Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture

Bretherton, Chris; Claireaux, Harry; Achten, Juul; Athwal, Amrita; Dutton, Susan; Peckham, Nicholas; Petrou, Stavros; Kearney, Rebecca S.; Appelbe, Duncan

doi:10.1186/s12891-021-04560-7

Cited by 12 publications

(6 citation statements)

References 18 publications

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“… 9 - 11 , 30 The requirement for non-weightbearing for patients who have surgery for ankle fracture is being challenged. 31 If supportive evidence is found, this may ease the burden of disability in early recovery for this group of patients.…”

Section: Discussionmentioning

confidence: 96%

Understanding patient experience of distal tibia or ankle fracture: a qualitative systematic review

et al. 2023

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AimsTo systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery.MethodsWe undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes.ResultsFrom 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of ‘being the same but different’ conveyed the substantial disruption to patients’ self-identity caused by their injury. Patient experience of ‘being the same but different’ was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future.ConclusionAnkle injuries were disruptive, draining, and impacted on patients’ wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients.Cite this article: Bone Jt Open 2023;4(3):188–197.

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Section: Discussionmentioning

confidence: 96%

Understanding patient experience of distal tibia or ankle fracture: a qualitative systematic review

et al. 2023

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“…The implications for treatment and rehabilitation are that support maybe required for: (i) mental wellbeing throughout periods of increased vulnerability that include consideration of self-identity, ageing and disability, and counselling on prognosis, (ii) developing confidence and self-efficacy in decision making around being safe and (iii) training where further functional gain could enhance quality of life. A move towards treatments that facilitate earlier weight bearing ( Bretherton et al, 2021 ) or maintenance of weight bearing status may reduce the detrimental effects of dependency and loss of mobility. The health benefits of maximising recovery in this age group have potential to mitigate the impact of increasing frailty with age and effect of co-morbidities on overall health.…”

Section: Discussionmentioning

confidence: 99%

‘It Makes Me Feel Old’: Understanding the Experience of Recovery From Ankle Fracture at 6 Months in People Aged 50 Years and Over

et al. 2023

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Ankle fracture is a common injury, and depending on injury severity, treatment may be a support boot, cast or surgery. Older people, particularly those with severe injuries who are asked to restrict weight bearing, struggle with early recovery. To elicit older peoples’ experience of recovery 6 months after injury, we drew on a phenomenological approach using interviews. Findings revealed that getting on with life was a way of accepting what it feels like to ‘be vulnerable’, needing to ‘be safe’ while determinedly working hard to ‘be myself’. Being vulnerable identified endurance of inactivity, loneliness and dependency in the non-weight bearing period of recovery, followed by a struggle to weight bear while lacking confidence and being fearful of falling and causing further damage. Being safe conveyed fragility where sensations, pain and stiffness acted as bodily reminders of injury. Lack of function and awareness of danger led to carefulness where planning or curtailing of activities ensured their safety. Being myself showed a determination to push away from a disrupted self-identify of being older or disabled while being challenged by the continuous process of learning to be more mobile. A lack of readiness for old age created a drive to age well. Despite loss of ability, participants hoped to regain their pre-injury way of living. This study challenges practice that disregards the hard work required to recover from ankle fracture. As comorbidity increases with age, failure to consider this aspect may contribute to frailty in this group of older people.

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“…Level I evidence is lacking to guide the postoperative instructions. The Weight-bearing in Ankle Fractures (WAX) trial may provide confidence in weightbearing after ankle fracture surgery, 29 but other sites remain a challenge for research. This partly reflects the lower incidence of non-hip fragility fractures.…”

Section: Discussionmentioning

confidence: 99%

The Fragility Fracture Postoperative Mobilisation multicentre audit

Richardson

Bretherton

Raza

et al. 2022

The Bone & Joint Journal

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Aims The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. Methods The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, “all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living ”. Results A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). Conclusion Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972–979.

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Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture

Cited by 12 publications

References 18 publications

Understanding patient experience of distal tibia or ankle fracture: a qualitative systematic review

Understanding patient experience of distal tibia or ankle fracture: a qualitative systematic review

‘It Makes Me Feel Old’: Understanding the Experience of Recovery From Ankle Fracture at 6 Months in People Aged 50 Years and Over

The Fragility Fracture Postoperative Mobilisation multicentre audit

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