Weight Bearing

Two low level retrospective studies (Atzmon 2021, Otteson 2018) compared weight-bearing as tolerated to weight bearing restrictions (partial or non-weight bearing) following intra and extra-capsular hip fractures. Both studies found higher mortality in the non-weight bearing group. Ottesen (2018) performed a review of 4918 patients through the NSQIP database of over 600 US centers and found that 75% of patients were allowed to weight-bear as tolerated. They reported that 30-day mortality, length of stay, post-operative delirium, infection, transfusion rates, pneumonia, and adverse events were lower in the weight bearing as tolerated cohort with no difference between groups with return to the operating room within 30 days. However, in the study by Atzmon (2021) weight-bearing restrictions were applied based on the surgeon or therapist’s judgement of patient inability to fully bear weight due to prior functional or cognitive limitations, inadequate fixation or bone quality, or high pain level. Ottesen (2018) lacked information on the surgeon’s reason for imposing restrictions, the duration for which these restrictions were imposed, or the surgeon’s criteria that were used to lift the restrictions later in the recovery. Therefore, the results are subject to substantial risk of bias by indication.

Benefits/ Harms of Implementation

No studies reported adverse events and this recommendation has been adopted by ~75% of US orthopedic surgeons based on 2018 NSQIP report. Potential benefits include improved functioning and independence and reduced adverse outcomes.

Outcome Importance

Patient functioning, cost of care, adverse outcomes, and mortality may be improved by further adoption of early, unrestricted weight bearing.

Cost Effectiveness/Resource Utilization

Weight-bearing as tolerated does not require increased resources or costs.

Acceptability

Approximately 25% of patients receive weight-bearing restrictions, indicating lack of acceptability for a substantial proportion of providers and/or patients. 

Feasibility

Evidence that 75% of patients are allowed to weight-bear as tolerated supports feasibility.

Future Research

Inconsistent adoption highlights the need for larger, prospective, multi-institutional longitudinal studies. Future research should endeavor to specify the reasons for weight-bearing restrictions, and investigate patients’ ability to comply, as well as the relationship between restrictions and lower extremity strength, power, functional mobility.