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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

A cross-sectional study of the impact of physiotherapy and self directed

exercise on the functional outcome of internally fixed isolated
unimalleolar Weber B ankle fractures
E. Karam, F.S. Shivji, A. Bhattacharya, D.J. Bryson, D.P. Forward, B.E. Scammell* ,
B.J. Ollivere
University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK

A R T I C L E I N F O A B S T R A C T

Article history:
Received 19 June 2016 This study aimed to measure the functional outcome and quality of life in a group of patients with the
Received in revised form 29 October 2016 same fracture type (unimalleolar Weber B ankle fractures) treated operatively at various time points and
Accepted 16 November 2016 to explore the determinants of such outcomes. A cross-sectional retrospective population study was
conducted. Validated Patient Related Outcome Measures (PROMs) and patient interviews were used.
Keywords: Fifty-one patients were included with a mean age of 54.9 years. Mean follow-up was 25 months (range 4–
Ankle fracture 46 months). Mean functional scores were high (mean AOFAS 79.2, O&M 75.7, VAS-FA 80.5). However, 32%
Function of patients did not classify themselves as fully recovered during interviews. Patient reported self-directed
Outcome
exercise had a statistically significant positive effect on self-reported patient perceptions of outcome
Exercise
(p = 0.022) and PROMs (AOFAS p = 0.01, O&M p = 0.016, VAS-FA p = 0.011). Formal physiotherapy
Physiotherapy
rehabilitation was found to have no effect on self-reported patient perceptions (p = 0.242) or PROMs
(AOFAS p = 0.8, O&M p = 0.73, VAS-FA p = 0.46). Our finding that physical activity is associated with
improved outcome would suggest structured exercise programmes should be considered in place of
physiotherapy to optimise patient outcomes.
ã 2016 Published by Elsevier Ltd.

Introduction
Ankle fractures are common injuries, with an incidence of
between 223 and 248 fractures per 100,000 persons [1,2]. The
distribution of fractures throughout the population is not linear,
with two main subgroups: young men aged 15–25 and older
women aged 75–84 [2].
Ankle fractures do not have uniformly good outcomes. Reported
outcomes in 736 fractures showed Weber A type fractures resulted
in 82.7% of patients having a good or excellent outcome, 83.8% for
Weber B types, and 70.4% for Weber C [3]. Better functional
outcomes after surgery have been reported for Weber B and C
types, compared to Weber A fractures, but the difference was not
significant [4,5,6]. Longer-term studies show this difference
between fracture types to be maintained [3]. Whatever the
* Corresponding author at: University of Nottingham, Academic Orthopaedics,
Trauma and Sports Medicine, Arthritis Research UK Pain and Sports, Exercise and
Osteoarthritis Centres, Queen’s Medical Centre, C Floor, West Block, Nottingham,
NG7 2UH, UK.
E-mail address: b.scammell@nottingham.ac.uk (B.E. Scammell).
fracture type, many patients perceive their function and quality of
life following trauma to be compromised, with decreased
functional scores and incomplete recovery, at 5 years post-
operatively [7,8].
There is a lack of research regarding the long-term functional
outcomes following ankle fracture surgery, and an even greater
paucity of studies measuring quality of life as well as function. We
aimed to measure the functional outcome and quality of life in a
group of patients with the same fracture type (unimalleolar Weber
B fractures) treated operatively, at various time points, and to
explore some of the determinants of outcome and quality of life.
Methods
Approval to conduct a cross-sectional study was obtained from
the Nottingham University Hospitals audit committee. Using the
hospital trauma database, all patients with unimalleolar, Weber B
type ankle fractures that underwent operative fixation during the
time period between 2008 and 2012 were reviewed (Fig. 1). The
initial decision to treat a patient with operative fixation was
determined by the clinical judgement of the lead clinician. Patients

http://dx.doi.org/10.1016/j.injury.2016.11.009
0020-1383/ã 2016 Published by Elsevier Ltd.

