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A
This is Mark Easley, and I have the distinct honor of talking with Dr. Brian Weatherford, the senior author of March Lead paper in Foot and Ankle International. The paper is titled Effect of Earlier Weight Bearing on Ankle Range of Motion and Complications after Primary total ankle arthroplasty. Dr. Brian Weatherford is a clinical assistant professor at the University of Illinois, Chicago and works at the Illinois Bone and Joint Institute and has expertise in total ankle replacement. Dr. Saltzman and I selected this article that compares ankle range of motion when post operative weight bearing is initiated at three weeks versus six weeks after in bone two total ankle arthroplasty. Welcome to the program, Brian.
B
Thanks for having me.
A
Brian, as senior author, would you please provide the listeners a brief summary of your paper and its major findings?
B
Yes. So the paper is looking at two cohorts of my own patients who were allowed to weight bear at either three weeks or six weeks. So this was not randomized in any way. Basically, earlier in my practice, like most people doing ankle replacements, I was conservative with weight bearing. But as I got more experience with it, I began to wonder why we were doing this. Because we had made such tremendous advances in the technology, but we hadn't at all updated any of our physical therapy or rehab protocols to reflect that. So I started to move my weight bearing time up earlier and earlier. And there's been some good data in the trauma world for ankle fractures allowing that. So I just decided, okay, their first visits at three weeks, what if we just let them start to weight bear then and follow them closely and see what happens? That's basically what this study is, is we looked at two things. One, how did the patients do in terms of their outcomes? And number two, did it increase their risk of complications? And basically it turns out that earlier weight bearing did not increase the rate of complications, number one. And that number two, the people who were weight bearing earlier actually seem to be doing better in terms of ankle range of motion, which was a little bit of a surprise, but I guess as I've reflected on it, not too surprising. So that's the study.
A
Great. Would you please clarify weight bearing as tolerated in a cam boot? Is that walking in the boot with or without assistive devices?
B
That's correct. Yeah. So they are allowed to put as much weight as they are comfortable with starting at three weeks. And in fact, I've even moved it up further. It's now two weeks. And in fact, for some elderly patients, I'm even letting them weight bear at one week. And so, yes, they are allowed to walk in the Boot with or without any assistive device starting at three weeks.
A
Got it, thanks. Your post operative protocol included beginning on day one or two, working on gentle ankle range of motion independent at that day one or two, and then starting at three weeks, participating in formal physical therapy focusing on ankle range of motion. Would you please share with the listeners details of this physical therapy protocol?
B
Yes. So I will give credit to Steve Haddad here. I took this right from him and so he was already doing what's called lymphedema compression wrapping for his ankle replacements. And when I saw how that was doing, it looked incredible because my experience, like a lot of people's, is we would do these major foot and ankle surgeries, we put them in a splinter, a cast for a couple of weeks and then they would show up in your office at two weeks post op and you'd be like, ooh, that's, that doesn't look great. So we started to do the lymphedema compression wrapping for ankle replacements. Again, I took that from Steve. It's either done with home healthcare or outpatient. It's done by a physical therapist. So for the first three weeks they're getting motion every couple of days, but it's pretty limited. Right. So the therapist is coming in or they're going to the pt, they're doing range of motion exercises with them, then they apply this compressive bandage and they're going back into the boot until their next visit at the three week mark. They're then allowed to weight bear is tolerated, their stitches come out and then we get more aggressive. They're doing weight bearing, standing stretch at that point in, in the kam boot and sometimes I'll even let them come out. The therapist can be starting to do some, I would say gentle manipulation, tissue massage, so on and so forth.
A
Got it. So you already touched on this a bit, but in reference 23 of your publication, you and your co authors, including Steve Haddad, popularized this immediate post operative compression wrapping technique for calcaneal fractures. In your experience, do you believe that controlling edema immediately following total ankle arthroplasty or not just improves the soft tissues, but actually in itself improves ankle range of motion?
B
I think so. I mean, it's going to be hard to prove or disprove that, but I would just say that I have really applied this across the board. Ankle fractures, pilon fractures, Liz Franks. Any major foot and ankle trauma or reconstructive injury. And I cannot tell you how thrilled I am with how these wounds look at two or three weeks. And that Makes a big difference. I mean, they're not draining. The patients have less pain because they don't have this constant edema that has to help in some way with range of motion.
A
Perfect. All right, I'll step away a little bit like I sometimes do for these podcasts from the paper. Brian, I love visiting Chicago in the summer, but currently it is March and you live in Chicago, or at least close to it. I am in North Carolina and already wearing T shirts and shorts. Realistically, when will the winter finally end for you?
