization 7, 2.

Infection or wound complications delay weight bearing 6. If pus discharge or wound dehiscence occurs, address infection aggressively before progressing rehabilitation 6, 2.