The findings are relevant to a common challenge in orthopedic recovery: how soon patients should begin moving and bearing weight after open reduction and internal fixation (ORIF) of an unstable ankle fracture.
Comparing Early Mobilization With Traditional Casting
Ankle fractures are among the common injuries treated by orthopedic surgeons. For unstable fractures, ORIF is widely used to restore the position of the bones and stabilize the ankle.
After surgery, however, there is no universal agreement about the best rehabilitation strategy. Traditional treatment often involves immobilization in a cast for several weeks. Early-mobilization protocols instead use a removable boot, brace, or orthosis, combined with protected weight-bearing and progressive movement.
Adilio and Bahari conducted a comprehensive systematic review following the PRISMA 2020 framework. Their analysis included 25 reports representing 23 independent cohorts and 3,613 participants. The researchers compared early mobilization without a traditional cast with conventional cast immobilization following ORIF.
Functional Recovery Improved During the First Months
One of the clearest differences appeared in the Olerud-Molander Ankle Score (OMAS), a commonly used measure of ankle function.
At six to eight weeks after surgery, patients in the early-mobilization groups had an average 9.42-point advantage over those treated with casting. The 95% confidence interval ranged from 4.80 to 14.03, with p<0.0001. The analysis included four randomized trials involving 480 participants.
The benefit remained visible at 12 weeks to four months, although it became smaller. The average difference was 6.12 points, with a 95% confidence interval of 2.28 to 9.96 and p=0.0018.
By 12 months or later, however, the difference was no longer statistically detectable. The pooled mean difference was only 0.71 points, with a 95% confidence interval from −1.20 to 2.61.
In other words, early mobilization appeared to accelerate recovery rather than permanently change the long-term functional outcome.
Better Ankle Movement and Earlier Return to Work
The advantages were not limited to functional scores.
At six weeks, patients receiving early mobilization demonstrated approximately 10.12 degrees greater range of motion than patients treated with casting. The finding came from two randomized trials involving 160 participants and was statistically significant.
Return to work also appeared to occur sooner. Across three trials involving 157 participants, early mobilization was associated with a reduction of approximately 28.92 days in time to return to work. However, the researchers noted substantial variation among the studies, meaning this result should be interpreted with caution.
Short-term quality of life also favored early mobilization. Two randomized trials involving 380 participants reported a standardized mean difference of 0.59, while other findings suggested earlier return to pre-injury activities and full weight-bearing.
What About Safety?
One of the most important questions is whether moving the ankle earlier could damage the surgical fixation.
The review found no statistically significant increase in fixation failure, loss of reduction, or non-union. Five studies involving 546 participants reported only three relevant events, with a risk ratio of 1.07 and a 95% confidence interval of 0.22 to 5.11.
The analysis also found no statistically significant increase in venous thromboembolism. However, these events were uncommon, making precise estimates difficult.
The main safety concern involved the surgical wound.
Although the overall complication difference was not statistically significant, wound complications showed a numerical trend toward greater risk with early mobilization. The pooled risk ratio was 2.03, but the confidence interval was wide and crossed the line of no difference.
The review therefore emphasizes that “early mobilization” should not automatically mean unrestricted movement immediately after surgery.
Timing Matters
The evidence suggests that the timing and protection of movement are important.
The review describes a more favorable balance when patients initially use a protective device and unrestricted ankle movement is delayed until the surgical wound has been assessed. One approach supported by the evidence is protected weight-bearing in a boot while postponing unprotected movement until approximately 10–14 days after surgery, depending on the clinical protocol and wound condition.
This distinction is important because early loading and early unrestricted movement are not necessarily the same treatment.
Who May Benefit Most?
The evidence most strongly supports early mobilization for selected patients, particularly working-age adults with isolated Weber B fibular fractures, stable fixation, healthy soft tissue, normal sensation, and no major metabolic or vascular risk factors.
Traditional casting may remain appropriate for patients with fragile or compromised skin, peripheral neuropathy, poorly controlled diabetes, marked osteoporosis, open fractures, certain syndesmotic fixation situations, cognitive impairment, or difficulty following weight-bearing restrictions.
This means rehabilitation decisions should be individualized rather than based solely on the desire to mobilize patients as quickly as possible.
The Main Benefit May Be Faster Recovery, Not a Better Final Result
The researchers' analysis showed a consistent decline in the functional advantage of early mobilization over time. The OMAS difference decreased from 9.42 points at six to eight weeks, to 6.12 points at 12 weeks to four months, and finally to 0.71 points at 12 months or later.
The pattern suggests that early mobilization primarily changes how quickly patients recover, rather than determining their eventual level of ankle function.
For patients, that distinction can be significant. Faster recovery may mean earlier walking, improved mobility, a quicker return to work or daily activities, and a better quality of life during the months immediately following surgery.
Implications for Orthopedic Care
The findings provide evidence for rehabilitation protocols that allow carefully protected movement after ORIF rather than automatically relying on prolonged casting.
However, the review does not suggest that every patient should abandon casting. Instead, the evidence points toward a more individualized approach in which surgeons consider fracture stability, fixation quality, wound condition, patient characteristics, and the ability to follow rehabilitation instructions.
The authors conclude that early mobilization can improve function, ankle range of motion, short-term quality of life, and return to work or activity during the first three to four months after surgery. At approximately one year or later, the functional differences become indistinguishable.
About the Authors
Wellyan Rahmat Adilio is affiliated with the Faculty of Medicine, University of Bengkulu, Indonesia, and serves as the corresponding author of the review.
Pramudya Akbar Bahari is also affiliated with the Faculty of Medicine, University of Bengkulu.
The source article does not provide the authors' academic degrees or detailed professional biographies, so those details are not added here.
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