Impact of Postoperative Weight-Bearing Protocols on Prognosis in Geriatric Hip Fracture Patients: A Systematic Review...

Background: Clinical controversy persists regarding the optimal weight-bearing strategy for elderly patients following hip fractures. Whilst early unrestricted weight-bearing may improve functional outcome and reduce the risk of bed-related complications, concerns about implant stability and failure often lead clinicians to adopt restricted weight-bearing protocols. To address this, we conducted a systematic review and meta-analysis to identify the effects of unrestricted weight-bearing compared with restricted weight-bearing on clinical outcomes in this patient population. We hypothesized that unrestricted weight-bearing may be associated with lower all-cause mortality without increasing postoperative complications, reoperation rates or length of hospital stay (LOS). Methods: This systematic review was conducted based on a study protocol registered on the PROSPERO platform and reported strictly in accordance with the PRISMA guidelines. We included clinical studies involving patients aged ≥65 years with hip fractures undergoing surgical treatment that directly compared the effects of different postoperative weight-bearing strategies on outcomes. Patients were further classified into unrestricted and restricted weight-bearing groups according to the postoperative weight-bearing protocols reported in each study. The primary outcome was all-cause mortality. Secondary outcomes included postoperative complications, reoperation rates, and LOS. A random-effects model was used for meta-analysis. Dichotomous variables were expressed as risk ratios (RRs), continuous variables as mean differences (MDs), and study heterogeneity was assessed using the I² statistic. The certainty of evidence of each outcome was assessed by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Ten studies (one randomized controlled trial and nine cohort studies) were included with 5806 patients in total. Extra-capsular fractures (intertrochanteric/subtrochanteric fractures) were the most common, with 3694 patients, followed by femoral neck fractures, with 1929 patients. Unrestricted weight-bearing was significantly associated with lower long-term mortality compared with restricted weight-bearing (RR = 0.67, 95% CI 0.51-0.88, p = 0.004, I² = 34%; 95% PI 0.52-0.83), with an absolute risk difference of -0.10%. Short-term mortality did not differ significantly in the primary analysis (RR = 0.58, 95% CI 0.14-2.34, p = 0.44, I² = 70%; 95% PI 0.00-126.98). Furthermore, the corresponding absolute risk difference was only -0.03%. No significant differences were observed for short-term complications, long-term complications, reoperation risk, or LOS between the two groups (all p > 0.05). GRADE assessment showed low certainty of evidence for long-term mortality and short-term complications, and very low certainty of evidence for the remaining outcomes. Conclusions: This meta-analysis suggests that unrestricted weight-bearing may be a feasible postoperative rehabilitation approach in selected patients. However, the results should be interpreted with caution. Further well-designed prospective studies are required to confirm these findings.