B
So the answer to that is probably early May. You know, I mean, what's crazy is, in fact almost 60 degrees here today, which is unheard of. So people are just wandering outside as if like the apocalypse has happened. But of course it'll drop to the 20s next week. I've got no argument. I mean, so winter is going to end. April, early May, it always you think it's done and they hit you with one more snowstorm in late April. I grew up in southeast Texas. My wife is from Glenview, Illinois. And so I had no choice in the matter. But this is the time of year where I always complain.
A
Great. All right, back to the paper. Into three and six week groups, you performed Achilles tendon lengthening in 66% and 78% of patients, respectively. What is the intraoperative ankle dorsiflexion, or lack of dorsiflexion that prompts the tendo Achilles lengthening in your hands?
B
So I'm doing this under live fluoroscopy on a lateral view, right? Because sometimes I think that I'm moving the ankle and I'm actually moving pathologically through adjacent joints. So I have them come to a lateral with the trial poly that I've selected. We've got our tibial talus components already in, and I arrange their ankle under fluoro. And if their tailless component is only getting to neutral or just maybe slightly beyond that, that's when I will do an Achilles lengthening. Now, I would say an adjunct to that is, again, as I've gotten more and more experience, I've become much more aggressive about my gutter debridements. And I think if I was to look at those patients or my patients in the last couple of years, I would bet that rate of Achilles lengthening has gone down to some degree.
A
Fair enough. We'll touch on that again in one of my upcoming questions. Brian, the range of motion, especially dorsiflexion for the case example that you provided in Figure 1 is truly terrific. You and your co investigators studied overall range of motion, but I did not see a breakdown of dorsiflexion versus plantar flexion, just overall range of motion. In your experience and in the study, where did you see the greatest improvement in range of motion? Endorsiflexion or plantar flexion?
B
It was an endorser flexion. You know, and I wish we had quantified that better I guess, or looked at it a different way in seeing these folks post operatively. Again, the ability to bear weight and bend the ankle loaded in that manner, I just don't think can be replicated another way. And the other thing is muscle atrophy, right? So. So being non weight bearing for six weeks or more, your limb atrophies your tissues fibrosis, even with pretty aggressive pt. So I think those two factors really contributed to the improvement in motion. Again, I would say anecdotally from my perspective, it seemed to be more so in dorsiflexion.
A
Got it. Thanks. You're an expert in total ankle replacement surgery, just like your previous colleague Steve Haddad. Here he is again. I know that you are meticulous in your technique, mobilizing the ankle, excising scar tissue, cleaning the ankle gutter like you just mentioned, re establishing a physiologic joint line and appropriately sizing the components and balancing the soft tissues. In my experience, despite my attention to all of these details, rarely am I able to re establish physiologic range of motion in total ankle arthroplasty. My patients remind me that my total ankles that I've implanted, while less painful, do not have the same range of motion as the uninvolved contralateral ankle. And I'm relegated to explaining, well, your ankle was stiff before surgery, so it'll be stiff after surgery. Perhaps you are able to re establish physiologic motion for your total ankle arthroplasty patients. But in the event your experience is similar to mine, why are we unable to achieve physiologic range of motion after total ankle arthroplasty?
B
So my experience is just like yours in conversations with Carl Schweitzer too. You know. You know, I've become just a zealot for gutter debridements, you know, spending a lot of extra time on that. And I do think that's helped. I don't know the answer exactly. I think our design has gotten so much better. But perhaps that can be fine tuned in some way to have maybe just a little less constraint to allow that motion. The other thing is that I think on the patient side, I mean, a lot of our patients are post traumatic. Right. And so I think that there's a significant amount of damage to the surrounding tissue that occurs with those events that cannot be undone just by replacing the ankle joint. It's not to all blame the patient for this, but I think that. Yeah, I mean, I have the same thing where I think people like their replacements. They feel a ton better, but they still don't move as well as their other side. The best I can think of is a lot of times it's post traumatic in nature, and then also it's got to be something on the design side. So I feel like we figured out how to get these things moving intraoperatively.
A
Good, thanks. All right, we'll step away from the paper one more time, and we'll come back to Steve Haddad. I knew you probably predicted that would happen.
B
Yeah.
A
Brian, I have mentioned Steve Haddad a few times. You work in Steve's former practice. What do you and the Illinois Bone and Joint Institute miss most about Steve? And what is your favorite, ideally humorous story about Steve?
