Hip Early Weight Bearing After Operative Fixation of Lower-Extremity Fractures: From Fracture Protection to Construct-Driven Rehabilitation

Abstract

Postoperative weight-bearing restrictions have traditionally been prescribed after lower-extremity fracture fixation to protect healing bone and prevent loss of reduction or implant failure. Contemporary fixation constructs, however, may provide sufficient stability to permit earlier functional loading, whereas prolonged non-weight bearing can contribute to muscle atrophy, joint stiffness, impaired gait, loss of independence, and poor compliance. This narrative review evaluates contemporary evidence for early weight bearing after operative treatment of ankle, tibial shaft, tibial plateau, and distal femur fractures. The strongest evidence concerns ankle fractures: a large multicenter randomized trial and subsequent meta-analysis of randomized trials support weight bearing beginning approximately 2 weeks after stable fixation, with improved early function and no clear increase in complications in appropriately selected patients. Randomized and meta-analytic data also support immediate weight bearing as tolerated after intramedullary nailing of selected tibial shaft fractures. More recent randomized evidence suggests that immediate loading can be safe after stable fixation of selected Schatzker I-IV tibial plateau fractures, although extrapolation to complex bicondylar injuries is not justified. For distal femur fractures, observational and meta-analytic evidence is increasingly reassuring, particularly when fixation is deliberately constructed to tolerate early loading, but the certainty of evidence remains lower. The emerging principle is not universal immediate loading, but individualized rehabilitation based on fracture morphology, reduction quality, bone quality, fixation mechanics, soft-tissue constraints, and patient factors. Postoperative weight-bearing prescriptions should increasingly be construct driven rather than diagnosis driven.