Please cite this article in press as: E. Karam, et al., A cross-sectional study of the impact of physiotherapy and self directed exercise on the
functional outcome of internally fixed isolated unimalleolar Weber B ankle fractures, Injury (2016), http://dx.doi.org/10.1016/j.
injury.2016.11.009
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2 E. Karam et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Fig. 1. Selection Process.
with factors known to affect outcome including smoking,
substance abuse, co-morbidities (diabetes, rheumatoid arthritis,
malignancy) and steroid use were excluded. Fracture specific
factors such as open fractures, and bi- and trimalleolar fractures
were also excluded to standardise the patient group.
Fig. 2. Mean postoperative scores v length of follow-up.
Please cite this article in press as: E. Karam, et al., A cross-sectional study of the impact of physiotherapy and self directed exercise on the
functional outcome of internally fixed isolated unimalleolar Weber B ankle fractures, Injury (2016), http://dx.doi.org/10.1016/j.
injury.2016.11.009
Eligible patients were contacted by post and telephone during
the data collection period in 2012 and invited to participate in the
study. Patients underwent clinical review and scoring via Patient
Related Outcome Measures (PROMs). All authors were blinded
during the data analysis. PROMs were assessed using the American
Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale (AOFAS)
[9], the Olerud and Molander (O&M) score [10] and the Visual
Analogue Scale Foot and Ankle (VAS-FA) score [11] . The AOFAS
and VAS-FA are domain specific scores, designed to evaluate the
function of the ankle as a whole. The O&M is a disease specific
score, aimed solely at assessing function following ankle fractures.
The AOFAS has been widely used in the literature, which allows
comparison of our results with existing research [11,16]. It is
divided in 3 sections: pain, function and alignment, assessing
objective and subjective aspects of the impact of injury on the
patient. The O&M has also been widely used in the literature,
making it desirable as a comparative tool with existing research
[7,8]. It is divided in various sections such as pain, stiffness,
swelling, etc. and is very similar in administration to the AOFAS.
The VAS-FA is much more recent than the other two scores and has
not yet been as widely used in the existing literature. It is one of the
only functional outcome scores to have been validated against the
SF-36, a widely used qualitative score, which gives the VAS-FA a
high level of discrimination when measuring more subjective
aspects of recovery. It uses analogue scales rather than tick boxes
and assesses purely subjective questions.
Medical records, correspondence, and radiographs were
reviewed to collate demographic and treatment data.
In addition to these scores, a series of qualitative semi-
structured interviews were conducted, explaining themes related
to quality of life that was not covered by the questionnaires.
Patients were asked whether they considered themselves to be
fully recovered or not, what that meant to them, how long it had
taken them to get to this level, their main concerns at the time,
whether the fracture affected their daily lives, their impressions/
feelings about the postoperative period and finally how much of an
impact did they consider their involvement during the recovery
process to have had on their postoperative outcome.
All patients were operated upon in the same unit using
standard AO operative techniques and a standardised postopera-
tive protocol. Patients were treated using open reduction and
internal fixation using lateral plating for the fibula with or without
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lag screws. Following ward review, all were placed in a below knee 100
non-weight bearing cast for 6 weeks before full weight bearing.
Statistical analysis was performed using Prism 6 (GraphPad
Software. Released 2012. Prism 6 for Mac OS X, Version 6.0b. La
Jolla, California) and SPSS (IBM Corp. Released 2013. IBM SPSS 80 n=2 n=4 n=5 n=3
Statistics for Macintosh, Version 22.0. Armonk, NY: IBM Corp.).

Proportion of patients (%)

Data using AOFAS and O&M scores was found to be normally
distributed and therefore analysed using unpaired t-tests. VAS-FA
scores were not normally distributed, hence analysed using Mann- 60
Whitney testing. When analysing quality of life results, data was
analysed using Chi-squared tests or Fisher’s exact tests (when
values were 5). We used logistic regression when analysing
qualitative data with varying lengths of follow-up. A p-value of 40
0.05 was regarded as significant and an odds ratio greater than 1
indicated a more likely event in the first group compared. n=5 n=9 n = 11 n=5

Results 20

One hundred and forty one patients met the inclusion criteria
and 90 patients were lost to follow-up for various reasons (Fig. 1).
The study group (n = 51) formed the final sample. There was no 0
statistically significant difference in the female to male gender