B
So, yeah, I mean, Steve is, you know, full of energy. Right. I mean, he is always going enthusiastic, pretty intense about what he does. I do miss having him around. He can be very critical of things, but in a way, I don't know how else to describe it, he deeply cares about this stuff. He really does. He was great with his patients, and his patients all love him. And the humorous story I'll share is any Haddad patient that walks in the door, you know, immediately is asking me why I'm not getting on the ground, taking pictures of their feet, videotaping them walking down the hall. And I just would say, I'm not him. Unfortunately, I'm the best you're going to get for the moment. But, yeah, I mean, I miss the conversations with him. I still get to talk to him all the time, which is a great resource. But when we were in practice together, I think it was really fun to see some of the things he was doing and then also to take my crazy ideas and bounce it off of him.
A
That's great. Well, thanks for sharing. It's always good to get a little background. Brian, in your publication's introduction and discussion, you cite references that illustrate the benefits of early weight bearing following ankle and foot surgery. You carefully controlled most variables to demonstrate a statistically significant difference in your two cohorts. And both groups had similar demographics, surgical technique, physical therapy, and compression wrapping. As you Described, the patient groups participated in the exact same PT protocols. Why do you think axial weight bearing in a cam boot that limits muscle activation and ankle movement leads to improved ankle range of motion when initiated at three weeks rather than six weeks as an independent variable? Why is ankle range of motion improved with earlier weight bearing?
B
That's a good question. I don't know if I have a great answer to that. I mean, I think that they are activating to some extent in the kam boot. And I still think that loading the limb has to have some beneficial effect on the muscle, even if they are in a kam boot, that's constraining their range of motion. The other thought, as an aside, is I think that for a long time, and I was this way too, that myself and the therapist were almost afraid of the ankles to some extent. We just really wanted to avoid a complication. And instead, I think it's kind of changed the personality of the approach to it, where we think it's a functional, well fixed joint and we can be aggressive with it early. I think the kambu in and of itself has very little role. And I've actually had situations where I've had patients with issues with the boot rubbing on a medial malleolus causing a wound or something like that, where I told them, just get rid of the boot. And this is at the three or four week mark. And again, interestingly, I'm not seeing any issues with those folks. So, yeah, I don't know if the cam boot helps or hurts. I think it just helps people to feel comfortable with when they start to put weight on it.
A
Got it. All right. Your overall complication rate was low for both patient cohorts. We've already been over that. For my patients undergoing total ankle arthroplasty, I'm concerned about wound complications with early active ankle dorsiflexion, allowing the extensor tendons to create pressure on the incompletely healed extensor retinaculum and the incision, especially when trapped against the anterior shield of a cam boot. So you went over some of that. I therefore limit active dorsiflexion for several weeks for my total ankle patients while they heal that anterior soft tissue envelope, should I not be concerned?
B
So, to go back to the protocol, I have the same concerns. And what I would say is, for the first three weeks for these folks, they're performing pretty limited range of motion, working with the physical therapist, and perhaps we could have fleshed that out a little bit more in the paper in that for about three weeks, they are doing some range of motion with the pt, then getting compression wrapped and they're going back into the boot and they're not moving for another two or three days until they see the therapist again. So for three weeks or so they're performing fairly limited range of motion.
A
Fair enough. Okay, good. Thanks for clarifying. Brian. You had patients, especially in the six week study group, with associated simultaneous procedures. These included several calcaneal osteotomies and a few hindfoot arthrodies. You acknowledge that these procedures influence your weight bearing protocol. In your opinion, when is it okay to fully weight bear? These patients with hindfoot osteotomies and arthrodesis perform concomitantly to total ankle arthroplasty.
B
I am still doing six weeks for those people and I wish I had a better answer, or I wish I just, you know, had the fortitude to do some of the same things I started to do with ankles and just say go ahead and walk on it. Like I said, I really believe so I do orthopedic trauma as well as foot and ankle surgery. And every study that comes out in the trauma world basically says we are too conservative with weight bearing, that we've been protecting patients, but instead probably protecting ourselves. So my short answer is I still wait six weeks. I still worry about it for midfoot fusion fusions, TN fusions, calcane osteotomy. This folks, I'm still making them wait six weeks, but I. I really always think about it and think about what negative impact that will have on them.
A
Thank you. It's good. All right. One more step away from the paper. And you explained that you're from Texas. So you may not care about this, but I think you've been in Chicago long enough with major league baseball spring season around it right around the corner. Cubs or White Sox?
