Weight-bearing in ankle fractures
Overview
The question
For decades, most people who had surgery for a broken ankle were told not to put weight on their leg for six weeks. Doctors worried that walking too soon might damage the repair. But this advice was based on limited evidence. The WAX trial asked a simple but important question: was it safe, and better, for patients to start walking just two weeks after surgery instead?
Who it affected
Around 70,000 people break their ankle in the UK each year, and about 27,000 need surgery. These injuries affect adults of all ages, but are especially common in older people and women. Recovery can disrupt work, independence, and everyday life.
What we found
The WAX trial was carried out in 23 NHS hospitals across the UK. It compared early weight-bearing (walking from two weeks after surgery) with the traditional six weeks of non-weight-bearing.
We found that:
- Early walking was safe.
Complication rates were similar in both groups, and there was no meaningful increase in re-operations. - Ankle function was at least as good.
At four months, ankle function scores were slightly higher in the early walking group. - People returned to work sooner.
Those who walked earlier had less time off work in the first weeks after surgery. - Quality of life was better.
Patients reported more time in good health. - It saved money.
Early weight-bearing reduced overall costs by an average of £722 per person, when healthcare use and time off work were considered.
Patients told us that being allowed to walk sooner made them feel more independent, confident, and in control of their recovery.
Why it matters (impact)
The findings changed national guidance and clinical practice.
The British Orthopaedic Association (BOA) introduced its first national recommendation supporting early weight-bearing after ankle fracture surgery, directly informed by the WAX results.
The evidence was shared with NICE and is contributing to national policy discussions.
Hospitals across the NHS began updating rehabilitation advice, with more patients now encouraged to walk earlier.
This change has major public benefit. If most eligible patients move to early weight-bearing, an estimated 15,000–19,000 additional people each year could recover more quickly. This could save the NHS around £1 million annually and deliver wider societal savings of more than £10 million through faster return to activity and work.
The trial also influenced further research, including qualitative studies on patient experience, a Cochrane review on ankle fracture rehabilitation, and a planned national audit to measure real-world adoption across every NHS hospital.
Most importantly, the research shifted expectations: patients no longer had to accept six weeks of immobility as routine. Early movement became the new standard of care.
Outputs and reach
The main trial was published in The Lancet in 2024. The findings were highlighted in an NIHR Evidence Alert and informed the 2025 BOA national ankle fracture guidelines.
The study team also published related work on patient experience and clinician beliefs, and contributed to a 2024 Cochrane review on ankle fracture rehabilitation. The research was presented nationally and internationally and is now informing economic modelling work in the US, Canada, and Australia.
A UK-wide “sprint audit” planned for 2026 will assess how practice has changed since the trial.
Who was involved
The trial was led by researchers at Queen Mary University of London, including Professor Xavier Griffin and Mr Chris Bretherton, and delivered across 23 NHS hospitals. It was funded by the National Institute for Health and Care Research (NIHR).
The team had a strong track record in trauma trials and national audits, including earlier work establishing baseline UK practice. Patients were closely involved throughout the research, shaping its design and interpretation.