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ratio between the 90 patients lost to follow-up and the 51 included

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3
in the final group (p = 0.19). The gender distribution was bimodal,

with a female mean age of 58.9  2.7 and male mean age of
48.7 4.8. However, the patients lost to follow-up did have a lower
mean age (48.9 years vs 54.9 years), but this was not significant
(p = 0.07). Minimum follow-up time was 4 months (n = 3),
maximum was 3 years and 10 months (n = 5) and mean follow-
up was 2 years and 1 month (SD  1.04 year).
Our patients’ injuries were a mix of sports injuries, falls of a
height less than 1 m, twisting injuries and falls downstairs.
Functional scores
All questionnaires are scored from 0 to 100; 100 points being
the best functional outcome score possible. The mean scores for
the whole sample were AOFAS 79.2 (95% CI 73.8–84.6), O&M 75.7
(95% CI 68.5–82.9), and VAS-FA 80.5 (95% CI 74.9–86.2). Three
AOFAS and 2 O&M scores were excluded from the data analysis due
to incomplete questionnaires.
Functional outcome with length of follow-up time
Functional scores declined with increasing length of follow-up
time (Fig. 2), with a small increase in VAS-FA from 2 to 3 years of
follow-up time (75.9 and 83.7 respectively). There was no
significant difference in mean scores at 0.5 year and 3 year
follow-up for any scoring system (AOFAS p = 0.16, O&M p = 0.35,
VAS-FA p = 0.95).
Patient perceived recovery over time
Using qualitative data from the patient interviews (n = 44), the
number of patients who classified themselves as fully recovered or
not can be seen in Fig. 3. When comparing these results at 0.5 year
and 3 years follow-up, there was no statistical difference (p = 0.57)
between patients considering themselves fully recovered and the
others. 31 patients (70%) felt they could perform all the activities
they used to do prior to their injury. 13 patients (30%) felt they were
unable to perform all their previous activities. 14 (32%) patients
still experienced pain and 8 (18%) complained of discomfort from
the metalwork. At the time of follow-up, no patient had undergone
revision surgery for pain.
6
n = numbers of patients (non statistically significant)
Not Fully Recovered Fully Recovered
Fig. 3. Percentage of patients self-reported recovery against time post-fracture.
Determinants of outcome
Further cross sectional analysis was undertaken using themes
from the structured interviews (Table 1) using logistic regression
to adjust for different length of follow-up. Patient reported
informal exercise had a statistically significant effect on self-
reported patient perceptions of outcome. This significant differ-
ence was also seen in comparisons between PROMs. Mean AOFAS
in those not undertaking exercise was 70 compared with a score of
85 with exercise (p = 0.01), mean O&M 64 vs 83 (p = 0.016), mean
VAS-FA 73 vs 85 (p = 0.011), respectively. Exercise was defined as
any form of physical exercise performed on a regular basis
throughout the entirety of the recovery period observed.
Formal physiotherapy rehabilitation (p = 0.242), age (p = 0.57)
and gender (p = 0.51) were found to have no effect on self-reported
patient perceptions. Physiotherapy also had no effect on PROMs,
with no differences between those receiving physiotherapy and
not (mean AOFAS 78 vs 80, p = 0.8, mean O&M 79 vs 75, p = 0.73,
mean VAS-FA 80 vs 81, p = 0.46). There was a marginally significant
difference in VAS-FA scores in men (87) compared with women
(77) (p = 0.046), and no significant differences in other outcome
measures (AOFAS in men 82 vs 77 in women, p = 0.37, O&M 79 vs
73, p = 0.46).
Finally, a significant difference in all PROMs was found when
comparing those patients aged below 40 and over 40 years.
Patients below 40 scored a mean AOFAS of 90, O&M of 91, and VAS-
FA of 89. All scores were significantly lower in those over 40 years,
with a mean AOFAS of 77 (p = 0.04), O&M of 72 (p = 0.001), and VAS-
FA of 78 (0.002).
Discussion
This study aimed to quantify the outcome of patients with an
operatively treated unimalleolar Weber B ankle fracture. Gender
distribution was bimodal, in line with previous literature [2]. Mean
functional scores were generally high (mean AOFAS 79.2, O&M