B
Yeah, that's an easy one. Astros. But if I had to pick between those two, it's the Cubs. My wife's family. My wife's one of six kids, all from Chicago. They're die hard North Siders, Cubs fans. So my kids all root for the Cubs despite everything I've tried. So we're going to be cheering for the Cubs.
A
Got it? All right, Astros. Understood. All right, Brian, in your introduction and discussion, you and your co authors acknowledged the concern for tibial component loosening, citing previous published investigations suggesting that stemmed or keeled Tibet tibial components confer a protective effect against tibial sided failure. In addition to using the Inbone 2 stem tibial implant for all of your patients, you also cemented the tibial and tailor components to mitigate the risk of diminished bone implant ingrowth, especially in the older patients. Seems you're aiming for the best of both worlds. My understanding is that the majority of total ankle surgeons do not use cement. Do you routinely use cement in total ankle replacement?
B
I do. I would say, basically universally, I am putting some cement on the tibial side. And, you know, I've gotten some pushback from people on that because I'm not just doing it at where the tray is. I'm actually doing it in the reaming path, basically up into the tibial canal. And I would say on the talus side, I'm putting a little bit. But it's much more, I think, important, I guess I would say, on the tibial side, or at least I think it is. And, yeah, I'm trying to shoot for the best of both worlds, Almost kind of hybrid fixation. I think the cement gives early stability that allows me to have them bear weight sooner. Now, I'd be fascinated to do a study where we actually looked at that and thought, you know, if it made any difference whatsoever. But I think that early cement interdigitation into that cancellous bone, I do think it helps a little bit to support this as they load it early.
A
Great, thank you. Yeah. Given your expertise in total ankle replacement, in addition to early weight bearing, as your investigation demonstrates, would you please tell the listeners your three most important tips to optimize ankle range of motion in total ankle arthroplasty?
B
So one of them I already talked about, but I'll mention it again. Gutter debridement. I think so many of the Achilles that I have lengthened. Probably not so many, but a percentage of the Achilles that I have lengthened could be absolutely secondary to gutter impingement, especially on the fibula side. I think we don't do a great job of clearing out the lateral or posterolateral aspect of the ankle joint. And so we're just replacing the top and bottom. We've got to create room for it to move. So be aggressive with your gutter debridements. Look at it under fluoro. Make sure you've really made enough space for the ankle to move. The other thing is that this. I really, really believe in this. Lymphedema, compression wrapping, active edema control is going to help your patients to move sooner. And so I think looking into that or something like it, I do think will help with early range of motion because the wounds are healed and you can safely move them early. The third one. It's a good question. Yeah, I'd have to think about the third reason. You know, I mean, I guess it's early aggressive range of motion, but that kind of goes along with the pt. I mean, I guess, you know, the whole point of the operation is not just to get paid people pain relief. It's for them to move. So don't be afraid to let your pts get after it and have these patients move.
A
Got it. All right, good. Well, congratulations to you and your colleagues on another impactful research effort. As our podcast comes to its conclusion, is there anything else you would like to share with the listeners?
B
I mean, the only thing I would share is that I think ankle replacement's come such a long way. I mean, you and Steve and people like yourselves really were imperative in showing us what could be done. And now I think it's on the next generation to try to push that envelope a little bit further and see how far we can take this. But I would say it's a great operation. I know there's still a lot of ankle fusions out there, but I would just say there's a role for that still. But I think if you can provide motion while alleviating pain, I think it is great for our patients. So hopefully you'll think about doing it a little more.
A
Oh, great. Now you made me feel old. I really appreciate it.
B
No problem. Well, I do it to Steve all the time, so it's okay. Yeah, I remind him.
A
I have to say, I'm really excited about you and the quote unquote younger generation. It's really exciting to see what you guys are doing. I feel very comfortable that patients will continue to benefit because of surgeons like yourself and thinkers, thought leaders like yourself. So I'd like to thank Dr. Weatherford for sharing his insights on his and his co authors FAI publication effects of early weight bearing on ankle, Range of Motion and complications after Primary total Ankle arthroplasty. And now I'd like to thank everyone for participating in this month's FAI podcast. This is Mark Easley. I look forward to next month's podcast.
Podcast: Foot & Ankle International
Host: Mark Easley (A)
Guest: Dr. Brian Weatherford (B), University of Illinois, Chicago
Date: March 18, 2026
This episode dives into Dr. Brian Weatherford’s recent study published in FAI, exploring how earlier postoperative weight bearing (at 3 weeks vs. 6 weeks) affects ankle range of motion and complication rates after primary total ankle arthroplasty (TAA) using the InBone 2 implant. The discussion covers protocol details, clinical interpretations, and implications for surgical practice, as well as insights into postoperative care and physical therapy.
