Early Weight-Bearing Following Ankle Fixation in a United Kingdom Major Trauma Centre: Real-World Adoption Versus a Contemporary Randomised Trial and British Orthopaedic Association Standards for Trauma.

Background Ankle fractures are common and place a substantial burden on services. Contemporary guidance generally permits weight-bearing as tolerated after stable fixation with early outpatient review. Recent randomised evidence suggests that beginning weight-bearing at around two weeks after open reduction and internal fixation (ORIF) can achieve at least comparable functional outcomes without increased complications and may be resource-efficient. Despite this, the adoption of early weight-bearing remains variable. We evaluated our centre's timing to first weight-bearing and early safety in the year following the dissemination of new evidence. Methods We conducted a single-centre retrospective cohort study at a UK major trauma centre (September 2024-August 2025). Adults (≥18 years) undergoing ankle ORIF were included; exclusions were hindfoot nails, tibial plafond (pilon) fractures, open fractures, or missing follow-up. Data sources were the local trauma database, operative notes, discharge summaries, fracture-clinic letters, imaging, and general practitioner records. Variables included age, sex, length of inpatient stay (LOS), fracture pattern (unimalleolar/bimalleolar/trimalleolar), posterior malleolus fixation (yes/no), syndesmosis fixation (none/screw/suture-button), and discharge device (cast/boot). The primary outcome was time to first weight-bearing (bands: at 2 weeks, 2-6 weeks, >6 weeks; sub-bands 6-8 and >8 weeks). Safety within eight weeks comprised unplanned emergency department/clinic contact, re-operation, and radiographic loss of reduction. Analyses used descriptive statistics (mean/standard deviation (SD); median/interquartile range (IQR)); between-group comparisons employed Kruskal-Wallis or Mann-Whitney U for days to weight-bearing and chi-square for proportions >6 weeks (two-sided p<0.05). Continuous outcomes (LOS, days to first weight-bearing) were non-normally distributed (Shapiro-Wilk p<0.001); hence, non-parametric tests were used. Results Forty-two patients were included. The mean age was 51.1 years (SD 16.5), with a median age of 49.5 years (IQR 39.2-62.5). LOS had a mean of 7.0 days (SD 7.9) and a median of 3.5 days (IQR 1.0-13.0). Time to first weight-bearing: at 2 weeks 2/42 (4.8%), 2-6 weeks 9/42 (21.4%), >6 weeks 31/42 (73.8%) (including 6-8 weeks 21/42 (50.0%), >8 weeks 10/42 (23.8%)). Safety ≤8 weeks in the 6-week or longer group showed unplanned contact 1/42 (2.4%), re-operation 0/42, loss of reduction 0/42, and delayed union 2/42 (4.8%). Safety margins in the 2-week group did not show any complications (0/42 in all parameters). Days to first weight-bearing did not differ significantly by fracture pattern (p=0.066) or syndesmosis fixation (p=0.383); posterior malleolus fixation was associated with longer time (Mann-Whitney p=0.036). Proportions exceeding six weeks did not differ significantly across subgroups. Conclusions Early weight-bearing after ankle ORIF was seldom implemented locally, with most patients first weight-bearing at ≥6 weeks despite reassuring short-term safety. In light of the recent clinical guidance, a default "weight-bearing as tolerated from two weeks" pathway (with clearly defined exceptions), standardised discharge/clinic instructions, and planned re-audit may improve implementation without compromising safety.