Please cite this article in press as: E. Karam, et al., A cross-sectional study of the impact of physiotherapy and self directed exercise on the
functional outcome of internally fixed isolated unimalleolar Weber B ankle fractures, Injury (2016), http://dx.doi.org/10.1016/j.
injury.2016.11.009
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4 E. Karam et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Table 1
Self reported recovery outcome in various patient subgroups.
Not fully Recovered Fully Recovered
Exercise 6 23
No exercise 9 7
No Physiotherapy 2 8
Physiotherapy 13 22
Male 7 11
Female 8 19
Age  40 3 8
Age > 40 12 22
75.7, VAS-FA 80.5), indicating a good outcome for such patients.
However, 32% of patients did not classify themselves as fully
recovered during interviews.
This study found mean functional scores were comparable with
previous studies [6,7,8,12]. Ponzer et al. [7] used an O&M score in
their 2-year follow-up study of 41 patients with Weber B fractures
and obtained a mean of 84  22.5. Shah et al. [8] also used an O&M
score in their 5-year follow-up study of 69 patients and obtained a
mean of 75.1, which is similar to our findings. Stufkens et al. [6]
reported a mean AOFAS score of 86.6 for 36 patients at a mean
follow-up time of 13 years and mean age of 46.9 years. Their
sample was smaller and younger than ours, in addition to being
mostly sports injuries, implying a high level of activity within their
patient group. This could explain why their mean AOFAS score is
higher than as observed in our study.
Overall, 32% of patients did not consider themselves to be fully
recovered in our study at mean follow-up of 25 months. The
proportion of patients reporting full recovery did not increase with
longer follow-up times, with 69% of patients fully recovered at 1-
year follow-up versus 63% at 3 years. 30% of patients were unable
to perform activities that they were participating in prior to their
injury. Our data shows a significant disability remains up to 4 years
after suffering a Weber B ankle fracture. There are a range of
reported functional outcomes in the literature, with Ponzer et al.
[7] reporting that 2 years post-surgery, 64% of their patients had
not recovered, whilst Shah et al. [8] finding 39% had not fully
recovered. There is obviously a wide variation in the results from
these studies and our own, most likely due to the method of
assessing recovery.
This study is the first to report the effects of physical activity
levels on PROMs. Those patients with an active lifestyle were more
likely to have fully recovered (p = 0.022). When adjusting for length
of follow-up, patients doing exercise were found to be more likely
to be fully recovered (OR 4.8 (1.25, 18.35)). There might be a
confounder here, as the patients with a better score on our PROMs
are likely to be the ones enjoying exercise and with a general
overall better level of fitness. However, formal prescribed
physiotherapy was not found to make a difference (p = 0.242s).
Recall bias could have influenced the way patients reported their
experience of rehabilitation, however a lack of benefit of formal
physiotherapy has been shown previously in a randomized control
trial (114 patients) [14]. This found no difference with regard to
O&M and SF-36 scores between those given a 12-week physio-
therapy programme and the control group. However, muscle
strength was found to be significantly improved [14]. Our finding
that physical activity improves outcome would suggest structured
exercise programmes should be considered in place of physiother-
apy to optimise patient outcomes. A recent publication by Moseley
et al. [17] supports this conclusion as it suggests supervised
exercise programmes (rehabilitation) offer no benefits in quality of
life or activity limitation compared to advice alone in the context of
Please cite this article in press as: E. Karam, et al., A cross-sectional study of the impact of physiotherapy and self directed exercise on the
functional outcome of internally fixed isolated unimalleolar Weber B ankle fractures, Injury (2016), http://dx.doi.org/10.1016/j.
injury.2016.11.009
p-value (*: significant) Odds ratio (95% CI)
0.022 * 4.8 (1.25, 18.35)
0.242 0.35 (0.06, 2.01)
0.51 1.54 (0.43, 5.45)
0.57 0.99 (0.96, 1.03)
isolated, uncomplicated ankle fractures such as the ones observed
in this study.
It has previously been shown that patients below 40 years of
age had a significantly better outcome than those over this age
[14,15]. Our results match those conclusions according to the
PROMs, but not according to patients’ own perceived outcome. This
difference might stem from the fact that PROMs are not normalised
for age. It is also worth noting the presence of previous literature
that has found no significant difference in patients above and
below the age of 40, but were using different questionnaires to the