Advances in TAA: While prosthetic designs have improved, rehabilitation protocols had not kept pace. Dr. Weatherford noticed this gap and became curious about the necessity of delayed weight bearing.
“We had made such tremendous advances in the technology, but we hadn’t at all updated any of our physical therapy or rehab protocols to reflect that.” — B [00:53]
Study Design: Two cohorts (3-week and 6-week weight-bearing groups) from Dr. Weatherford’s practice; not a randomized study.
Primary Questions:
Key Findings:
“Earlier weight bearing did not increase the rate of complications, number one. And that number two, the people who were weight bearing earlier actually seem to be doing better in terms of ankle range of motion.” — B [01:38]
“They are allowed to put as much weight as they are comfortable with starting at three weeks. ... In fact, for some elderly patients, I’m even letting them weight bear at one week.” — B [02:19]
“For the first three weeks they’re getting motion every couple of days, but it’s pretty limited.” — B [03:05]
“I cannot tell you how thrilled I am with how these wounds look at two or three weeks. ... Patients have less pain because they don’t have this constant edema.” — B [04:46]
“If their talus component is only getting to neutral or just maybe slightly beyond that, that’s when I will do an Achilles lengthening.” — B [06:36]
“It was in endorser flexion. … The ability to bear weight and bend the ankle loaded in that manner, I just don’t think can be replicated another way.” — B [07:55]
“People like their replacements. They feel a ton better, but they still don’t move as well as their other side.” — B [09:42]
“I think the cam boot in and of itself has very little role. … I’m not seeing any issues with those folks [without the boot at 3–4 weeks].” — B [12:52]
“They are performing fairly limited range of motion.” — B [14:37]
“I really believe … every study that comes out in the trauma world basically says we are too conservative with weight bearing, that we’ve been protecting patients, but instead probably protecting ourselves.” — B [15:40]
“Basically universally, I am putting some cement on the tibial side. … I think the cement gives early stability that allows me to have them bear weight sooner.” — B [17:39]
“Be aggressive with your gutter debridements. Make sure you’ve really made enough space for the ankle to move.” — B [18:46]
“Lymphedema, compression wrapping, active edema control is going to help your patients to move sooner.” — B [19:10]
“The whole point of the operation is not just to get people pain relief. It’s for them to move. So don’t be afraid to let your PTs get after it and have these patients move.” — B [19:38]
"As I got more experience with it, I began to wonder why we were [waiting for weight bearing]." — B [00:53]
"Every study that comes out in the trauma world basically says we are too conservative with weight bearing." — B [15:40]
"I took this right from Steve Haddad… My experience, like a lot of people’s, is we would do these major foot and ankle surgeries… and you’d be like, ‘ooh, that doesn't look great’." — B [03:05]
“Any Haddad patient that walks in the door, you know, immediately is asking me why I’m not getting on the ground, taking pictures of their feet, videotaping them walking down the hall.” — B [11:06]
| Time | Segment | |-----------|------------------------------------------------------------------------| | 00:53 | Study motivation, design, and key findings | | 02:19 | Weight bearing definitions and protocol evolution | | 03:05 | Detailed PT and lymphedema control protocol | | 04:46 | Role of compression wrapping in edema and tissue healing | | 06:36 | Indications for Achilles tendon lengthening | | 07:55 | Specific improvements in dorsiflexion | | 09:42 | Why physiologic ROM is rarely restored post-TAA | | 12:52 | Mechanistic theories behind improved ROM with early weight bearing | | 14:37 | Protection of anterior tissues and limited early dorsiflexion | | 15:40 | Approach to weight bearing after concomitant procedures | | 17:39 | Dr. Weatherford’s use of cement and rationale | | 18:46 | Top three tips to optimize ROM in TAA |
Dr. Weatherford emphasizes that modern TAA, when combined with an updated, evidence-based rehab approach, is safe and potentially more effective when early weight bearing is encouraged—providing improved range of motion without increasing complications. He advocates for ongoing reassessment of protocols, the importance of aggressive soft tissue management, and the role of thoughtful postoperative therapy. The conversation closes with a call for surgeons to continue pushing the field forward and not to fear innovation if it benefits patient function.
“If you can provide motion while alleviating pain, I think it is great for our patients. So hopefully you’ll think about doing it a little more.” — B [20:08]