Weightbearing after ankle fracture fixation; a systematic review and meta-analysis of randomised controlled trials, a modern perspective

BACKGROUND: Optimal post-operative rehabilitation after ankle fracture fixation remains debated, particularly regarding early versus non weightbearing. This systematic review and meta-analysis evaluated outcomes following these weightbearing protocols. METHODS: A comprehensive search of scientific databases was performed on 12 December 2025 for randomised controlled trials (RCTs) published within 20 years comparing early weightbearing (≤2 weeks) with non weightbearing (≥6 weeks) after ankle fracture fixation. RESULTS: Six RCTs (1190 patients) were included. Early weightbearing significantly improved Olerud-Molander Ankle Scores at 6 weeks (MD 6.63, 95%CI 4.66-8.60; p < 0.0001) and 3 months (MD 3.70, 95%CI 1.57-5.82; p = 0.0007), and EuroQol-5D scores at 6 weeks (MD 6.62, 95%CI 3.71-9.54; p < 0.0001). Differences were not maintained beyond 6 months. Complication rates were similar between groups. CONCLUSION: Early weightbearing improves short-term functional outcomes without increasing complications. These findings support its use in appropriately selected patients with stable fixation and adequate bone quality, facilitating earlier recovery without compromising safety. LEVEL OF EVIDENCE: 1a; Systematic review of randomised controlled trial.