PROMs used in this current study [12,13]. Gender did not
significantly affect patients’ recovery in our study, which is also
in line with previous literature [13,14], with the exception of the
VAS-FA score that showed a marginally significant difference
(p = 0.046) between men and women. This was attributed to the
analogue scale grading system of the score, allowing for more
nuanced and discriminatory replies.
The main limitation of this study is that ninety patients were
lost to follow-up. However, we found no significant demographic
differences between those lost to follow-up and those included in
the study, except for the older age of the group included. Our group
of 51 patients is comparable to the other recent studies, of Ponzer
et al. [7] (n = 41), Stufkens et al. [6] (n = 39), and Shah et al. [8]
(n = 69 patients). Comparing our patient group to those lost to
follow-up, there were no significant differences regarding age or
gender, allowing meaningful conclusions to be made. Furthermore,
the addition of qualitative data allows more detailed analysis [7,8].
All scores had a similar progression up to 2 years, indicating that
the results are a true reflection of patient recovery as assessed by
PROMs. At 2 years and beyond, the VAS-FA scores were better than
the other two scores, possibly because VAS-FA measures outcomes
with a scale rather than set point increments. This allows for a
more detailed variation in scoring when grading outside of the
extremes of the scale, as was observed with the longer follow-up
patients. Early on after injury, patients will tend to assess their
recovery in absolutes. As time from trauma increases, they will
require more flexibility and nuancing to define the extent of their
recovery, which is not provided by scores using a Multiple Choice
Questions format, such as the AOFAS and O&M but is afforded with
the analogue scale design of the VAS-FA. A cross sectional study
such as this has the strength of assessing patients at different
follow-up times, and allows for normalised curves for comparison
with future studies.
Our study brings into question the validity of the PROMs used
when assessing patient recovery. The PROMs may be recording
what clinicians feel are important factors in recovery, but not
necessarily what patients themselves feel are important. Although
the mean PROMs for our sample showed a ‘good’ recovery, almost a
third of patients were not fully recovered by their own admission.
Also, age was deemed to significantly affect PROMs but had no
effect on patient perceived recovery. Further research is required to
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assess the reliability of these scores in relation to assessing
tangible recovery post ankle fracture.
Another limitation of this study is the small numbers of patients
when observing groups of different lengths of physiotherapy time
performed. Although this data was analysed, no significant or
meaningful conclusion could be drawn. This should be investigated
in a larger prospective study.
Our study used strict inclusion and exclusion criteria in an effort
to reduce confounding variables such as co-morbidities, which
strengthens the quality of data. In a further effort to reduce bias, all
authors were blinded during the data analysis. All patients were
allocated randomized numbers for allocation to clinics, in an effort
to blind the clinicians administering the tests and scores.
Conclusions
This study shows that at a mean follow-up of 2 years and 1
month post surgical fixation of unimalleolar Weber B ankle
fractures, a significant proportion (30.5%) of patients self-reported
that they have not fully recovered and are unable to function at
their pre-injury level. Self- directed exercise was found to have a
significant impact on recovery (p = 0.022), whereas formal
physiotherapy, gender and age did not. These are important
findings as this fracture is commonly thought of as a relatively
benign injury, but we have shown that this is not always the case.
Patients benefit from postoperative exercise, and clinicians should
encourage this. However, the positive impact of formal physio-
therapy may be questionable, and would benefit from further
investigation. These results can be used to counsel patients as to
the prognosis of their injury, and by clinicians to tailor
postoperative care.
Conflict of interest
None.
Acknowledgement
The University of Nottingham for funding as part of a BMedSci
dissertation.
Please cite this article in press as: E. Karam, et al., A cross-sectional study of the impact of physiotherapy and self directed exercise on the
functional outcome of internally fixed isolated unimalleolar Weber B ankle fractures, Injury (2016), http://dx.doi.org/10.1016/j.
injury.2016.11.009
5
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