Discussion
fracture, dislocation, pain, fractures, atrophy
ATROPHY
Permissive weightbearing using a walking boot resulted in both better ankle function and health-related quality of life after six weeks when compared to non-weightbearing immobilization using a below-the-knee cast.This study is not the first to compare mobilization and weightbearing to immobilization and non-weightbearing [The comparison of calf circumference measurements between treatment groups did not yield any statistically significant differences at any of the follow-up intervals. It should be acknowledged that this study was not designed with sufficient statistical power to accurately determine the significance of any differences in calf circumference between groups. Therefore, it would be premature to draw definitive conclusions regarding the significance of any observed differences in calf circumference. However, when comparing the baseline and 6-week follow-up, a significant decrease in calf circumference was observed in the control group. After 12 weeks, patients in the control group no longer showed a difference in calf circumference when compared to baseline. These changes of the calf as observed during the follow-up were according to the expected outcome, as long-term immobilization causes adaptive changes including atrophy and loss of strength, which are reversible after physical training [At the time of the initiation of this study, the weightbearing radiograph was not standard practice in [location blinded]. Ankle joint stability was assessed in a non-weightbearing radiograph by measuring medial clear space and was deemed unstable if this was > 6 mm. With the intervention group mobilizing within 10 days after fracture, there was need for elimination of possible false positive stable fractures because of the possibility of dislocation after weightbearing. In this study, assessment of the stability of the ankle joint was performed through physical and radiological examination. Notably, a total of 23 patients (comprising 16% of the total screened patients) who had been deemed eligible for conservative treatment based on the non-weightbearing mortise assessment were subsequently excluded due to the detection of medial clear space widening on the weightbearing Mortise assessment. Images depicting the ankle of a patient were added as supplementary material. These images demonstrate the transition from a stable ankle joint, as observed in non-weightbearing radiographs, to an unstable joint, as evident in weightbearing radiographs.This study explores different aspects of fracture care in a randomized design, not only does it investigate ankle functionality after fracture, but it also aimed to explore quality of life differences between the intervention and control group. By using standardized outcome measures, we aimed to reduce the risk for detection bias.Unfortunately, the study encountered difficulties with regard to patient inclusion, as several patients declined to participate due to various reasons. These reasons included apprehension about mobilization and weightbearing, concerns about joint instability during mobilization, and general fears of pain. Furthermore, some patients who were deemed fit for inclusion by the study's supervising surgeon were ultimately excluded due to pre-existing immobility. Another limitation pertains to the measurement of ankle functionality after 6 weeks: while patients in both the control and intervention group were asked to complete the OMAS approximately 30 min after removal of the cast or walker, patients in the control group were immobilized for 6 weeks and those in the intervention group were allowed to remove the walker from time to time at home and engage in physical exercise. Although a direct comparison between the two groups may not be appropriate at this time as the intervention group has been mobilizing for 6 weeks, while the control group has not had this opportunity yet, the study was designed to assess the differences in outcomes after 6 weeks. Cast-related stiffness is a well-known consequence of immobilization as previous research has shown that functional recovery after casting may take up to 10 weeks after immobilization [